In January 2018, female patient presented to her dermatology office for evaluations of skin lesions on chest and forehead. Seen by PA and shave biopsy on the chest came back positive for basal cell carcinoma. There was no evaluation or biopsy performed on the forehead skin lesion.
Patient continued to follow-up as recommended. In December 2018, for the first time the PA diagnosed the forehead lesion as Morphea and prescribed triamcinolone acetone due 0.1% and ordered patient to follow up in one month.
Patient followed up in January 2019 and the PA’s plan was to continued to use triamcinolone cream and follow up again in one month. Patient followed up in February 2019 and was told to continue to use the triamcinolone with no scheduled follow-up date. Patient returned for her scheduled annual skin check on October 2019. At this visit, the PA now prescribed desoximetasone 0.25% and instructed her to follow-up in one year.
In October 2020, patient returned and PA now diagnosed the forehead lesion as Lichen Sclerosis et Atrophicus vs. Morphea and a punch biopsy was performed. Biopsy came back positive for basal cell carcinoma, nodulo-infiltration type and she was referred for Mohs surgery.
Patient ultimately got a second opinion and was referred to a surgical oncologist for treatment options. Surgical oncologist performed a wide local excision on the patient’s forehead and patient subsequently underwent a reconstruction with a plastic and reconstructive surgeon. Plastic surgeon noted due to size of the area and how long lesion had been present there were concerns that excision would be somewhat significant to achieve good margins.
Interested in causation opinions, opinions on treatment options had there been no delay in the diagnosis of basal cell carcinoma, as well as prognosis opinions.
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Do you believe there might have been medical error?
In retrospect there was some delay in diagnosis of the basal cell carcinoma. Would need expert dermatology review best for this portion of the case, and I would like to see some photographs.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Would need to review case further in terms of the extent of surgery. Generally basal cell carcinomas can cause local issues; however, it is very rare for a basal cell carcinoma to spread to lymph nodes or other sites of disease (metastatic). If diagnosed earlier would still have needed local excision or MOHS surgery
What makes you a good expert for this case?
Professor of Surgical Oncology in one of the major cancer centers in the Country. NCCN board member.
How often do you encounter cases similar to this one in your practice?
I oversee our Melanoma and Skin cancer program. I see dozens of patients with BCC per year. That being said I personally do not treat head and neck skin cancers- as our Head and Neck surgeons cover this.
Do you believe there might have been medical error?
When lesions aren’t improving with prescribed medicines/ creams that’s an indication to biopsy. Return 1 year for a lesion that wasn’t improving with a years worth of cream treatment is too long. 4-6 weeks no improvement it’s ok to change creams but to constabulary do that for 2-3 years is too Long to not have suspicion something else was going on
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Larger lesion (would be nice to see pictures in 2018 vs late 2020 ) means larger surgery
What makes you a good expert for this case?
I see basal cell carcinomas every day. I’m an internationally recognized melanoma and skin cancer expert.
How often do you encounter cases similar to this one in your practice?
I see basal cell carcinoma’s on the skin every day in clinic in my practice
Do you believe there might have been medical error?
Based on the available information, it is highly likely that the lesion on the forehead the patient presented with in January 2018 was in fact basal cell carcinoma, as subsequently diagnosed in October 2020. Hence this would potentially represent an error in diagnosis resulting in a delay of diagnosis of over 2.5 years.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Based on the information provided, it is at least more likely than not that the extent of surgery was far more extensive and potentially deforming than would have been required 2+ years previously if a timely diagnosis had been made. It is not clear whether this resulted in a decreased likelihood of successful treatment of the cancer, nor whether specific complications (harms) can be identified as a result of the delay in diagnosis. Also, it is not clear whether the patient suffered any subjective harms due to the delay in diagnosis and the prolonged treatment with topical agents, but considering the lesion was apparently on very visible skin this may we have been the case.
What makes you a good expert for this case?
I am an expert surgical oncologist with extensive experience in the diagnosis and treatment of cutaneous malignancies, and as director of a large multidisciplinary clinic exclusively for skin cancer patients and staffed by dermatologists and dermatology physician assistants I am familiar with the standard of care governing their practice for cases of possible skin cancer.
How often do you encounter cases similar to this one in your practice?
I frequently see skin cancer cases where there has been a substantive delay in diagnosis, most often on the part of the patient themselves. This is an unusually long period of time to treat a skin lesion in a patient with a known history of skin cancer without performing a diagnostic biopsy.
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