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Malignant melanoma diagnosis

01 May 2006

Following a minor surgical procedure Ms B, a 30-year-old shop manager, attended her GP surgery for wound inspection and a change of dressings. During one of these visits, Ms B drew Dr M’s attention to a mole on her leg which had been present for many years.

Five months later Ms B registered with a new GP, Dr W. She again drew attention to the mole on her leg. Dr W’s notes record that the mole had recently increased in size and itchiness and changed colour. Dr W sent an urgent referral letter to a consultant dermatologist, Dr R, with a suspected diagnosis of malignant melanoma.

Mrs B’s skin lesion was excised 19 days later. A diagnosis of malignant melanoma was confirmed histologically. In a subsequent letter to Dr W, the consultant dermatologist, Dr R, stated that although there was no clinical evidence of lymphadenopathy, the patient was suitable for sentinel node biopsy.

The results of the sentinel node biopsy were found to be positive, as a result of which Mrs B’s lesion was classified under the AJCC1 (American Joint Committee on Cancer) as stage IIIB melanoma. Ms B underwent interferon treatment and subsequently brought a claim for negligence against Dr M.

Expert opinion

A GP expert felt that Dr M’s records were poor and contained no details of the patient’s complaints or symptoms or details of the appearance of the lesion. He concluded that the lesion presented during Dr M’s examination would have been sufficiently suspicious to have warranted a referral for a second opinion. The delay in diagnosis forced Ms B to undergo a wide block excision and more aggressive treatment than she would otherwise have done.

A consultant dermatologist with a special interest in melanoma stated that the five month delay in diagnosis had decreased Mrs B’s chances of survival after five and ten years, but that the figures were within 5%.

In a joint discussion, the experts agreed that the delay in Ms B’s diagnosis had only marginally affected her survival probability.

However, as a result of the delay, treatment was more aggressive and risk of reccurrence was increased.

The case was settled out of court for £45,000 plus costs. MPS was able to use causation arguments to achieve a settlement figure significantly lower than originally claimed.

Learning points

  • Attention should always be paid to patients raising additional matters in appointments. If there is not time within the appointment to deal with the issue, then an additional appointment should be made.
  • Accurate and detailed medical notes should be kept regarding both a patient’s presenting complaint or any other issues that he or she may raise during a consultation.
  • Prompt diagnosis is particularly important in cases of malignant melanoma. The probability of recurrence is very closely related to the depth to which the tumour cells have invaded into the dermal layers.
  • When examining a skin lesion, record the site and size and describe its appearance (irregular margins, irregular pigmentation, ulceration etc).Any other pigmented lesions should be recorded, as should signs of lymphadenopathy or hepatomegaly.
  • When taking a history of a suspected melanoma, record whether or not there has been a change in size, colour, shape or symptoms (itching or bleeding, etc).

Further information

www.cancerstaging.org

Koops HS et al. J Clin Oncol. 1998 Sep;16(9):2906–12

Balch CM, et al. Intergroup Melanoma Surgical Trial. Ann Surg Oncol 2000Mar; 7(2): 87–97[Medline]

Clinical Practice Guidelines in Oncology. Melanoma 2006. National Comprehensive Cancer Network, www.nccn.org.

Roberts et al, UK Guidelines for the Management of Cutaneous Melanoma, Br J Dermatol 146(1):7–17 (2002)

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