Missed Diagnosis of Skin Cancer Results in Facial Reconstruction Surgery


This case involves a woman who presented to her dermatologist with complaints of a dark spot on the left side of her nose. The patient had a history of basal cell carcinoma on her nose, which prompted the dermatologist to take a shave biopsy for further investigation. The pathology report stated that the findings were consistent with that of actinic keratosis with chronic inflammation in the dermal tissue. Over the next five months, the patient saw the dermatologist on six occasions for liquid nitrogen and photodynamic therapy treatments on the lesion. It was noted in the chart that the wound was having a difficult time healing, and the dermatologist prescribed Doxycycline and Bactrim. After nine months of no improvement, the dermatologist finally ordered a four-millimeter punch biopsy be taken of the patient’s nasal tip. The pathology report showed evidence of a poorly differentiated squamous cell carcinoma with marked spindle cell differentiation. There was also perineural invasion by the tumor and it was noted to invade into and through the cartilaginous tissue. Finally, the lesion was staged as T2 N0 poorly differentiated SCC of the nose and the patient required life-altering surgery of the face.

Question(s) For Expert Witness

  • 1. Is it possible to confuse malignancy for actinic keratosis without doing further diagnostic testing?

Expert Witness Response E-005951

Actinic keratoses and their derived squamous cell carcinomas are distinctive lesions forming a continuum in a multi-step carcinogenesis process. They are typically found on chronically sun-exposed skin. Actinic keratoses, however, should be distinguished from squamous cell carcinomas, both conceptually and for therapeutic implications. The histological differences between these lesions are well defined and should not be blurred. I have diagnosed thousands of these cases including many consultation cases where patients were diagnosed elsewhere and came to my office for confirmatory testing. I can certainly determine if the biopsy provided was of poor quality and be able to render a definitive opinion based on the slides.

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