Clinical Applications

The Case of the Aging Surfer

Seth, a thirty-eight year-old white male of Scandinavian descent, has lived his entire life in Southern Florida. He is very concerned with maintaining a "healthy" appearance. Seth is very athletic and especially enjoys surfing. He has been surfing since the age of twelve and he started making surfboards while he was in high school. After obtaining a college degree in marketing Seth decided to start his own business making surfboards and giving surfing lessons for a local resort near his home. During a routine physical examination the physician assistant that Seth sees commented on the presence and appearance of a small growth (approximately 2-cm in diameter) above Seth's right eyebrow. This growth was shiny with a pearly border, a central ulcer and engorged surface blood vessels. The physician assistant was concerned that this might be a tumor and asked Seth a number of questions to aid in the diagnosis. Seth reported that he noticed this growth approximately six months ago but thought nothing about it since he often developed "pimples" when he was working on surfboards because of the heat and dust. Seth noticed that the growth would occasionally bleed, but he thought the bleeding most often occurred when he absently scratched above his eyebrows when he was working. Seth also reported that after bleeding the growth would "crust over" and appear to heal, but not disappear. Seth also thinks the lesion has increased in size, but he can't be certain.

The physician assistant asks Seth to come back in two days to visit with the attending physician and encourages Seth to be sure to use sunscreen whenever possible, especially when he is surfing or teaching surfing classes. Upon returning to see the physician, Seth is told that he probably has a basal cell carcinoma. This, the physician explains, is a cancer that while not benign, rarely metastasizes and grows very slowly. This type of cancer usually occurs in areas that have the greatest exposure to the sun (i.e. the face, head, and neck). While this cancer would probably not metastasize, the physician suggests surgical removal to minimize damage to any underlying tissues and a histological examination of the excised tissue to confirm the diagnosis.

Seth is concerned that if this is indeed cancer he will have to undergo radiation and/or chemotherapy and suffer from both hair loss and nausea like his mother did when she was being treated for breast cancer 10 years ago. The physician assures Seth that these treatments are not required for basal cell carcinoma and explains that this cancer usually remains localized to the specific area of the skin and does not usually spread to other tissues, so radiation and chemotherapy would not be necessary. Seth then asks why it is necessary to remove the tumor if it will not spread and is told that while the tumor does not spread to other body areas it will continue to grow and also invade deeper layers of the skin, such as the dermis, and destroy normal tissues. Seth agrees to the procedure and schedules a follow-up appointment to discuss the results of the biopsy the following week. At the follow-up appointment, Seth is told that the lesion was indeed a basal cell carcinoma. He is told that it will be important for him to try to use both sunscreens, specifically those containing para-aminobenzoic acid or PABA, and protective clothing as much as possible to minimize the effects of the ultraviolet (UV) rays of the sunlight. Seth is also told that while he should not be overly concerned, he should also pay close attention for similar lesions in the future, since a person with a single basal cell carcinoma is likely to develop additional basal cell carcinomas in the future.

1		Define the bold terms in the text.
2		How are benign and malignant tumors similar and different from each other?
3		Describe the anatomy of the skin and the relationship of these layers to the type of cancer that Seth presents with.
4		What are oncogenes and how are they believed to be related to cancer?
5		Identify both the primary risk factors that Seth presents with and other risk factors that may or may not be related to Seth's case.
6		How do chemotherapy and radiation therapy act as treatments for cancer?
7		Why does chemotherapy cause the side effects of hair loss and nausea?