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 plastic 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, 2012, 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 would a biopsy likely have been positive for carcinoma
2. Can any conclusions be made based upon visual observation of wound
3. Assuming diagnosis and treatment began sooner, when, more likely than not, would the leg amputation have been avoided.
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Do you believe there might have been medical error?
In the earliest photo shown, from 3/14/11, the ulcer does not have the appearance of a venous stasis ulcer. These types of ulcers are usually shallow, fairly round or symmetrical with smooth edges. This ulcer is elongated, with in irregular and heaped up edge and an irregular, verrucous base. It looks like cancer. It should have been biopsied at that time, if not before. No photo is provided from 2009. Possibly it was smooth and shallow with none of the heaped up edge and irregular base seen in 2011. The question is why would this man have a venous stasis ulcer? Did he have venous stasis? Was there a history of deep venous thrombosis of vein injury from trauma? Was there chronic edema? None of the pictures seem to show edema. Venous stasis ulcers are typically treated with topical therapies and compression wraps (Una's boot), not skin grafts. If the skin won't heal of its own accord, there is no reason to suspect that a graft would take. After the first graft did not take, a search for more data was in order, i.e. a biopsy, particularly if the same process was not occurring on the other leg.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As early as 3/14/11, this ulcer looks like a cancer and should have been biopsied. However, there is the question of whether at that time, the cancer was so invasive and so much tissue would need to be removed, that cure of this could not be achieved without amputation. After the cancerous ulcer was removed, there would have been a large defect, probably requiring a flap or skin graft for it to heal. From the look of the surrounding tissues healing may not have been feasible, even if there was no edema. No vascular studies, either venous or arterial are provided. These would provide insight as to whether, with the cancer resected, the non-cancerous deep tissues could have healed or supported a graft.
What makes you a good expert for this case?
I have 30 years of experience in general medicine, hematology, and general oncology. My expertise is not focused in one small area of oncology or one protein or procedure. While have been in academic medicine, conducted clinical trials, taught, and written some articles and book chapters, this has not been the focus of my career. Patient care has been my focus, and I have always paid attention on the whole patient and what is most important to and for that patient, not just on my narrow interest.
How often do you encounter cases similar to this one in your practice?
Fortunately similar cases are rare where I work as the dermatologists are quick to suspect cancer and do a biopsy. Sometimes patients progress despite the best of care and sometimes they are slow to present themselves, so every few years have seen a similar case.
Do you believe there might have been medical error?
If not only was wound not responding, but rather getting worse, further investigation should have taken place: biopsy and culture. Just observing a worsening condition and continuing with same treatment is wrong.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Earlier diagnosis of aggressive cancer of skin could have been treated with extensive resection or radiation, and strong likelihood for better outcome-- sparing amputation.
What makes you a good expert for this case?
Medical oncologist for 25 years, several times a year sees chronic skin infections and several times over a career, have diagnosed aggressive skin cancer in patient with nonhealing ulcer.
How often do you encounter cases similar to this one in your practice?
Probably once every 3-4 years, in hospital, with either aggressive anal cancer under treatment, or chronically ill patient with decubitus ulcer, nonresponsive to typical therapy.
Do you believe there might have been medical error?
If this was confirmed squamous cell carcinoma of the skin of one or both legs requiring bilateral bologna amputation to get clearance of the wound, one cannot determine from the appearance of venous stasis ulcers which may have been complicated by arterial insufficiency that there was concomitant squamous cell carcinoma of the skin. Only the progression of the ulceration in the presence of autografting and slow healing may have prompted the biopsy and it seems that the patient was in Puerto Rico for a number of months before a biopsy was obtained. A biopsy may have been positive for a squamous cell carcinoma in May or June but that would’ve been dependent on sampling of the correct area. Appearance of the wound by itself is not sufficient to differentiate between benign causes for ulceration and malignant cause. Only the failure to heal overtime might lead to suspicion of cancer. And attempt at treatment with combine chemotherapy and radiation therapy using electron beam for such an extensive area may have been justifiable but I’m not sure that it would have prevented the leg amputations. Therefore, with more common causes of leg ulceration including arterial insufficiency and venous stasis changes it would also be important to know if this was a diabetic and a smoker that would have led to nonhealing and potentially earlier diagnosis since these conditions prolong wound healing time
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The cause of extensive squamous cell carcinoma of the skin is unknown but may be contributed to by smoking history as well as sun exposure so there is no causation from medical error
What makes you a good expert for this case?
37 years of practice in adult medical Oncology. 15 years on staff is clinical professor of medicine at University of California Irvine from the mid-1990s until 2009.
How often do you encounter cases similar to this one in your practice?
These are very rare cases and I may have seen three over the course of the last 20 years
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