A nice internal medicine physician, originally Canadian, refers patients to me often from afar. I am very honored and humbled at the same time. Recently, he referred a patient in his early 60s. This patient had seen two dermatologists prior, in addition to his internal medicine physician, one who prescribed a corticosteroid and the other blew him off.

He complained about redness in his forehead, it was not very itchy. It mostly bothered him cosmetically and he wanted laser treatment to remove it.
In a seated position, I examined him from multiple angles. I pressed on it and it blanched. There was no pain whatsoever. It was growing and it had an interesting brownish border and looked like simple chronic sun damage.
Something about this struck me and I recalled photographs that looked almost identical to the gentleman that was sitting in front of me from residency over 20 years ago.

I told him I wanted to make sure he did not have a very rare disease and I needed to do not one but two punch biopsies, even if it left a scar on his face. Mind you, the patient was very cosmetically conscious and the furthest thing from his mind was to add more scars to an area that was already very reddened. To avoid cosmetic damage, he would pay good money to expunge!

I put down one and only one diagnosis: Angiosarcoma.
About 10 days later, I got the pathology report and after special testing the diagnosis is: angiosarcoma. The prognosis is very poor and there’s a 50% recurrence rate even after all measures taken.

I spoke to the patient as soon as I possibly could to explain that he will need a team of physicians including the radiation oncologist, a medical oncologist, and a surgeon to address this issue.

I referred him to the University of Washington.

The ironic twist in the story is that he and the referring doctor are in-laws, expecting their first grandchild.