Allegation:
The misread of an abdominal CT by the defendant radiologist caused a five-month delay in diagnosis of cancer; an earlier diagnosis would have prevented loss of the right kidney and prevented metastasis to the lung.
The Case:
The patient, a 72 YOM (6’0”, 219 lbs.), presented to a clinic to see a family practitioner for complaints of back pain that radiated to the right flank. The patient’s history included a renal ultrasound nine months prior that was read as normal. Two weeks later, the patient complained of RLQ abdominal pain for one week. He reported it was worse with eating and sometimes when riding the stationary bike. Three weeks later, flat and upright abdominal x-rays showed a non-obstructed bowel gas pattern and no free gas.
One month later, the patient complained of abdominal pain, particularly in the area of the right kidney; the pain had been constant since the last visit. Four days later, the defendant radiologist read an abdominal/pelvic CT with and without contrast as showing diffuse fatty infiltration of the liver, arteriovascular calcification, numerous small- to moderately-sized colonic diverticuli, but no diverticulitis. The prostate gland was mildly enlarged, inhomogeneous, and lobulated with calcifications. The kidneys were excreting contrast bilaterally. There was no hydronephrosis and no stone identified within the urinary tract.
The patient reported two months later that he continued to have grabbing in the right kidney area, which was worse after eating. A few weeks later, he presented to an urgent care complaining of right lower back pain for two months. The patient had a cholescintigraphy which was normal. Two months later, he continued to complain of right-sided abdominal pain with associated RLQ, LLQ, or back pain. His abdominal aortography showed a vascular tumor at the lower pole of the right kidney, probably renal cell carcinoma. An MRI of the kidneys showed a 3.6 x 3.1 x 3.2 cm solid mass.
Three weeks later, a surgeon attempted a right retroperitoneal robotic-assisted partial nephrectomy; the procedure was converted to an open radical nephrectomy due to difficult anatomical factors. Pathology reported a clear cell renal cell carcinoma unifocal. The tumor invaded the renal sinus adipose tissue. The diagnosis was T3a with perinephric or renal vein involvement, N0M0 Grade III, clear cell type. Six weeks after the surgery, the patient underwent a cystoscopy of the prostate; pathology diagnosed an adenocarcinoma, Gleason score 7 with 70% involvement of the total core volume. The following month, the patient was diagnosed with prostate cancer, and started on radiation and hormonal treatment.
A nuclear PET scan six months later showed numerous hypermetabolic nodules bilateral lungs compatible with metastatic disease. An RLL CT-guided biopsy showed metastatic renal cell carcinoma of clear cell type. Pathology revealed renal cell carcinoma, clear cell type. Immunohistochemical stains showed the tumor cells expressed PAX-8, CD10, and carbonic anhydrase IX. The cells were negative for cytokeratin 7, TTF-1, RCC antigen, and PSA. The patient also underwent a CT-guided biopsy of a pulmonary nodule, which was positive for renal cell carcinoma. He was treated with systemic chemotherapy, which was discontinued due to side effects.
One year later, the patient underwent a right video-assisted thoracoscopy and wedge resection surgery for a large renal cell metastatic carcinoma in the right upper lobe and lower lobe. Three months later, he underwent a left video-assisted thoracoscopy, therapeutic left lower lobe wedge resection x 2, and a therapeutic left upper lobe wedge resection x 4. Two weeks after the surgery, the patient indicated he had SOB occasionally at rest and with activity, but that his SOB continued to improve since surgery. He reported he uses his incentive spirometer and walks around his home for exercise. He denied cough, hemoptysis, weight loss, and decrease in appetite. The incision sites were healing well and the sutures were removed. A CXR showed small bilateral effusions with left basilar scarring, atelectasis or pneumonia, and a small left apical pneumothorax.
The following month, the patient refused possible next line therapy with nivolumab because of possible side effects. He stated he wanted CAR T-cell therapy instead, and that he was going to seek a second opinion. The patient continued receiving radiation and hormonal therapy for his prostate. He subsequently had a relapse of his prostate cancer. Symptoms included frequency, urgency, and dysuria.
The plaintiff experts believed the defendant’s failure to find the tumor on the CT scan resulted in a delay in diagnosis of renal cell carcinoma.
The defense experts testified the alleged kidney mass on the abdominal/pelvic CT was a very inconspicuous finding and the failure to mention it met the standard of care. The defense expert did not initially see the kidney mass, and after closer examination of the scan, finally found the kidney mass. The defense expert testified the alleged four- to five-month delay did not impact the patient's outcome.
The Verdict:
On the sixth day of trial, the court granted a directed verdict in favor of the defense.
---
If you have questions on this topic, please email RiskAdvisor@ProAssurance.com or call 844-223-9648.