Photographic Confirmation of Biopsy Sites Saves Lives

Case 1 Presentation

A 36-year-old traveling veteran who relocates frequently and receives care at multiple VA medical centers (VAMCs) presented for excision of a melanoma. The patient had been managed at another VAMC where the lesion was biopsied in September 2016. He presented to the Orlando, Florida, VAMC dermatology clinic 5 months later with the photographs of his biopsy sites along with the biopsy reports. The patient had 6 biopsies labeled A through F. Lesion A at the right mid back was positive for melanoma (Figure 1), whereas lesion C on the mid lower back was not cancerous (Figure 2). On examination of the patient’s back, he had numerous moles and scars. The initial receiving HCP circled and photographed the scar presumed to be the melanoma on the mid lower back (Figure 3).

On the day of surgery, the surgeon routinely checked the biopsy report as well as the photograph from the patient’s most recent HCP visit. The surgeon noted that biopsy A (right mid back) on the pathology report had been identified as the melanoma; however, biopsy C (mid lower back) was circled and presumed to be the melanoma in the recent photograph by the receiving HCP—a nurse practitioner. The surgeon compared the initial photos from the referring VAMC with those from the receiving HCP and subsequently matched biopsy A (melanoma) with the correct location on the right mid back.

This discrepancy was explained to the patient with photographic confirmation, allowing for agreement on the correct site before the surgery. The pathology results of the surgical excision confirmed melanoma in the specimen and clear margins. Thus, the correct site was operated on.

Case 2 Presentation

A veteran aged 86 years with a medical history of a double transplant and long-term immunosuppression leading to numerous skin cancers was referred for surgical excision of a confirmed squamous cell carcinoma (SCC) on the left upper back. On the day of surgery, the biopsy site could not be identified clearly due to numerous preexisting scars (Figure 4). No photograph of the original biopsy site was available. The referring HCP was called to the bedside to assist in identifying the biopsy site but also was unable to clearly identify the site. This was explained to the patient. As 2-person confirmation was unsuccessful, conservative treatment was used with patient consent. The patient has since had subsequent close follow-up to monitor for recurrence, as SCC in transplant patients can display aggressive growth and potential for metastasis.

Case 3 Presentation

A veteran was referred for surgical excision of a nonmelanoma skin cancer. The biopsy was completed well in advance of the anticipated surgery day. On the day of surgery, the site could not be detected as it healed well after the biopsy. Although a clinical photograph was available, it was taken too close-up to find a frame of reference for identifying the location of the biopsy site. The referring HCP was called to the bedside to assist in identification of the biopsy site, but 2-person confirmation was unsuccessful. This was explained to the patient, and with his consent, the HCPs agreed on conservative treatment and close follow-up.