Allegation
A breakdown in communication resulted in a failure to diagnose and treat testicular cancer and the death of the patient.
The Case
The patient, a 37 YOM (5’8”, 225 lbs.), presented to his PCP with complaints of pain and swelling in his testicles that he had been experiencing for approximately one and a half years. The patient also reported diarrhea, loss of appetite, and vomiting. Examination revealed gross enlargement of the left testicular sac to 10 cm diameter. The scrotum was too taut to evaluate for hernia, so the patient was referred for an ultrasound.
The ultrasound revealed an intratesticular hypoechoic solid-appearing mass concerning for neoplasm with heterogeneous areas and micro-calcifications. There did not appear to be any increased internal flow to this mass. The ultrasound also revealed a large left-sided hydrocele. The radiologist recommended consultation with urology.
The patient presented to the defendant urologist the next day. He indicated the problem had persisted for over a year, but that the pain had begun two weeks prior. The patient’s clinical presentation included testicular pain, nausea, chills, and low-grade fever. The defendant urologist reviewed the ultrasound and performed a physical exam. The exam revealed non-tender swelling which was translucent and anterior to the testicle on the left, swelling of the left testicle, and a scrotal mass. He prescribed Cipro® and an analgesic, and instructed the patient to return in two weeks for a repeat scrotal ultrasound. The visit was the only interaction the defendant urologist had with the patient.
Nine months later, the patient presented to the ER with complaints of intermittent testicular pain. He was prescribed Lortab®, Norco®, and Levaquin® and told to follow-up with his PCP or urologist. A week later, the patient presented to his PCP with complaints of abdominal and testicular pain. The PCP noted drug-seeking behavior, and the patient refused any effort to diagnose or treat his condition.
Three months later, the patient presented to a different ER for abdominal pain with an onset of six months prior. He reported that he was referred to urology for testicular swelling, but was told it was a hydrocele. Physical exam noted a large mass in the left upper quadrant. An abdominal CT showed an obvious malignancy that had the CT morphologic appearance of a high-grade advanced malignancy. An ultrasound showed a left testicular mass with associated micro-calcification worrisome for testicular neoplasm. Fine needle aspiration confirmed malignant cell groups compatible with malignant germ cell tumor.
The patient was diagnosed with metastatic testicular cancer, non-seminomatous germ cell tumor. He received chemotherapy for seven months. Restaging imaging conducted after chemotherapy was concerning for findings in the lower right lobe of the lung. The patient underwent a wedge resection of the right lower lobe mass. One month later, a CT scan showed a right hilar node, left retroperitoneal lymphadenopathy. Tumor marker of AFP was markedly elevated at 4511 (10-20). The patient completed two additional cycles of chemotherapy.
Nine months after the cancer diagnosis, the left testicle was removed since it was thought to be the source of the cancer. Pathology confirmed a 2.5 cm mass of necrosis and fibrosis but no visible tumor. The patient developed worsening abdominal pain. CT scans showed enlargement of the retroperitoneal mass into the mesentery with a partial bowel obstruction. Palliative radiation therapy was offered but the patient declined. He died five months later.
Accounts differ between the patient and the defendant urologist regarding communication about possible testicular cancer. The patient claimed that when he saw the urologist he was not advised of a potential cancer diagnosis. The defendant urologist testified that the patient presented with an ultrasound finding suggestive of testicular cancer. The patient’s clinical presentation, acute onset of testicular pain, nausea, chills, and low-grade fever suggested a possible infection. Testicular cancer was high on the differential; however, the defendant urologist stated that treating with antibiotics first would help determine whether the mass was cancer or an abscess. The defendant urologist was certain he discussed with the patient the possibility of the mass being cancer, and the need to return for a follow-up ultrasound in two weeks.
Expert witnesses for the patient stated the defendant urologist deviated from the standard of care by failing to communicate to the patient that he had testicular cancer, and to further impress upon him the need for surgical treatment during their appointment. The experts were unable to state when the patient had first developed symptoms of testicular cancer. They were also unable to state whether a two-week delay to pursue treatment with antibiotics caused any harm. An expert further admitted it was possible the patient had a secondary infection when he was treated by the defendant urologist; if an orchiectomy were performed, it would make sense to control the infection prior to surgery.
Defense experts believe the defendant urologist met the standard of care. They also agreed that the patient presented with a mixed clinical picture. It was appropriate, they stated, to include both neoplasm of testis and orchitis in the differential diagnosis. If surgical removal of the diseased testicle were recommended, it was reasonable for the defendant urologist to address the inflammation and possible infection before proceeding with surgery. The defense experts further maintained the patient’s lack of follow-up and failure to follow medical advice contributed to any delay in diagnosis and treatment.
Verdict
At trial, the jury found in favor of the defense.
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