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Sample not sent to histology

01 September 2008

Mrs F, a 60-year-old retired gardener, attended her GP surgery enquiring about a lesion on her scalp. It had been bothering her for several years but she had ignored it. She assumed it was scar tissue from a head injury sustained several years ago, which had required stitches.

She had spent the majority of her childhood living in India and had attended the surgery in the past with concerns about moles on her legs – all of which had been found to be benign. Mrs F was assessed by Dr S who considered an infected sebaceous cyst to be the most likely diagnosis in view of the position of the lesion and the abundance of hair follicles. He prescribed a course of oral antibiotics. She returned to the surgery a week later with no significant improvement in her symptoms, so a further course of antibiotics was tried.

Mrs F returned to the surgery again after a fortnight, reporting that the lesion was now bleeding occasionally, and that the antibiotics had had no effect. Dr S booked her in to his regular minor surgery clinic to excise the lesion. The procedure was uneventful with a good result, but Dr S elected not to send the tissue sample for histology. Nearly a year passed, by which time Mrs F had moved house and changed GPs. She consulted her new GP Dr G, and once again brought attention to the lesion on her scalp, which had failed to improve. Dr G prescribed her a course of antibiotics and referred her for surgical removal of the infected lesion, which was carried out a few weeks later.

Histology was performed on the excised lesion this time and showed evidence of an infiltrating basal cell carcinoma. Mrs F was left with significant disfigurement and hair loss to her scalp and required frequent follow-up appointments to monitor for recurrence. She brought a claim against Dr S for failing to make an early diagnosis by neglecting to obtain a histological diagnosis.

Expert opinion

A GP expert was critical of Dr S’s management of the case. A history of a scaly granulating lesion that bleeds intermittently and does not respond to antibiotics should alert a GP to the possibility of something more sinister. Given Dr S’s experience of minor surgery, his decision to excise the lesion was reasonable, but his failure to obtain a proper histological diagnosis was inexcusable and breached his duty of care.

The vast majority of cases of basal cell carcinoma can be treated successfully before complications occur, but left undiagnosed, they can go on to cause destruction of local tissues and may invade vital structures.

Learning points

  • Although normally associated with sun-damaged skin in fair skinned people with a family history of the disease, BCC can arise around scars. An unusual presentation should prompt referral to more experienced colleagues.
  • Good practice dictates that tissue samples taken from patients are sent to pathology. There should be a robust system in place to track and act upon the results.
  • Basal cell carcinoma is the most common skin malignancy, typically occurring in areas of chronic sun exposure. Prognosis is excellent with adequate treatment since it’s usually slow growing and rarely metastasises. However, significant local destruction may occur if neglected.