Face - Non-Melanoma Malignant Neoplasm of the Skin — ICD-10 C44.3

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been invented and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Face - Non-Melanoma Malignant Neoplasm of the Skin

Example 1 of 1 · fictitious patient (Veteran DN)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been invented and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

Face - Non-Melanoma Malignant Neoplasm of the Skin

BOP Code: 79 of 2024 (Non-Melanoma Malignant Neoplasm of the Skin)
RH Code: 78 of 2024 (Non-Melanoma Malignant Neoplasm of the Skin)

ADF History

Veteran DN, date of birth 02 March 1923, Australian Army, Infantry soldier and later Vehicle Mechanic, enlisted 10 July 1941, discharged 01 March 1978. Operational service: Malaya and Singapore, 15 August 1941 to 15 February 1942 (operational service); prisoner of war of Japan, 15 February 1942 to 15 September 1945, including the Burma-Thailand Railway. Peacetime service in Australia from 1946 to 1978, including defence service from 07 December 1972.

Occupational History

As an infantry soldier in Malaya and then a prisoner of war the veteran worked outdoors in tropical sun without protective clothing, under conditions of starvation, tropical disease and physical abuse. As a vehicle mechanic from 1946 to 1978 he worked outdoors in workshop yards and on exercises in northern Australia, did arc welding, and had prolonged skin contact with mineral oils, solvents, soot and timber preservatives.

Service in tropical and subtropical Australia in that era involved high ultraviolet exposure with little sun protection. Remote postings relied on bore water and on arsenical termite treatments, and smoking was almost universal among servicemen.

History

Veteran DN, a prisoner of war of Japan who later served as an Army vehicle mechanic until 1978, developed a squamous cell carcinoma of the left cheek, arising in an old injury scar and osteomyelitis sinus, together with a basal cell carcinoma of the nasal ala, with onset on 14 September 2023. This followed extreme tropical sun exposure in captivity, decades of service in northern Australia, and long-term immunosuppression after a kidney transplant and for multiple immune and blood disorders; the cheek carcinoma worsened in 2024 while excision was delayed.

Timeline

12 Jul 1943 — On the Burma-Thailand Railway a guard struck the veteran across the left jaw with a rifle butt, fracturing the mandible. A tropical ulcer of the left cheek followed and persisted for about 14 months, and chronic osteomyelitis developed with a sinus draining to the left cheek. He worked bareheaded in tropical sun for 10 to 12 hours a day and had repeated blistering facial sunburn. "mandible fracture, tropical ulcer cheek"
14 Mar 1946 — On repatriation the veteran was found to have chronic osteomyelitis of the left mandible with a discharging cheek sinus, which was drained surgically, and plaque psoriasis of the face and limbs. He was given superficial X-ray therapy for severe facial acne later that year and began nightly coal-tar ointment to the face. He continued in full-time service as a vehicle mechanic. "mandibular osteomyelitis, cheek sinus"
12 Jun 1995 — After a long service career in northern Australia, with PUVA therapy for psoriasis from 1979, Fowler's solution in 1950 to 1952, arsenical keratoses documented in 1992 and HIV infection from a 1984 transfusion, the veteran received a kidney transplant for end-stage kidney failure. He began ciclosporin and later other immunosuppressants. "renal transplant, immunosuppression commenced"
21 Mar 2005 — A basal cell carcinoma of the left cheek was treated with 55 Gy in 20 fractions of radiotherapy, completed on 18 April 2005. Facial lymphoedema of the left cheek followed. He stopped smoking on 30 June 2005 after 64 years at about 25 cigarettes a day. Lichen sclerosus of the penis was diagnosed in 2008, and post-transplant lymphoma in June 2008. "left cheek BCC, radiotherapy 55 Gy"
18 Oct 2016 — Chronic lymphocytic leukaemia with small lymphocytic lymphoma was diagnosed and ibrutinib started. Over the following years he was treated for autoimmune hepatitis, ulcerative colitis, rheumatoid arthritis, psoriasis, multiple sclerosis, myelofibrosis, myeloma, melanoma and a gastrointestinal stromal tumour with multiple immunosuppressive and targeted drugs. "CLL, ibrutinib commenced"
10 Mar 2023 — A full skin examination by his general practitioner, done every six months because of his transplant, recorded actinic damage and scarring of the left cheek with a dry healed sinus opening, but no suspicious lesion on the face. Multiple actinic keratoses were treated with cryotherapy. "skin check, no suspicious lesion"
02 Oct 2023 — The veteran's carers noticed a rapidly growing, crusted and bleeding lump in the scar on his left cheek from mid-September 2023. Biopsy showed a well-differentiated invasive squamous cell carcinoma, 14 mm, and a second biopsy of the left nasal ala showed a nodular basal cell carcinoma. Urgent wide excision was recommended. Further primaries of the prepuce, perianal skin, scrotum and left axilla were diagnosed in October 2023. "invasive SCC left cheek, BCC ala"
18 Mar 2024 — While still awaiting excision, the left cheek carcinoma had enlarged to 32 mm with fixation to the underlying tissues and new facial numbness. MRI showed perineural spread along the infraorbital nerve. Wide excision with flap reconstruction and adjuvant radiotherapy were then arranged. "SCC 32 mm, perineural invasion"

Symptoms

At onset the veteran had a rapidly enlarging, crusted, tender and bleeding nodule in the scar on his left cheek, and a slowly growing pearly lesion on the left side of his nose. Over the following months the cheek lesion ulcerated and bled with minor contact, and by March 2024 he had numbness of the left cheek and upper lip.

He now has a large reconstructed defect of the left cheek with numbness, pain and disfigurement, and ongoing surveillance for further skin cancers.

Imaging

14 Sep 2012 — CT facial bones: "Chronic osteomyelitis of the left mandibular body with sclerosis, a sequestrum and a cutaneous sinus tract to the left cheek."
18 Mar 2024 — MRI face and skull base with gadolinium: "32 mm enhancing soft-tissue mass of the left cheek invading the subcutaneous fat and superficial muscle, with thickening and enhancement of the left infraorbital nerve consistent with perineural spread."

Onset Date

The most likely date of onset of this condition is 14 Sep 2023.

At that date the veteran was 100 years old, living in residential aged care, and taking long-term transplant immunosuppression and several other immunosuppressive and targeted drugs. His carers first noticed a growing, bleeding lump in the scar on his left cheek in the week of 14 September 2023.

This date is appropriate because the full skin examination on 10 March 2023 found no suspicious lesion on the face, and biopsies on 02 October 2023, less than three weeks after this date, confirmed a squamous cell carcinoma of the left cheek and a basal cell carcinoma of the nasal ala.

For the medication factors, the 10 years before onset run from 14 Sep 2013 to 14 Sep 2023 and the 5 years run from 14 Sep 2018 to 14 Sep 2023, and each listed drug was taken within those windows. The radiotherapy of 2005, the kidney transplant of 1995, the scar, the ulceration, the sinus tract, the lymphoedema, the arsenic exposures, the coal tar, the welding burns, the sunburns, the tanning sessions and the PUVA therapy all precede onset by more than the required 2, 5 or 10 years. Smoking ceased on 30 Jun 2005, 18 years before onset. The sunlight exposure was accrued in captivity from 1942 to 1945 and in peacetime service from 1946 to 1978.

For the worsening factor, the documented clinical worsening is the MRI of 18 Mar 2024, showing growth of the cheek carcinoma from 14 mm to 32 mm with perineural spread. Before that date, from 02 Oct 2023 to 18 Mar 2024, the recommended urgent excision could not be obtained.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Face - Non-Melanoma Malignant Neoplasm of the Skin (ICD-10-AM C44.3), a well-differentiated invasive squamous cell carcinoma of the left cheek with a nodular basal cell carcinoma of the left nasal ala, under the Statements of Principles concerning non-melanoma malignant neoplasm of the skin, Balance of Probabilities No. 79 of 2024 and Reasonable Hypothesis No. 78 of 2024.

Non-melanoma malignant neoplasms of the skin are cancers of the keratinocytes, mainly basal cell carcinoma and squamous cell carcinoma. They are caused principally by cumulative ultraviolet radiation, and their risk is greatly increased by immunosuppression, particularly after organ transplantation, by ionising radiation, arsenic, polycyclic aromatic hydrocarbons, chronic scars, ulcers and sinus tracts, and by human papillomavirus infection. Squamous cell carcinoma can invade locally, spread along nerves and metastasise, especially in immunosuppressed people.

The facial carcinomas began on 14 September 2023, were confirmed on biopsy on 02 October 2023, and the cheek carcinoma worsened by March 2024 while treatment was delayed.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

14 September 2023.

When did the veteran first present to a health / medical provider for this condition?

02 October 2023.

When was the condition confirmed / formally diagnosed?

02 October 2023.

When did the veteran first present to you (or your practice) for this condition?

14 July 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was confirmed on histopathology of biopsies taken on 02 October 2023: an invasive, well-differentiated keratinising squamous cell carcinoma of the left cheek arising in scarred, sun-damaged skin, and a nodular basal cell carcinoma of the left nasal ala. Both meet the Statement of Principles definition of non-melanoma malignant neoplasm of the skin.

Progression was confirmed on MRI on 18 March 2024, which showed enlargement of the cheek carcinoma to 32 mm with perineural spread along the infraorbital nerve, and on histology of the excision specimen.

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

Legislation: the veteran's service ended on 01 March 1978, before the Military Rehabilitation and Compensation Act 2004 commenced, so although the clinical onset was on 14 September 2023, this is a Veterans' Entitlements Act 1986 (VEA) claim and the Statements of Principles apply. The Reasonable Hypothesis instrument applies to his operational service in Malaya and Singapore in 1941 to 1942 and as a prisoner of war of Japan from 1942 to 1945. The Balance of Probabilities instrument applies to his peacetime service from 1946 to 1978, including defence service from 07 December 1972.

Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.

Balance of Probabilities — Statement of Principles concerning Non-Melanoma Malignant Neoplasm of the Skin, No. 79 of 2024

Causative factors

Factor 9(1): having sunlight exposure to unprotected skin for a cumulative period of at least 4,500 latitude equivalent hours before clinical onset; — MET

- In peacetime service from 1946 to 1978 the veteran worked outdoors in vehicle workshops, field parks and on exercises in Townsville and the Northern Territory, recorded in his service history. An occupational hygienist's reconstruction on 04 December 2023 calculated about 9,600 latitude equivalent hours of sunlight to his unprotected face over that service, including 2,900 hours at tropical latitude in the Northern Territory from 1970 to 1978, more than twice the 4,500 required.

Factor 9(2): having at least 10 sunburns at the affected site at least 5 years before clinical onset; — MET

- His service medical records document at least 12 painful sunburns of the face, each lasting more than 48 hours, on field exercises and in workshop yards in Townsville and the Northern Territory between 1952 and 1976, all at least 5 years before onset on 14 September 2023.

Factor 9(3): having ultraviolet radiation exposure from an ultraviolet-emitting tanning device (excluding sunlamps) on at least 20 occasions at the affected site before clinical onset, at least 5 years before clinical onset; — MET

- On his dermatologist's advice for psoriasis the veteran attended a commercial solarium for 32 whole-body sessions, including the face, between March and November 1987, about 36 years before onset.

Factor 9(4)(a): having PUVA therapy, where: the first PUVA treatment commenced at least 5 years before clinical onset; and — MET

- PUVA therapy for psoriasis began on 12 February 1979, more than 44 years before onset.

Factor 9(4)(b): having PUVA therapy, where: at least 100 PUVA treatments were administered before clinical onset; — MET

- The veteran received about 160 PUVA treatments, including treatment of facial plaques, between 1979 and 1991, all before onset.

Factor 9(5): having received a cumulative equivalent dose of at least 0.5 sievert of ionising radiation to the affected site at least 10 years before clinical onset of basal cell carcinoma; — MET

- In 1946 the veteran received a course of superficial X-ray therapy to the face for severe acne, and on 21 March 2005 to 18 April 2005 he received 55 Gy in 20 fractions of radiotherapy to a basal cell carcinoma of the left cheek. The dermatology and radiation oncology records estimate a cumulative equivalent dose to the facial skin of several sieverts, received more than 18 years before onset.

Factor 9(6): undergoing a course of radiotherapy for cancer at the affected site, at least 10 years before clinical onset; — MET

- From 21 March 2005 to 18 April 2005 the veteran received 55 Gy in 20 fractions of radiotherapy for a basal cell carcinoma of the left cheek, the affected site, 18 years before onset on 14 September 2023.

Factor 9(7): being infected by the same human papillomavirus type 16, 18 or 33 for at least 2 consecutive years before clinical onset of squamous cell carcinoma of the penis, vulva or perianal skin; — MET

- The veteran also developed a squamous cell carcinoma of the perianal skin, diagnosed on 20 October 2023. Anal swabs showed persistent infection with human papillomavirus type 16 on 11 April 2019, 17 May 2021 and 03 April 2023, more than 2 consecutive years before that onset, in the setting of HIV infection and transplant immunosuppression.

Factor 9(8): being infected with human immunodeficiency virus before clinical onset; — MET

- HIV infection was diagnosed on 09 November 1984 after a transfusion of unscreened blood during surgery in March 1984, and the veteran has taken antiretroviral therapy since 1996. The infection preceded the onset by 39 years.

Factor 9(9): undergoing solid organ (excluding corneal transplant) or bone marrow transplantation at least 10 years before clinical onset; — MET

- The veteran received a deceased-donor kidney transplant on 12 June 1995 for end-stage kidney failure, 28 years before onset, and has taken transplant immunosuppression since.

Factor 9(10)(a): taking one of the following medications within the 5 years before clinical onset: acalabrutinib; — MET

- Acalabrutinib 100 mg twice daily was taken for chronic lymphocytic leukaemia from 06 March 2020 to 18 August 2021. This falls within the 5 years before onset, from 14 September 2018 to 14 September 2023.

Factor 9(10)(b): taking one of the following medications within the 5 years before clinical onset: azathioprine; — MET

- Azathioprine 100 mg daily was taken for autoimmune hepatitis from 22 May 2017 continuously to the onset. This falls within the 5 years before onset, from 14 September 2018 to 14 September 2023.

Factor 9(10)(c): taking one of the following medications within the 5 years before clinical onset: ciclosporin; — MET

- Ciclosporin was taken for kidney transplant immunosuppression from 12 June 1995 until 04 February 2019. This falls within the 5 years before onset, from 14 September 2018 to 14 September 2023.

Factor 9(10)(d): taking one of the following medications within the 5 years before clinical onset: elotuzumab; — MET

- Elotuzumab infusions, with lenalidomide and dexamethasone, were given for IgG multiple myeloma from 11 January 2021 to 30 November 2022. This falls within the 5 years before onset, from 14 September 2018 to 14 September 2023.

Factor 9(10)(e): taking one of the following medications within the 5 years before clinical onset: fingolimod — MET

- Fingolimod 0.5 mg daily was taken for relapsing multiple sclerosis from 15 August 2016 to 30 June 2020. This falls within the 5 years before onset, from 14 September 2018 to 14 September 2023.

Factor 9(10)(f): taking one of the following medications within the 5 years before clinical onset: hydroxycarbimide (hydroxyurea); — MET

- Hydroxycarbimide (hydroxyurea) 1 g daily was taken for essential thrombocythaemia from 10 April 2014 to 26 July 2019. This falls within the 5 years before onset, from 14 September 2018 to 14 September 2023.

Factor 9(10)(g): taking one of the following medications within the 5 years before clinical onset: ibrutinib; — MET

- Ibrutinib 420 mg daily was taken for chronic lymphocytic leukaemia from 18 October 2016 to 05 March 2020. This falls within the 5 years before onset, from 14 September 2018 to 14 September 2023.

Factor 9(10)(h): taking one of the following medications within the 5 years before clinical onset: methotrexate; — MET

- Methotrexate 15 mg weekly was taken for psoriasis and rheumatoid arthritis from 1998 to 30 September 2019. This falls within the 5 years before onset, from 14 September 2018 to 14 September 2023.

Factor 9(10)(i): taking one of the following medications within the 5 years before clinical onset: mycophenolate; — MET

- Mycophenolate mofetil 1 g twice daily was taken for transplant immunosuppression from 04 February 2019 continuously to the onset. This falls within the 5 years before onset, from 14 September 2018 to 14 September 2023.

Factor 9(10)(j): taking one of the following medications within the 5 years before clinical onset: ruxolitinib; — MET

- Ruxolitinib 15 mg twice daily was taken for post-thrombocythaemia myelofibrosis from 29 July 2019 continuously to the onset. This falls within the 5 years before onset, from 14 September 2018 to 14 September 2023.

Factor 9(10)(k): taking one of the following medications within the 5 years before clinical onset: siponimod — MET

- Siponimod 2 mg daily was taken for secondary progressive multiple sclerosis from 01 July 2020 continuously to the onset. This falls within the 5 years before onset, from 14 September 2018 to 14 September 2023.

Factor 9(10)(l): taking one of the following medications within the 5 years before clinical onset: sirolimus; — MET

- Sirolimus was taken for transplant immunosuppression from 04 February 2019 to 12 April 2021. This falls within the 5 years before onset, from 14 September 2018 to 14 September 2023.

Factor 9(10)(m): taking one of the following medications within the 5 years before clinical onset: tacrolimus; — MET

- Tacrolimus was taken for transplant immunosuppression from 13 April 2021 continuously to the onset. This falls within the 5 years before onset, from 14 September 2018 to 14 September 2023.

Factor 9(10)(n): taking one of the following medications within the 5 years before clinical onset: tofacitinib; — MET

- Tofacitinib 5 mg twice daily was taken for rheumatoid arthritis and ulcerative colitis from 02 October 2018 to 14 June 2020. This falls within the 5 years before onset, from 14 September 2018 to 14 September 2023.

Factor 9(10)(o): taking one of the following medications within the 5 years before clinical onset: upadacitinib; — MET

- Upadacitinib 15 mg daily was taken for rheumatoid arthritis from 15 June 2020 to 20 December 2022. This falls within the 5 years before onset, from 14 September 2018 to 14 September 2023.

Factor 9(10)(p): taking one of the following medications within the 5 years before clinical onset: ustekinumab; — MET

- Ustekinumab injections were given every 12 weeks for psoriasis from 10 January 2018 continuously to the onset. This falls within the 5 years before onset, from 14 September 2018 to 14 September 2023.

Factor 9(10)(q): taking one of the following medications within the 5 years before clinical onset: zanubrutinib; — MET

- Zanubrutinib 160 mg twice daily was taken for chronic lymphocytic leukaemia from 19 August 2021 continuously to the onset. This falls within the 5 years before onset, from 14 September 2018 to 14 September 2023.

Factor 9(10)(r): taking one of the following medications within the 5 years before clinical onset: tumour necrosis factor-α inhibitors adalimumab, certolizumab, etanercept, golimumab, or infliximab; or — MET

- Infliximab infusions were given for ulcerative colitis from 03 March 2016 to 28 December 2018, and adalimumab for psoriasis from 09 January 2019 to 30 June 2019. This falls within the 5 years before onset, from 14 September 2018 to 14 September 2023.

Factor 9(10)(s): taking one of the following medications within the 5 years before clinical onset: BRAF kinase inhibitors dabrafenib, encorafenib, vemurafenib. — MET

- Dabrafenib 150 mg twice daily, with trametinib, was taken for BRAF V600E metastatic melanoma from 05 November 2019 to 24 May 2021. This falls within the 5 years before onset, from 14 September 2018 to 14 September 2023.

Factor 9(11): taking ripretinib within the 5 years before clinical onset of squamous cell carcinoma of the skin; — MET

- Ripretinib 150 mg daily was taken for a metastatic gastrointestinal stromal tumour from 06 September 2021 to the onset of the squamous cell carcinoma of the left cheek on 14 September 2023.

Factor 9(12): taking ozanimod or ponesimod within the 5 years before clinical onset of basal cell carcinoma of the skin; — MET

- Ozanimod 0.92 mg daily was taken for ulcerative colitis from 10 August 2021, and the basal cell carcinoma of the nasal ala, part of the claimed facial neoplasms, was found on 02 October 2023 with an onset no later than 14 September 2023.

Factor 9(13): taking voriconazole continuously for at least 3 months, at least 1 year before clinical onset of squamous cell carcinoma of the skin — MET

- Voriconazole 200 mg twice daily was taken continuously from 11 March 2019 to 20 December 2019, more than 9 months, for invasive pulmonary aspergillosis, ending 3 years and 9 months before onset of the squamous cell carcinoma. Long-term voriconazole causes phototoxicity and squamous cell carcinoma of sun-exposed skin.

Factor 9(14): taking a cumulative dose of at least 25 g of hydrochlorothiazide, at least 1 year before clinical onset of squamous cell carcinoma of the skin; — MET

- Hydrochlorothiazide 25 mg daily was taken for hypertension from 1985 to 2015, a cumulative dose of about 270 grams, all of it more than 8 years before onset.

Factor 9(15): having autoimmune hepatitis at the time of clinical onset; — MET

- Autoimmune hepatitis was diagnosed on liver biopsy on 22 May 2017 and was present at onset, treated with azathioprine.

Factor 9(16): having inflammatory bowel disease at the time of clinical onset; — MET

- Ulcerative colitis was diagnosed on colonoscopy on 14 August 2014 and was active at onset, treated with ozanimod.

Factor 9(17): having chronic osteomyelitis with a sinus tract draining to the affected skin site at least 5 years before clinical onset of squamous cell carcinoma; — MET

- On 12 July 1943, on the Burma-Thailand Railway, a guard struck the veteran across the left jaw with a rifle butt, fracturing the mandible. Chronic osteomyelitis of the left mandible followed, with a sinus tract draining intermittently to the skin of the left cheek, documented in repatriation and service records from 1946 and on CT in 2012. The squamous cell carcinoma arose at the sinus opening, 80 years after the sinus formed.

Factor 9(18): having non-Hodgkin lymphoma before clinical onset; — MET

- A post-transplant lymphoproliferative disorder, diffuse large B-cell non-Hodgkin lymphoma, was diagnosed on 30 June 2008 and treated with rituximab, 15 years before onset.

Factor 9(19): having mature B-cell lymphoid leukaemia and small lymphocytic lymphoma before clinical onset; — MET

- Chronic lymphocytic leukaemia, a mature B-cell lymphoid leukaemia, with small lymphocytic lymphoma nodal disease, was diagnosed on flow cytometry and lymph node biopsy on 18 October 2016, before onset.

Factor 9(20): having phimosis for a continuous period of at least 2 years before clinical onset of squamous cell carcinoma of the glans penis or prepuce of the penis; — MET

- The veteran also developed a squamous cell carcinoma of the prepuce, diagnosed on 26 October 2023. A urologist had documented phimosis, with an inability to retract the foreskin, continuously from 14 May 2010, more than 13 years before that onset.

Factor 9(21): having a scar at the affected site at least 10 years before clinical onset; — MET

- The left cheek carries a scar from the mandibular injury of 1943 and its surgical drainage in 1946, and a surgical and radiotherapy scar from the 2005 basal cell carcinoma, all more than 18 years before onset. The squamous cell carcinoma arose within the scar.

Factor 9(22): having ulceration at the affected site for a cumulative period of at least 1 year, at least 10 years before clinical onset; — MET

- The veteran had ulceration of the left cheek from a tropical ulcer for about 14 months in 1943 and 1944, and recurrent ulceration at the sinus opening for a further 10 months in 1951 and 1952 during peacetime service, a cumulative period of about 2 years, all more than 70 years before onset.

Factor 9(23): having lichen sclerosus at the affected site, at least 10 years before clinical onset of squamous cell carcinoma of the penis, vulva or perianal skin; — MET

- Lichen sclerosus of the penis and perianal skin was diagnosed on biopsy on 22 September 2008, 15 years before the squamous cell carcinomas of the prepuce and perianal skin diagnosed in October 2023.

Factor 9(24): having hidradenitis suppurativa at the affected site, at least 10 years before clinical onset of squamous cell carcinoma of the skin; — MET

Factor 9(25)(a): being exposed to arsenic as detailed below, at least 10 years before clinical onset; consuming arsenic containing compounds (for example, Fowler's solution) for a cumulative period of at least 3 months; or — MET

- A dermatologist prescribed Fowler's solution (potassium arsenite) for psoriasis from March 1950 to April 1952, a cumulative period of about 25 months, more than 70 years before onset.

Factor 9(25)(b): being exposed to arsenic as detailed below, at least 10 years before clinical onset; consuming drinking water with an average arsenic concentration of at least 50 micrograms per litre for a cumulative period of at least 5 years; or — MET

- During peacetime service from 1970 to 1978 at a remote camp in the Northern Territory the veteran drank bore water with an arsenic concentration of 110 micrograms per litre, a cumulative period of 8 years, more than 40 years before onset.

Factor 9(25)(c): being exposed to arsenic as detailed below, at least 10 years before clinical onset; inhaling, ingesting or having cutaneous contact with a pesticide containing arsenic, or arsenic in copper smelting operations, for a cumulative period of at least 1,000 hours; or — MET

- As part of camp maintenance in the Northern Territory from 1970 to 1978 the veteran applied arsenic trioxide termite dust to buildings and timber, about 4 hours a week, a cumulative total of about 1,600 hours, more than 40 years before onset.

Factor 9(25)(d): being exposed to arsenic as detailed below, at least 10 years before clinical onset; having clinical evidence of chronic arsenic toxicity. — MET

- A dermatologist documented chronic arsenic toxicity on 15 May 1992, with multiple arsenical keratoses of the palms and soles and raindrop hyperpigmentation of the trunk.

Factor 9(26): having cutaneous contact at the affected site with coal-tar distillate, for a cumulative period of at least 3,000 hours, at least 10 years before clinical onset; — MET

- From 1946 to 1985 the veteran applied coal-tar distillate ointment to the face every night, a cumulative total of more than 100,000 hours of contact at the affected site, all more than 38 years before onset.

Worsening factors

Factor 9(27): inability to obtain appropriate clinical management for non-melanoma malignant neoplasm of the skin before clinical worsening. — MET

- The squamous cell carcinoma of the left cheek was diagnosed on biopsy on 02 October 2023 and wide excision was recommended urgently. The veteran, then 100 years old and living in residential aged care, waited 5 months for a public plastic surgery appointment, and two appointments were cancelled because DVA transport could not be arranged. By 18 March 2024 the tumour had grown from 14 mm to 32 mm with perineural invasion on MRI. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management before the clinical worsening.

Reasonable Hypothesis — Statement of Principles concerning Non-Melanoma Malignant Neoplasm of the Skin, No. 78 of 2024

Causative factors

Factor 9(1): being a prisoner of war of Japan before clinical onset; — MET

- The veteran was captured at the fall of Singapore on 15 February 1942 and was a prisoner of war of Japan until 15 September 1945, including 18 months on the Burma-Thailand Railway in 1943 and 1944. He worked bareheaded and shirtless in tropical sun for 10 to 12 hours a day, with severe malnutrition, tropical ulcers and beatings, all decades before the onset on 14 September 2023.

Factor 9(2): having sunlight exposure to unprotected skin for a cumulative period of at least 2,250 latitude equivalent hours before clinical onset; — MET

- As a prisoner of war of Japan from 1942 to 1945, at tropical latitudes in Singapore and Thailand, the veteran worked outdoors without a hat, shirt or sunscreen for about 10 hours a day. That alone is more than 12,000 latitude equivalent hours of sunlight to unprotected skin, far above the 2,250 required, all before the onset on 14 September 2023 and all on operational service.

Factor 9(3): having at least 5 sunburns at the affected site at least 2 years before clinical onset; — MET

- The veteran had repeated blistering sunburn of the face as a prisoner of war on the Burma-Thailand Railway in 1943 and 1944, recorded in his post-war repatriation medical history as more than 20 episodes, and at least 6 further painful sunburns of the face lasting more than 48 hours on exercises in northern Australia in the 1950s and 1960s, all more than 2 years before onset.

Factor 9(4): having ultraviolet radiation exposure from an ultraviolet-emitting tanning device (excluding sunlamps) on at least 10 occasions at the affected site before clinical onset, at least 2 years before clinical onset; — MET

- On his dermatologist's advice for psoriasis the veteran attended a commercial solarium for 32 whole-body sessions, including the face, between March and November 1987, about 36 years before onset.

Factor 9(5): having received a burn from an electric welding device on at least 10 occasions at the affected site, at least 10 years before clinical onset; — MET

- As a vehicle mechanic from 1946 to 1978 the veteran did arc welding in unit workshops, and his health record documents at least 14 arc flash burns to the face, including the left cheek, between 1951 and 1974, all more than 10 years before onset. Arc welding was part of his duties as a mechanic, which began with vehicle repair in the field in Malaya in 1941.

Factor 9(6)(a): having PUVA therapy, where: the first PUVA treatment commenced at least 5 years before clinical onset; and — MET

- PUVA therapy for psoriasis began on 12 February 1979, more than 44 years before onset.

Factor 9(6)(b): having PUVA therapy, where: at least 50 PUVA treatments were administered before clinical onset; — MET

- The veteran received about 160 PUVA treatments, including treatment of facial plaques, between 1979 and 1991, all before onset.

Factor 9(7): having received a cumulative equivalent dose of at least 0.1 sievert of ionising radiation to the affected site at least 10 years before clinical onset; — MET

Factor 9(8): undergoing a course of radiotherapy for cancer at the affected site, at least 5 years before clinical onset; — MET

Factor 9(9): undergoing a course of radiotherapy for acne at the affected site, at least 5 years before clinical onset; — MET

- In 1946, after repatriation, the veteran received a course of superficial X-ray therapy to the face for severe acne vulgaris, a common treatment of the time, 77 years before onset.

Factor 9(10): being infected by the same human papillomavirus type 16, 18 or 33 for at least 2 consecutive years before clinical onset of squamous cell carcinoma of the penis, vulva or perianal skin; — MET

Factor 9(11): being infected with human immunodeficiency virus before clinical onset; — MET

Factor 9(12): undergoing solid organ (excluding corneal transplant) or bone marrow transplantation at least 5 years before clinical onset; — MET

- The veteran received a deceased-donor kidney transplant on 12 June 1995 for end-stage kidney failure, 28 years before onset, and has taken transplant immunosuppression since. The kidney failure followed chronic interstitial nephritis attributed to malnutrition, recurrent dysentery and malaria as a prisoner of war.

Factor 9(13)(a): taking one of the following medications within the 10 years before clinical onset: acalabrutinib; — MET

- Acalabrutinib 100 mg twice daily was taken for chronic lymphocytic leukaemia from 06 March 2020 to 18 August 2021. This falls within the 10 years before onset, from 14 September 2013 to 14 September 2023.

Factor 9(13)(b): taking one of the following medications within the 10 years before clinical onset: azathioprine; — MET

- Azathioprine 100 mg daily was taken for autoimmune hepatitis from 22 May 2017 continuously to the onset. This falls within the 10 years before onset, from 14 September 2013 to 14 September 2023.

Factor 9(13)(c): taking one of the following medications within the 10 years before clinical onset: ciclosporin; — MET

- Ciclosporin was taken for kidney transplant immunosuppression from 12 June 1995 until 04 February 2019. This falls within the 10 years before onset, from 14 September 2013 to 14 September 2023.

Factor 9(13)(d): taking one of the following medications within the 10 years before clinical onset: elotuzumab; — MET

- Elotuzumab infusions, with lenalidomide and dexamethasone, were given for IgG multiple myeloma from 11 January 2021 to 30 November 2022. This falls within the 10 years before onset, from 14 September 2013 to 14 September 2023.

Factor 9(13)(e): taking one of the following medications within the 10 years before clinical onset: fingolimod — MET

- Fingolimod 0.5 mg daily was taken for relapsing multiple sclerosis from 15 August 2016 to 30 June 2020. This falls within the 10 years before onset, from 14 September 2013 to 14 September 2023.

Factor 9(13)(f): taking one of the following medications within the 10 years before clinical onset: hydroxycarbimide (hydroxyurea); — MET

- Hydroxycarbimide (hydroxyurea) 1 g daily was taken for essential thrombocythaemia from 10 April 2014 to 26 July 2019. This falls within the 10 years before onset, from 14 September 2013 to 14 September 2023.

Factor 9(13)(g): taking one of the following medications within the 10 years before clinical onset: ibrutinib; — MET

- Ibrutinib 420 mg daily was taken for chronic lymphocytic leukaemia from 18 October 2016 to 05 March 2020. This falls within the 10 years before onset, from 14 September 2013 to 14 September 2023.

Factor 9(13)(h): taking one of the following medications within the 10 years before clinical onset: methotrexate; — MET

- Methotrexate 15 mg weekly was taken for psoriasis and rheumatoid arthritis from 1998 to 30 September 2019. This falls within the 10 years before onset, from 14 September 2013 to 14 September 2023.

Factor 9(13)(i): taking one of the following medications within the 10 years before clinical onset: mycophenolate; — MET

- Mycophenolate mofetil 1 g twice daily was taken for transplant immunosuppression from 04 February 2019 continuously to the onset. This falls within the 10 years before onset, from 14 September 2013 to 14 September 2023.

Factor 9(13)(j): taking one of the following medications within the 10 years before clinical onset: ruxolitinib; — MET

- Ruxolitinib 15 mg twice daily was taken for post-thrombocythaemia myelofibrosis from 29 July 2019 continuously to the onset. This falls within the 10 years before onset, from 14 September 2013 to 14 September 2023.

Factor 9(13)(k): taking one of the following medications within the 10 years before clinical onset: siponimod — MET

- Siponimod 2 mg daily was taken for secondary progressive multiple sclerosis from 01 July 2020 continuously to the onset. This falls within the 10 years before onset, from 14 September 2013 to 14 September 2023.

Factor 9(13)(l): taking one of the following medications within the 10 years before clinical onset: sirolimus; — MET

- Sirolimus was taken for transplant immunosuppression from 04 February 2019 to 12 April 2021. This falls within the 10 years before onset, from 14 September 2013 to 14 September 2023.

Factor 9(13)(m): taking one of the following medications within the 10 years before clinical onset: tacrolimus; — MET

- Tacrolimus was taken for transplant immunosuppression from 13 April 2021 continuously to the onset. This falls within the 10 years before onset, from 14 September 2013 to 14 September 2023.

Factor 9(13)(n): taking one of the following medications within the 10 years before clinical onset: tofacitinib; — MET

- Tofacitinib 5 mg twice daily was taken for rheumatoid arthritis and ulcerative colitis from 02 October 2018 to 14 June 2020. This falls within the 10 years before onset, from 14 September 2013 to 14 September 2023.

Factor 9(13)(o): taking one of the following medications within the 10 years before clinical onset: upadacitinib; — MET

- Upadacitinib 15 mg daily was taken for rheumatoid arthritis from 15 June 2020 to 20 December 2022. This falls within the 10 years before onset, from 14 September 2013 to 14 September 2023.

Factor 9(13)(p): taking one of the following medications within the 10 years before clinical onset: ustekinumab; — MET

- Ustekinumab injections were given every 12 weeks for psoriasis from 10 January 2018 continuously to the onset. This falls within the 10 years before onset, from 14 September 2013 to 14 September 2023.

Factor 9(13)(q): taking one of the following medications within the 10 years before clinical onset: zanubrutinib; — MET

- Zanubrutinib 160 mg twice daily was taken for chronic lymphocytic leukaemia from 19 August 2021 continuously to the onset. This falls within the 10 years before onset, from 14 September 2013 to 14 September 2023.

Factor 9(13)(r): taking one of the following medications within the 10 years before clinical onset: tumour necrosis factor-α inhibitors adalimumab, certolizumab, etanercept, golimumab, or infliximab; or — MET

- Infliximab infusions were given for ulcerative colitis from 03 March 2016 to 28 December 2018, and adalimumab for psoriasis from 09 January 2019 to 30 June 2019. This falls within the 10 years before onset, from 14 September 2013 to 14 September 2023.

Factor 9(13)(s): taking one of the following medications within the 10 years before clinical onset: BRAF kinase inhibitors dabrafenib, encorafenib, vemurafenib. — MET

- Dabrafenib 150 mg twice daily, with trametinib, was taken for BRAF V600E metastatic melanoma from 05 November 2019 to 24 May 2021. This falls within the 10 years before onset, from 14 September 2013 to 14 September 2023.

Factor 9(14): taking ripretinib within the 10 years before clinical onset of squamous cell carcinoma of the skin; — MET

- Ripretinib 150 mg daily was taken for a metastatic gastrointestinal stromal tumour from 06 September 2021 to the onset of the squamous cell carcinoma of the left cheek on 14 September 2023.

Factor 9(15): taking ozanimod or ponesimod within the 10 years before clinical onset of basal cell carcinoma of the skin; — MET

Factor 9(16): taking voriconazole continuously for at least 3 months, at least 6 months before clinical onset of squamous cell carcinoma of the skin — MET

Factor 9(17): taking a cumulative dose of at least 25 g of hydrochlorothiazide, at least 6 months before clinical onset of squamous cell carcinoma of the skin; — MET

- Hydrochlorothiazide 25 mg daily was taken for hypertension from 1985 to 2015, a cumulative dose of about 270 grams, all of it more than 8 years before onset.

Factor 9(18): taking a cumulative dose of at least 50 g of hydrochlorothiazide, at least 6 months before clinical onset of basal cell carcinoma of the skin; — MET

- Hydrochlorothiazide 25 mg daily was taken for hypertension from 1985 to 2015, a cumulative dose of about 270 grams, all of it more than 8 years before onset.

Factor 9(19): having autoimmune hepatitis at the time of clinical onset; — MET

- Autoimmune hepatitis was diagnosed on liver biopsy on 22 May 2017 and was present at onset, treated with azathioprine.

Factor 9(20): having inflammatory bowel disease at the time of clinical onset; — MET

- Ulcerative colitis was diagnosed on colonoscopy on 14 August 2014 and was active at onset, treated with ozanimod.

Factor 9(21): having psoriasis at the time of clinical onset; — MET

- Chronic plaque psoriasis was first diagnosed in 1946 and was active at onset, including on the face, treated with ustekinumab.

Factor 9(22): having rheumatoid arthritis at the time of clinical onset; — MET

- Seropositive rheumatoid arthritis was diagnosed on 02 June 1998 and was present at onset.

Factor 9(23): having sarcoidosis at the time of clinical onset; — MET

- Sarcoidosis was diagnosed on mediastinal lymph node biopsy on 19 March 2012 and was present at onset, with active pulmonary disease on CT in 2023.

Factor 9(24): having chronic osteomyelitis with a sinus tract draining to the affected skin site at least 2 years before clinical onset; — MET

Factor 9(25): having non-Hodgkin lymphoma before clinical onset; — MET

- A post-transplant lymphoproliferative disorder, diffuse large B-cell non-Hodgkin lymphoma, was diagnosed on 30 June 2008 and treated with rituximab, 15 years before onset.

Factor 9(26): having mature B-cell lymphoid leukaemia and small lymphocytic lymphoma before clinical onset; — MET

Factor 9(27): having phimosis for a continuous period of at least 2 years before clinical onset of squamous cell carcinoma of the glans penis or prepuce of the penis; — MET

Factor 9(28): having a scar at the affected site at least 5 years before clinical onset; — MET

Factor 9(29): having ulceration at the affected site for a cumulative period of at least 6 months, at least 5 years before clinical onset; — MET

- As a prisoner of war the veteran had a tropical ulcer of the left cheek from August 1943 to October 1944, about 14 months, recorded in his repatriation medical history, about 79 years before onset.

Factor 9(30): having lichen sclerosus at the affected site, at least 5 years before clinical onset of squamous cell carcinoma of the penis, vulva or perianal skin; — MET

Factor 9(31): having hidradenitis suppurativa at the affected site, at least 5 years before clinical onset of squamous cell carcinoma of the skin; — MET

- Hidradenitis suppurativa of both axillae was documented from 1958, and a squamous cell carcinoma arising in the left axillary hidradenitis was diagnosed on 30 October 2023, more than 60 years later. The hidradenitis began in the tropical conditions of captivity and was first recorded on repatriation.

Factor 9(32): having chronic lymphoedema at the affected site, at least 5 years before clinical onset of squamous cell carcinoma of the skin; — MET

- Chronic lymphoedema of the left cheek and lower eyelid followed the 2005 radiotherapy and has been documented since 2006, more than 17 years before the squamous cell carcinoma arose in that area.

Factor 9(33): smoking at least 15 cigarettes per day for at least 5 years, or the equivalent thereof in other tobacco products, at least 5 years before clinical onset of squamous cell carcinoma of the skin, and where smoking has ceased, clinical onset occurred within 20 years of cessation; — MET

- The veteran smoked about 25 cigarettes a day from 1941, including throughout his operational service and captivity when tobacco was traded as currency, until he stopped on 30 June 2005. That is 64 years of smoking, ending 18 years before onset, within 20 years of cessation.

Factor 9(34)(a): being exposed to arsenic as detailed below, at least 10 years before clinical onset; consuming arsenic containing compounds (for example, Fowler's solution) for a cumulative period of at least 3 months; or — MET

- A dermatologist prescribed Fowler's solution (potassium arsenite) for psoriasis from March 1950 to April 1952, a cumulative period of about 25 months, more than 70 years before onset.

Factor 9(34)(b): being exposed to arsenic as detailed below, at least 10 years before clinical onset; consuming drinking water with an average arsenic concentration of at least 50 micrograms per litre for a cumulative period of at least 2 years; or — MET

- From 1970 to 1978 the veteran was posted to a remote camp in the Northern Territory where drinking water came from a bore with an arsenic concentration of 110 micrograms per litre, tested in 1979, a cumulative period of 8 years, more than 40 years before onset.

Factor 9(34)(c): being exposed to arsenic as detailed below, at least 10 years before clinical onset; inhaling, ingesting or having cutaneous contact with a pesticide containing arsenic, or arsenic in copper smelting operations, for a cumulative period of at least 1,000 hours; or — MET

Factor 9(34)(d): being exposed to arsenic as detailed below, at least 10 years before clinical onset; having clinical evidence of chronic arsenic toxicity. — MET

- A dermatologist documented chronic arsenic toxicity on 15 May 1992, with multiple arsenical keratoses of the palms and soles and raindrop hyperpigmentation of the trunk.

Factor 9(35): having cutaneous contact at the affected site with coal-tar distillate, for a cumulative period of at least 1,500 hours, at least 5 years before clinical onset; — MET

- From 1946 to 1985 the veteran applied coal-tar distillate ointment to facial psoriasis plaques, including the left cheek, every night, about 8 hours of contact a night, a cumulative total of more than 100,000 hours, all at least 38 years before onset.

Factor 9(36)(a): having cutaneous contact at the affected site with one of the following polycyclic aromatic hydrocarbons, for a cumulative period of at least 1,500 hours, at least 5 years before clinical onset of non-melanoma malignant neoplasm of the scrotal skin; creosote; — MET

- The veteran also developed a squamous cell carcinoma of the scrotal skin, diagnosed on 30 October 2023. From 1947 to 1960 he treated timber with creosote in unit works, with daily soaking of his work trousers at the groin, about 2,000 hours of scrotal skin contact, more than 60 years before that onset.

Factor 9(36)(b): having cutaneous contact at the affected site with one of the following polycyclic aromatic hydrocarbons, for a cumulative period of at least 1,500 hours, at least 5 years before clinical onset of non-melanoma malignant neoplasm of the scrotal skin; shale oil; — MET

- In 1946 and 1947 the veteran was attached to fuel trials using shale oil at a shale oil works in New South Wales, with oil-soaked clothing in contact with the scrotal skin for about 1,600 hours, more than 75 years before the scrotal squamous cell carcinoma.

Factor 9(36)(c): having cutaneous contact at the affected site with one of the following polycyclic aromatic hydrocarbons, for a cumulative period of at least 1,500 hours, at least 5 years before clinical onset of non-melanoma malignant neoplasm of the scrotal skin; soot; — MET

- From 1955 to 1965 he cleaned unit boilers and incinerators, with soot penetrating his overalls to the scrotal skin, about 1,800 hours, more than 55 years before the scrotal carcinoma.

Factor 9(36)(d): having cutaneous contact at the affected site with one of the following polycyclic aromatic hydrocarbons, for a cumulative period of at least 1,500 hours, at least 5 years before clinical onset of non-melanoma malignant neoplasm of the scrotal skin; mineral oil. — MET

- As a vehicle mechanic from 1946 to 1978 he wore overalls soaked in engine and cutting oils, with mineral oil contact with the scrotal skin of more than 10,000 hours, more than 45 years before the scrotal carcinoma.

Worsening factors

Factor 9(37): inability to obtain appropriate clinical management for non-melanoma malignant neoplasm of the skin before clinical worsening. — MET

The % contribution of the causes is 100% and significant.

Sequelae

The facial non-melanoma skin cancers are a sequela of the veteran's accepted conditions arising from his captivity: the left mandibular fracture with chronic osteomyelitis and its cheek sinus, the tropical ulcer and scarring of the left cheek, and his solar skin damage. They are also a sequela of the long-term immunosuppression required after his kidney transplant.

Unintended Consequence

Met. The facial carcinomas are in part an unintended consequence of treatment provided or funded by the Commonwealth: superficial X-ray therapy for acne, Fowler's solution, coal-tar and PUVA therapy for psoriasis, radiotherapy in 2005, hydrochlorothiazide, voriconazole and transplant immunosuppression (the equivalent provisions of the VEA).

Inability to Attain Appropriate Medical Management

MET. After biopsy confirmed an invasive squamous cell carcinoma of the left cheek on 02 October 2023 and urgent excision was recommended, the veteran, aged 100 and in residential aged care, waited 5 months for a surgical appointment, and two appointments were cancelled because transport could not be arranged. The carcinoma grew from 14 mm to 32 mm with perineural spread. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the failure to provide timely access to prescribed surgery amounts to an inability to obtain appropriate clinical management.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

14 Mar 1946, Repatriation medical examination, Medical Officer
15 May 1992, Dermatology consultation, Dermatologist
12 Jun 1995, Transplant operation report, Transplant surgeon
21 Mar 2005, Radiation oncology treatment summary, Radiation oncologist
14 Sep 2012, CT facial bones report, Radiologist
18 Oct 2016, Haematology consultation, Haematologist
10 Mar 2023, Skin examination record, General practitioner
02 Oct 2023, Histopathology reports, Pathologist
04 Dec 2023, Occupational exposure assessment, Occupational hygienist
18 Mar 2024, MRI report and plastic surgery consultation, Radiologist and plastic surgeon
Statement of Principles concerning Non-Melanoma Malignant Neoplasm of the Skin (Balance of Probabilities) No. 79 of 2024, Repatriation Medical Authority
Statement of Principles concerning Non-Melanoma Malignant Neoplasm of the Skin (Reasonable Hypothesis) No. 78 of 2024, Repatriation Medical Authority

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Face - Non-Melanoma Malignant Neoplasm of the Skin — DVA claim example

Diagnostic Assessment — Face - Non-Melanoma Malignant Neoplasm of the Skin

Diagnostic Assessment

Face - Non-Melanoma Malignant Neoplasm of the Skin

ADF History

Occupational History

History

Timeline

Symptoms

Imaging

Onset Date

Balance of Probabilities — Statement of Principles concerning Non-Melanoma Malignant Neoplasm of the Skin, No. 79 of 2024

Reasonable Hypothesis — Statement of Principles concerning Non-Melanoma Malignant Neoplasm of the Skin, No. 78 of 2024

Sequelae

Unintended Consequence

Inability to Attain Appropriate Medical Management

References