82 year-old male nursing home resident presented with a subcutaneous lump on the left knee for three to six months. Medical history includes head injury with intra-cranial bleed due to a fall, resulting in permanent physical disability and cognitive deficit.
The lump was about four cm in diameter. The patient and family requested excision biopsy as the patient kept drawing their attention to the lump that progressively turned red, as if it was getting inflamed. My first impression was that this was not a lipoma but probably an inflamed sebaceous cyst. It was excised under local anesthetic without any complications.
Merkel cell carcinoma of the skin, 4 cm in size. Peripheral and deep margins were extensively involved with lymphovascular invasion.
Merkel Cell Carcinoma (MCC)
Merkel cell carcinoma, a rare type of skin cancer, usually appears as a flesh to bluish-red colored nodule on sun-exposed areas, like the face, head and neck.
Merkel cell carcinoma is usually found in older people. Around 80% are caused by Merkel cell polyomavirus. Exposure to sunlight and a weak immune system increase the chance of developing MCC.
The tumor is locally invasive and also spreads rapidly through the body. Early diagnosis and treatment lowers the chance of metastasis.
Since the lesion has no distinguishable features from other skin cancers, the first treatment is surgical excision. Once the pathology report comes back the lesion can be identified as Merkel cell carcinoma. Further therapies like lymph node biopsy, radiation or chemotherapy can be considered if needed, to prevent metastasis and recurrence.
In this case, no further investigation or treatment were planned, as the patient’s quality of life would be extremely poor should he survive recurrence. The family decided it was time to let nature take its course.
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