61 y/o male with history of "venous stasis ulcer" dating back to 2009 with failed skin graft in 2010. Began treating with Podiatrist in 2/2011 who attempted another skin graft that failed. In June, 2011, pt came under the care of wound care and hyperbaric expert. After 30 "dives", no improvement after 3 months. Thereafter, pt came under the care of a plastiuc surgeon for continued wound care. Treatment consisted of weekly wound care with dermal allograft patch in April 2012 and skin graft in August, 2012. Wound did not improve and finally, in November, 2011, pt travelled to Puerto Rico for treatment. In December, 2012, Dr. Immediately suspected carcinoma. Biopsy confirmed invasive squamous cell carcinoma. Below knee amputation was performed in June, 2013. Questions:
1. When was a biopsy indicated in course of treatment
2. When would a biopsy likely have been positive for carcinoma
3. Can any conclusions be made based upon visual observation of wound
4. When could the leg have been salvaged had treatment been undertaken sooner
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Do you believe there might have been medical error?
This is a case of a squamous cell carcinoma arising in a chronic leg ulcer.. There is no way of telling exactly when the SCC started. Chronic leg ulcers in patients with stasis dermatitis are extremely difficult to treat. The chronic inflammation can lead to the development of SCC
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is difficult to diagnose a SCC in this setting, and doing a biopsy can make the underlying condition worse.
What makes you a good expert for this case?
Associate clinical Professor of Medicine/Dermatology UCLA School of Medicine
How often do you encounter cases similar to this one in your practice?
I rarely encounter these type of cases.
Do you believe there might have been medical error?
The patient was not responding to standard treatment, Though a venous ulcer is possible on the lower extremity it should not cause a graft to fail and 30 hyperbaric oxygen treatments to not respond.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient amputation is likely secondary to delay in diagnosis. If the patient had been diagnosed earlier he may have been able to just de bulk the tumor and avoid amputation.
What makes you a good expert for this case?
I would be an excellent expert for this case as I diagnose skin cancers daily as a board certified dermatologist . I am also in a urban area so I am used to skin cancers in different ethnicities.
How often do you encounter cases similar to this one in your practice?
Cases like this are in frequent due to the size but the misdiagnoses is common.
Do you believe there might have been medical error?
This is a Marjolin Ulcer form of SCC. It appears at sites of trauma and tissue build up and breakdown. If not detected early there is a high mortality. Any ulcer that is hypertrophic and /or fails to heal needs an immediate biopsy. A skin biopsy is simple and takes 15 minutes to perform. the photos are obvious for this diagnosis.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If detected early the cancer can be excised with minimal tissue loss. If diagnosed late the patient needs amputation and has a risk of metastasis and loss of life.
What makes you a good expert for this case?
I have diagnosed numerous SCCs over the past 40 years as a board certified dermatologist.
How often do you encounter cases similar to this one in your practice?
I have diagnosed numerous patients with SCC. Over a thousand a year
Do you believe there might have been medical error?
Earliest picture is 3/14/2011. Latest picture is 11/12/2012. This should've been biopsied after roughly 6 months due to its longstanding / recalcitrant / worsening nature. With the pictures provided, that would've been either the 6/6/2011 visit or the 11/21/2011 visit. Something should've sat with the provider(s) as "not right." Just ask the provider from December 2012 who immediately suspected carcinoma.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
For sure, delay in proper diagnosis led to a much more involved / significant treatment, including putting the patient at increased risk for metastasis.
What makes you a good expert for this case?
I've served as an expert witness on numerous dermatology-related cases, both for plaintiffs and defendants. I've done everything from reviewing cases for merit to depositions to testifying.
How often do you encounter cases similar to this one in your practice?
In practice, I encountered venous ulcers a couple of times per year. However, cutaneous SCC on the other hand, was seen and/or treated on a nearly daily basis.
Do you believe there might have been medical error?
1. When was a biopsy indicated in course of treatment - Initial evaluation of any ulcer. If not taken at initial evaluation, when wound is not improving (usually at 12 weeks) or if visibly worsening despite treatment. 2. When would a biopsy likely have been positive for carcinoma - Most likely was present when the ulcer was worsening despite treatment. Probably from the outset between 3/2011 and 6/2011. 3. Can any conclusions be made based upon visual observation of wound - Many ulcers look the same, so clinical judgment is necessary. However, the worsening between 3/11 and 6/11 despite appropriate treatment for a venous ulcer would be consistent with presence of a malignancy. 4. When could the leg have been salvaged had treatment been undertaken sooner - If diagnosed early, there should not have been an amputation.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The delay in diagnosis allowed a skin cancer to grow to large proportions, necessitating amputation. This is not acceptable.
What makes you a good expert for this case?
I treat thousands of skin cancers annually, perform wound care on my patients, and understand ulcer management.
How often do you encounter cases similar to this one in your practice?
I see delayed diagnosis by wound care professionals several times a year.
Do you believe there might have been medical error?
Standard of care in non-healing leg ulcers includes referral to a dermatologist after three months of unsuccessful treatment. In this case, while the ulcer has the usual appearance of a venous stasis ulcer, lack of response to treatment -- and enlargement of the ulcer while on treatment, as is evident from the photos -- should have resulted in referral to a dermatologist, who would likely have obtained a biopsy, which could have diagnosed the malignancy at an earlier stage.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The ulcer as depicted in the photo from 3/14/11, and even that of 6/6/11, was limited to the medial ankle and medial malleolus of the left lower extremity, or at least one side of the leg, and as such was likely still operable. Later photos, from 4/02/12 and culminating in the photo from 11/12/12, depict a broad and circumferential ulcer, extending to both sides of the leg, which is not amenable to local surgical extirpation.
What makes you a good expert for this case?
I am a Mohs surgeon who specializes in surgical dermatology and cutaneous oncology, with 10 years experience since fellowship training in both academic and community settings, on two continents.
How often do you encounter cases similar to this one in your practice?
I encounter cutaneous squamous cell carcinoma nearly every day, and inoperable squamous cell carcinomas less frequently, perhaps several times a year.
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