1. J.M. 21 y/o female cc: scalp mass

2. History of Present Illness Slowly enlarging, firm, occasionaly tender mass on R parietoocipital area (3x3cm) Consult – A: Hemangioma – P: Excision 14 years PTA

3. ADMISSION 2 mos PTA Recurrence of slowly enlarging mass (5x5cm) Consult at UST OPD – Scalp X Ray – Ultrasound of neck

4. (-) HPN (-) DM (-) HPV infection (-) Asthma (-) Allergies (-) PTB

5. Mixed diet Nonsmoker Not an alcoholic beverage drinker

6. (+) HPN – mother (+) DM – grandfather (-) Asthma (-) CA

7. (-) weight loss, weakness, fatigue (-) Headache, dizziness, blurring of vision (-) hearing loss, aural discharge, tinnitus (-) epistaxis, nasal discharge, sinusitis (-) hoarseness, mouth sores, dysphagia (-) dyspnea, cough

8. Conscious, coherent, ambulatory, not in distress BP: 120/80 PR 80bpm RR 18cpm T 36.5°C Wt. 60 kg Ht. 162cm Warm moist skin, no active dermatoses Pink palpebral conjunctivae, anicteric sclerae No naso-aural discharge, non-congested turbinates, non-tender sinus, buccal mucosa, tonsils not enlarged, no bleeding gums Supple neck, (-) palpable cervical Lymph Nodes, no thyromegaly

12. Symmetric on chest expansion, (-) retractions, lungs resonant, clear breath sounds Adynamic precordium, AB 5 th LICS MCL, S1>S2 at the apex, S2>S1 at the base, no murmurs Flat abdomen, no organomegaly, (-) rebound tenderness, no masses (-) pallor, clubbing, petechiae, ecchymoses Pulses ++ on all extremities

13. Admitting Impression Soft tissue tumor to consider recurrent hemangioma vs. granuloma

14. Merkel’s Cell Carcinoma Classified as a neuroendocrine malignancy of the skin. Cutaneous small cell undifferentiated carcinoma Incidence of 1200 per year in the US Mortality rate of 33 % National Cancer Institute. Fact Sheet MERKEL’S CARCINOMA. 2007 Merkel Cell Carcinoma: More Deathsbut Still No Pathway to Blame Bianca Lemos and Paul Nghiem. Journal of Investigative Dermatology (2007)

15. Discussion Merkel’s cells located in the basal layer of the epidermis. Grossly, the primary tumor presents as a small, red, pink, or blue-violet, non-ulcerated, painless, intradermal nodular mass often located in sun-exposed areas of the skin such as the head and neck

16. Discussion Neuroendocrine markers – Neuron-specific enolase – Chromogranin – Synaptopysin Merkel cell carcinoma, Virve Koljonen. World Journal of Surgical Oncology 2006

17. American Joint Committee on Cancer Stage I (primary lesion ≤ 2 cm) Stage II (primary lesion > 2 cm). Stage III (nodal involvement) Stage IV disease (metastatic)

18. Prognosis Aggressive course with reported overall 5-year survival rates ranging from 30% to 64%. Survival after a diagnosis of MCC is highly dependent on the stage at presentation. 90 percent of recurrences occurring within three years of diagnosis Merkel Cell Carcinoma: A Case Report and Literature Review. Oncology. Medical Journal of Islamic World Academy of Sciences 15:3, 91-94, 2005