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Rare scalp tumour

01 February 2006

Mrs F, a 50-year-old school secretary, was a frequent attender at her GP surgery, suffering from troublesome perimenopausal symptoms. During one consultation she pointed out to her GP, Dr B, that she had noticed some lumps on the back of her head.

They had been there for a few years, but appeared to be growing and were itchy. Dr B kept a record of her provisional diagnosis as ‘sebaceous cysts scalp?’ There are no details as to the nature of the scalp lesions.

Mrs F brought the problem to Dr B’s attention again two months later.
The lumps were itchy. Dr B treated them with a topical steroid preparation. A further eight months on, Mrs F mentioned them again. Dr B recorded ‘Itchy cysts on scalp – sebaceous cysts.’ Dr B gave another prescription for steroid cream.

Eighteen months after originally bringing the lumps to Dr B’s attention, Mrs F asked to be referred to a dermatologist because the lumps were increasingly itchy and bothersome. Dr B recorded that there were multiple sebaceous cysts on the scalp with some associated seborrhoeic dermatitis, and referred Mrs F to a local dermatologist.

The dermatologist did not feel that the appearance of the lesions was consistent with sebaceous cysts, and took a skin biopsy. This showed that the lumps were due to dermatofibrosarcoma protuberans. This is a locally malignant tumour, requiring complete excision to effect a cure. This can be difficult over the skull.

Mrs F’s lesion needed excision with micrographic control of the surgical margin, and cosmetic surgery. Fortunately, Mrs F has suffered no recurrence of the tumour. Mrs F later sued Dr B, alleging that the delay in referral for dermatological advice had led to a need for more extensive treatment and a poorer cosmetic outcome.

We sought expert GP advice. After liaising with Dr B, it became clear that the lesion had grown significantly, and become increasingly nodular, during the time that Dr B was aware of it.

Unfortunately, Dr B had kept no record of the size and nature of the lesion. The expert felt that the management would not be supported by a responsible body of GPs, because although a correct diagnosis would not be expected, the changing nature of the lesion should have rung alarm bells and initiated earlier referral.

Expert opinion

Experts in dermatology and oncology commented that although the delay in diagnosis meant that Mrs F had to undergo more extensive and complex surgery, it had not materially affected her risk of future recurrence.

On this basis we settled the claim and paid Mrs F a sum equivalent to £16,000 (US$28,000), to compensate her for her suffering and poorer cosmetic appearance. We paid Mrs F’s legal costs, which were greater than the award she received.

Learning points

This was a tricky diagnosis and it would be unfair to expect a GP to routinely recognise it. However, purities is not a normal feature of sebaceous cysts and this atypical feature should have prompted a diagnostic rethink.

When dealing with skin lesions, it is good practice to note the size and site of the lesion (preferably with a diagram), and use descriptive rather than diagnostic terms in the notes.

This allows yourself or a colleague to note objectively any significant changes at review.