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This young man had neurofibromatosis type 2. He became progressively more deaf, eventually losing his hearing completely owing to bilateral acoustic neuromas. He underwent surgery for one of these, but sustained damage to the facial nerve, manifesting as a lower motor neuron lesion. He also lost all hearing on that side. Over the next few years, he developed numerous other tumours, eventually associated with intractable raised intracranial pressure. He died in his early 20s.
2 Carcinoma of the kidney
This 50-year-old man had a carcinoma of the kidney. He had a nephrectomy and did well, until several years later, when he developed this problem. A scan confirmed a large mass in the middle meatus extending through the antrum. It was a metastatic deposit from the renal carcinoma. He received radiotherapy, but died soon after.
3 Chronic lymphocytic leukaemia
This 84-year-old man was found to have chronic lymphocytic leukaemia when he had a routine FBC before a knee replacement. His WCC was 19,000 and following a haematology assessment, it was decided to take no action but watchful waiting with regular blood tests. Approximately two years later, his WCC leapt up. He had ?chemotherapy after this. The leukaemia had become much more aggressive and the neck swelling was due to cervical lymphadenopathy. His condition deteriorated over the following months and he eventually died.
4 Basal cell carcinoma
Basal cell carcinoma (BCC) is an extremely common condition in the elderly, owing to previous sun exposure. However, it is also seen in younger patients, especially if they have spent part of their early life in countries such as Australia or South Africa. This man is only 52 years old and has developed a nodular type BCC on his nose. It required excision and flap reconstruction because this area has no ‘spare’ skin to close the defect.
5 Neuroendocrine tumour
This patient presented to the practice with right-sided chest pain. It persisted, so he was referred for a chest X-ray, which revealed a mediastinal mass. Bronchoscopy and biopsy failed to confirm a diagnosis. He then developed enlarged lymph nodes in the neck and supraclavicular fossa. Biopsy from these confirmed poorly differentiated malignant cells with necrosis. Further analysis ?eventually confirmed the diagnosis, but in spite of chemotherapy, his condition deteriorated and he died within months.
6 Squamous cell carcinoma
This 69-year-old woman developed a very painful mouth ulcer. She was a heavy drinker and an ex-smoker, so a referral was made to the maxillofacial surgeons. The ulcer was growing rapidly and biopsy confirmed squamous cell carcinoma (SCC). Malignant mouth ulcers are often painless and patients may therefore present late. However, this is not always the case, as this patient’s experience shows. She was frightened of any surgical intervention, but agreed to the minimum possible surgical procedure. Sadly, the tumour recurred locally a few months later. She had further, more extensive surgery this time because there was no apparent distant spread. The tumour recurred and she died some months later.
7 SCC of the tongue
This 40-year-old man presented with swelling in his neck. It was clearly malignant, but it was not obvious where the primary was. He was referred to the ENT department, and an SCC of the back of the tongue was subsequently found. The man was a smoker. He underwent surgery and postoperative radiotherapy. It proved to be a very difficult course of treatment, with severe side-effects, but was successful, and he remains disease-free five years later.
8 SCC of the pinna
This 88-year-old patient developed a growth arising from her left ear. She had a confirmatory biopsy but refused any further treatment. Numerous family members, friends and members of the medical ?profession tried to persuade her to have surgery, but she refused. The SCC continued to grow for several months, before spreading and finally overwhelming her.
- Dr Marazzi is a GP in Surrey