Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
New or established Merkel cell carcinoma (MCC)
(Specify) Painless, red/bluish nodule or lump on the skin (often on sun-exposed areas)
May mention rapid growth, change in size or color of the lesion
History of Present Illness:
For new patients:
Location, size, color, and duration of the skin lesion.
Any recent changes in the appearance of the lesion (growth, bleeding, ulceration).
Associated symptoms (e.g., itching, burning).
For established MCC:
Follow-up since diagnosis and treatment.
Any new or worsening symptoms.
Treatment side effects or complications.
Past Medical History:
Risk factors for MCC:
Age (most common in older adults)
Immunosuppression (e.g., organ transplantation, HIV infection)
Chronic sun exposure
History of skin cancer
Medications:
List all current medications, including immunosuppressants.
Social History:
Occupation and sun exposure habits.
Tobacco use (may worsen prognosis).
Family History:
Family history of skin cancer (not a major risk factor for MCC).
Physical Exam:
Skin examination:
Careful examination of the primary lesion and surrounding skin for size, color, induration (hardness), satellite lesions (nearby smaller lesions).
Assess for regional lymph node enlargement.
General examination: Evaluate for signs of distant metastasis (e.g., enlarged liver, palpable lymph nodes in other areas).
Imaging Studies (as indicated):
Skin biopsy: The definitive diagnostic test for MCC. Biopsy should be performed with adequate margins to assess invasion depth.
Sentinel lymph node biopsy (SLNB): To assess for lymph node involvement, especially for tumors larger than 1 cm or with high-risk features.
Imaging studies (CT scan, PET scan): May be used to assess for regional or distant metastasis, depending on tumor stage and clinical suspicion.
Assessment:
Merkel cell carcinoma: Based on clinical presentation, biopsy confirmation, and imaging findings (if available), diagnose or confirm MCC.
Stage of MCC (using AJCC staging system): Staging is crucial for determining prognosis and guiding treatment decisions. Stage considers tumor size, lymph node involvement, and presence of distant metastasis.
Prognosis: Discuss the prognosis with the patient, considering stage, age, and overall health. MCC can be an aggressive cancer, and prognosis worsens with advanced stages.
Plan:
Treatment (depends on stage and patient factors):
Surgery: The mainstay of treatment for early-stage MCC, involves wide surgical excision with adequate margins to remove the tumor and surrounding tissue. Lymph node dissection may be performed if sentinel lymph node biopsy is positive.
Radiation therapy: May be used post-operatively to improve local control or for palliative purposes in advanced stages.
Immunotherapy: Immune checkpoint inhibitors (e.g., pembrolizumab, avelumab) have shown promise in treating advanced or recurrent MCC. May also be considered for adjuvant therapy (after surgery) in high-risk cases.
Clinical trials: Consider enrollment in clinical trials investigating new treatment approaches for MCC.
Multidisciplinary care: MCC often requires a multidisciplinary approach involving dermatologists, surgeons, radiation oncologists, medical oncologists, and supportive care specialists.
Pain management: Address any pain associated with the tumor or treatment side effects.
Follow-up: Schedule regular follow-up visits for monitoring, surveillance for recurrence, and management of potential long-term effects of treatment.
Education:
Educate the patient about MCC, symptoms, risk factors, treatment options, and prognosis.
Discuss the importance of sun protection measures to reduce the risk of recurrence or development of new skin cancers.
Provide resources for patient advocacy organizations specializing in Merkel cell carcinoma.
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. Merkel cell carcinoma is a rare and aggressive skin cancer. Early diagnosis and prompt treatment are crucial for improving