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Wrongly reassured over benign cyst

23 October 2018


Mrs D was a 59-year-old clerical worker who presented to her GP with a longstanding lesion on her scalp. She had ‘had it for years’ but felt it was starting to get bigger and catching on her comb. GP Dr N diagnosed it as a small 7-8mm sized sebaceous cyst and listed her for removal on the minor surgery list.

Dr N removed the lesion successfully on his minor surgery list a few months later. He did not send the excised material to histology for further analysis.

Almost one year later, Mrs D re-presented to the surgery with another cyst on her scalp, about the size of a marble. GP Dr C prescribed antibiotics for an infected sebaceous cyst, but the swelling persisted and two months later, Mrs D again requested removal of the cyst, and this time Dr C removed it on his minor surgery list. He also did not send the tissue to histology.

Mrs D noticed ongoing discomfort around the scar on her scalp and came back to the surgery three months later to see GP Dr H. He noticed an unusual appearance to the scar, describing an inverted pit with surrounding induration and tenderness. He also discovered a solitary gland in the posterior triangle of the neck. A referral was made to the plastics team.

The plastics team reviewed Mrs D two months later, noting a tethered hypertrophic scar, for which conservative scar management was advised. An ultrasound scan was performed on the neck nodes, which showed these were likely to be reactive nodes due to the recent surgery. The histopathology results for the two prior excisions were requested from the GP practice to be discussed at the follow-up appointment three months later.

The practice replied, stating that samples had not been sent to histology. Mrs D returned for her three-month review with plastics, and the neck nodes had enlarged, prompting the plastics team to initiate referral for further investigations.

Mrs D was diagnosed with an aggressive, poorly differentiated apocrine adenocarcinoma, with widespread metastases. Despite surgery and adjuvant radiotherapy, she was found to have multiple lung nodules and she died in a hospice a year later.

The GPs at Mrs D’s practice were criticised for failing to send the samples they excised for histological examination. Experts agreed that, had they done so, Mrs D would have had an earlier diagnosis and received curative treatment, and her life expectancy would not have been negatively affected.

Mrs D’s husband lodged a claim against both GPs involved. As Mrs D had been a higher earner than her husband, there was a notable financial dependency claim. There was also a significant future services dependency claim, including childcare Mrs D would have allegedly provided to her grandchildren.  

Although the claim was deemed indefensible, the Medical Protection legal team viewed the claim for future services as being overstated in particular, and was able to negotiate a 50% reduction in the amount being claimed. As with any indefensible claim, we aimed to resolve matters as quickly as possible, and it was eventually settled for a substantial sum.

Learning points

Apocrine adenocarcinoma is a rare diagnosis with few cases reported in the literature. They are typically slow growing and indolent, presenting as an asymptomatic, slow growing mass. Most patients report the presence of a longstanding lesion before the diagnosis is made. More than half of all patients have lymph node metastases at the time of diagnosis.

When performing minor surgery, all samples excised should be sent for histological examination. Following this, practices should have robust systems for handling the histology results and ensuring they are actioned, if necessary, and patients informed of the results.

It is important for GPs to maintain their skills in minor surgery by regularly updating or enhancing their training. Courses are available from a variety of sources.