Dermatology Experts Evaluate Repeated Failure to Diagnose Melanoma


Dermatology Expert WitnessThis case involves a female patient in Montana who was diagnosed with advanced melanoma. The patient had a known family history of melanoma, and her mother died from it a few years before the events in this case. The patient had a lesion which had been diagnosed as seborrheic keratosis on her back, which had been treated with liquid nitrogen on several occasions. On one occasion, the patient presented to the Defendant and reported that the lesion had changed, though no action was taken. The patient returned to the Defendant again some time later, with the lesion still present. The patient presented to a new dermatologist a few months later, and a punch biopsy was performed that same day. The biopsy results revealed the lesion to be a malignant melanoma. The patient then underwent a biopsy that revealed a metastatic melanoma that had spread to multiple lymph nodes. It is alleged that the patient would have had a better outcome if her cancer had been diagnosed sooner.

Question(s) For Expert Witness

  • 1. Do you routinely treat patients similar to the one described in the case?
  • 2. Have you ever had a patient develop the outcome described in the case?
  • 3. Would the patient's current prognosis been different had the cancer been diagnosed sooner?

Expert Witness Response E-011913

I specialize in the management of melanoma and non-melanoma skin cancers, and have been doing so for the past 20 years. I routinely treat patients with in situ and thin (< 1mm) melanomas, and I am a part of a multidisciplinary tumor board that sees patients with melanoma requiring multidisciplinary management. I personally have had one or two patients develop melanoma metastases from melanomas in the 0.75 to 1 mm thickness range, who were treated with excision alone, before sentinel lymph node biopsy became standard practice. The patient’s prognosis would likely have been different had the cancer been diagnosed during her earlier visit as opposed to the visit on which the biopsy was performed. The standard protocol when a patient presents with a lesion is to biopsy the lesion to rule out melanoma. In all similar cases that I have reviewed, a delayed diagnosis of melanoma resulted in metastatic disease and in some cases, death.

Expert Witness Response E-011942

I commonly diagnose and treat patients with skin cancer, including melanoma, though I currently do not have any patients with metastatic melanoma. I routinely refer these patients to our melanoma clinic where they are managed simultaneously by a surgeon, oncologist, and a dermatologist who specializes in melanoma. I have never treated a patient who developed a similar outcome, and generally speaking, the earlier the diagnosis, the lower the risk of morbidity and/or metastasis. It is standard protocol that a biopsy be performed when a patient presents with a lesion that has changed in pigment. Multiple failed attempts to clear the lesion with Cryotherapy also warrants a biopsy immediately.

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