BT40 A case of low-grade angiosarcoma of the face: is teledermatology effective in early diagnosis of rare skin tumours?

Abstract An 87-year-old White man presented with a gradual swelling of the right side of the face. This was clinically diagnosed by his general practitioner via teledermatology as erysipelas refractory to antibiotic treatment, with a clinical course of around 10 months. The differential diagnosis included rosacea. The lesion was gradually involving the cheek and spreading to the left side of the face. The patient was referred to the dermatology clinic and on examination the lesion was found to be indurated, tender and warm with a wet texture. The patient had a previous history of bladder cancer, which was treated 5 years earlier. A 4-mm punch biopsy from the right cheek was taken, which showed a permeative vasoformative tumour within the dermis composed of anastomosing vascular spaces lined by a single layer of plump endothelial cells. Mitotic figures were identified. ERG immunohistochemical stain highlighted the endothelial cells. Human herpesvirus 8 stain was negative. The diagnosis was a grade 1 angiosarcoma. This was also reviewed in the specialized unit and the patient was urgently referred to a sarcoma service. Computed tomography and positron emission tomography scans were performed and he was be referred for chemotherapy. The role of teledermatology for skin lesion assessment has been a recent development, particularly since the COVID-19 pandemic, and has impacted the ability to assess patients in person. In recent research, 22 studies were reviewed to include basal cell carcinoma, squamous cell carcinoma and melanoma. The authors stated that anxiety around missing early curable cases needs to be balanced against inappropriate referral and unnecessary excision of benign lesions. Their results suggest that teledermatology can correctly identify the majority of malignant lesions. In another recent review of 45 publications, the authors concluded that teledermatology offers a comparable standard of effectiveness to in-person assessment. It can save significant time in expediting advice and management. Image quality and inclusion of dermoscopy have a considerable bearing on the overall effectiveness. However, our case shows that the diagnostic accuracy of teledermatology in similar rare tumours needs to be carefully evaluated. Any clinical suspicion about lesions with diffuse growth patterns that mimic dermatoses refractory to medications should be taken seriously and an urgent referral to a dermatologist is to be recommended. In conclusion, we have presented a case of angiosarcoma of the face initially diagnosed as erysipelas, which needed further referral after being refractory to antibiotics. As primary cutaneous angiosarcoma is one of the most aggressive skin tumours and carries a very poor prognosis, further assessment of teledermatology as a reliable diagnostic method needs to be evaluated, and confusion with inflammatory dermatosis remains a serious diagnostic pitfall.