Diagnostic Assessment — Right Temple - Basal Cell Carcinoma
Example 1 of 1 · fictitious patient (Veteran C)
Diagnostic Assessment
Right Temple – Basal Cell Carcinoma
Balance of Probabilities SOP: No. 79 of 2024 - Non-Melanoma Malignant Neoplasm of the Skin Reasonable Hypothesis SOP: No. 78 of 2024 - Non-Melanoma Malignant Neoplasm of the Skin
ADF History
The veteran, Communications and Information Systems Controller (CISCON), enlisted 28 July 1986, discharged 22 Mar 2003 (transfer to Reserves).
Occupational History
As a Communications and Information Systems Controller in the RAAF, the veteran was exposed to significant occupational hazards including prolonged UV radiation exposure during deployments to tropical and subtropical regions. His role involved outdoor field operations, equipment setup and maintenance in austere environments, and tactical communications work in high UV exposure areas. Deployments to an overseas deployment (1997) and the an overseas area of operations (2008) involved extensive outdoor duties in regions with intense solar radiation.
History
The veteran the veteran a CISCON in the RAAF, developed basal cell carcinoma on his right temple following extensive UV exposure during warlike deployments to an overseas deployment and the an overseas area of operations between 1997 and 2008, where his occupational duties required prolonged outdoor activities in high UV environments.
Timeline
- 21 Feb 2016: The veteran underwent surgical excision of a right temple lesion, clinically suspected as basal cell carcinoma, presenting as a cream-colored scaly macule. The procedure was performed under local anesthesia with prophylactic antibiotics as part of multiple temple excisions. The lesion was asymptomatic beyond cosmetic concern but required removal due to its malignant potential. Surgical margins were marked for accurate pathological assessment, with post-operative care including antibiotic ointment and oral antibiotics.
- 31 Feb 2016: Pathology confirmed a nodular basal cell carcinoma on the right temple superior with clear margins following excision. The lesion measured 8x7 mm, extending into the mid/reticular dermis with no perineural invasion, indicating complete removal and reducing local recurrence risk. The patient reported no residual symptoms with the excision site healing appropriately under post-operative care protocols.
Symptoms
At the time of diagnosis, the veteran presented with a cream-colored scaly macule on the right temple that was asymptomatic beyond cosmetic concern. The lesion had been developing gradually over time as a result of cumulative UV damage from his service deployments. Currently, following successful surgical excision with clear margins, he has no residual symptoms related to the basal cell carcinoma, though ongoing skin surveillance is recommended due to his significant UV exposure history and risk of developing additional skin cancers.
Imaging
31 Feb 2016: Pathology confirmed nodular basal cell carcinoma extending into the mid/reticular dermis, with clear margins, measuring 8x7 mm, with no perineural invasion
1. What is the formal diagnosis of the condition claimed above?
Right Temple Basal Cell Carcinoma, DVA SOP codes: Balance of Probabilities No. 79 of 2024 and Reasonable Hypothesis No. 78 of 2024, ICD-10 code C44.31.
Basal cell carcinoma is the most common form of skin cancer, arising from the basal cells in the epidermis. It is a malignant neoplasm that typically develops as a result of cumulative ultraviolet radiation exposure, particularly in fair-skinned individuals. The tumor characteristically presents as a pearly, translucent nodule or a scaly macule that may ulcerate. Basal cell carcinomas are locally invasive but rarely metastasize. They most commonly occur on sun-exposed areas of the body, particularly the head and neck region. The nodular subtype, as identified in this case, is the most common variant and typically presents as a dome-shaped lesion with a pearly appearance and visible telangiectasias.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
The veteran first experienced symptoms attributable to basal cell carcinoma when the cream-colored scaly macule on his right temple became noticeable, likely several months to years before surgical intervention in March 2019, though the exact onset date is not documented.
When did the veteran first present to a health / medical provider for this condition?
The veteran first presented for medical management of this condition on 21 February 2016 when he underwent surgical excision of the right temple lesion by a medical practitioner specializing in skin cancer removal.
When was the condition confirmed / formally diagnosed?
The condition was formally diagnosed on 31 February 2016 when pathology examination confirmed nodular basal cell carcinoma extending into the mid/reticular dermis with clear margins, performed by a specialist pathologist.
When did the veteran first present to you (or your practice) for this condition?
24 Jun 2015.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results.
The diagnosis was confirmed through histopathological examination following surgical excision. The key clinical sign was a cream-colored scaly macule on the right temple that warranted surgical removal due to suspicion of malignancy. The definitive diagnosis was established by pathology examination on 31 February 2016, which identified nodular basal cell carcinoma extending into the mid/reticular dermis, measuring 8x7 mm, with clear surgical margins and no perineural invasion. The pathologist's report confirmed complete excision of the malignant lesion.
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.
Balance of Probabilities Analysis:
Having sunlight exposure to unprotected skin for a cumulative period of at least 4,500 latitude equivalent hours before clinical onset - MET
- The veteran served as a CISCON with deployments to an overseas deployment (1997, tropical latitude 8.6°S) and an overseas area of operations (2008, subtropical latitude ~30°S), requiring extensive outdoor duties. His calculated weighted sunlight exposure totaled 19,440 hours during service, significantly exceeding the 4,500-hour threshold. His role involved field operations, equipment setup, and tactical communications in high UV environments without adequate protection.
Having at least 10 sunburns at the affected site at least 5 years before clinical onset - NOT MET
- While the veteran had significant UV exposure during deployments, there is no specific documentation of 10 or more sunburns to the temple region occurring at least 5 years before 2022.
Inability to obtain appropriate clinical management for non-melanoma malignant neoplasm of the skin before clinical worsening - NOT MET
- The condition was appropriately managed with timely surgical excision and pathological confirmation, with no evidence of delayed or inappropriate clinical management.
Reasonable Hypothesis Analysis:
Having sunlight exposure to unprotected skin for a cumulative period of at least 2,250 latitude equivalent hours before clinical onset - MET
- The veteran's calculated weighted sunlight exposure of 19,440 hours during service substantially exceeds the 2,250-hour threshold required under the reasonable hypothesis standard. His deployments to high UV environments in occupational capacity clearly satisfy this factor.
Having at least 5 sunburns at the affected site at least 2 years before clinical onset - NOT MET
- While UV exposure was extensive, there is insufficient documentation of specific sunburn episodes to the temple region meeting this criterion.
Inability to obtain appropriate clinical management for non-melanoma malignant neoplasm of the skin before clinical worsening - NOT MET
- Appropriate clinical management was provided with surgical excision and pathological confirmation.
Sequelae
This condition is not a sequelae of another known condition but rather a primary malignancy arising from cumulative UV exposure during military service.
Unintended Consequence
This condition is not an unintended consequence of medical management. No procedures were performed or medications given that resulted in this basal cell carcinoma.
Inability to Attain Appropriate Medical Management
The factor of inability to attain appropriate medical management is NOT MET. The condition was appropriately managed with timely surgical excision upon identification. There were no barriers to healthcare access, and the patient received appropriate specialist treatment with complete excision and pathological confirmation. The Full Federal Court in Brew v Repatriation Commission (19 July 1990) establishes that inability encompasses both objective and subjective barriers to treatment access, but in this case, appropriate clinical management was readily available and provided without delay.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
