Allegation:
Despite an alleged failure to properly interpret and report a mass which potentially led to a delay in diagnosing lung cancer, the jury returned a verdict in favor of the defendant radiologist.
The Case:
The patient, a 61 YOWM (5’9”, 242 lbs.), presented to the ED complaining of chest heaviness for several months and worsening symptoms. A chest x-ray was ordered and interpreted by the defendant radiologist who testified there was no history provided that the patient was a smoker. The patient had reported a positive family history (father) of lung cancer. The radiologist testified that he read the chest x-ray and compared it with an x-ray from two years prior to formulate his impression that no acute disease was detected. He provided his report to the ED physician, and the patient was discharged with atypical chest pain and uncontrolled diabetes mellitus II.
The patient presented to his PCP nine months later with complaints of bloody sputum and a cough for the past month. Another chest x-ray was ordered and read with the impression of a 4.8 cm soft tissue mass in the right paratracheal space. A CT confirmed a 5.7 cm x 5 cm right suprahilar neoplasm with a 6 mm pulmonary nodule in the right upper lobe adjacent to the mass.
The mass was noted to be either a metastases or a benign non-calcified granuloma. The lymph nodes adjacent to the right paratracheal space and carina were larger than they were at the patient’s previous appointment, and possibly infiltrated with neoplasm. The patient was diagnosed with a new lung mass; it was thought that the mass may have been present as far back as the patient’s initial ED visit.
Five days later, a pulmonologist confirmed via biopsies of the right upper lobe mass that the mass was moderately differentiated adenocarcinoma.
Two weeks later, the patient underwent a right thoracotomy, right upper lobectomy, and lymphadenectomy. The mass was 5.1 cm. Pathology determined the patient’s staging was T3N0M0.
The patient had a CT five months after finishing chemotherapy. Two subtle lesions were identified in the liver. Metastatic disease was a possibility. A month later, a right lobe liver biopsy confirmed a metastatic moderate to poorly differentiated adenocarcinoma. The patient continued with various treatment modalities that year and expired two years later; a lawsuit was filed.
A board-certified radiologist testified as an expert witness for the plaintiff, and stated that the histopathology determines if an abnormality is actually a metastatic disease. The expert further testified that the biology of cancer is not affected by the time period by which the primary cancer is diagnosed. He indicated the growth of lung cancer in the liver is based on the patient, genomics, and the histology. The expert went on to testify that the natural history of any particular cancer will not change and is not dependent upon when the diagnosis is made.
Another plaintiff’s expert, a board-certified oncologist, agreed there was no way to say for sure whether the patient had microscopic lung cancer in the liver during the ED visit, or if the patient had metastatic disease before it was detectable on imaging.
A board-certified radiologist testifying as an expert for the defense stated the patient had the lung mass during the time of the chest x-ray in the ED. However, the mass was only apparent in retrospect once it was identified on the chest x-ray a few months later. The expert explained that shading of the area is so subtle that a reasonably careful radiologist would not see it, except in retrospect. Soft tissue and pulmonary vessels blend into the area of the subsequent mass, making it a difficult area to visualize.
Two other defense experts who were board-certified medical oncologists testified the patient already had stage IV metastatic cancer at the time of the chest x-ray in the ED, and when he was diagnosed a few months later. Their opinion was that most cancers metastasize well before they are diagnosed. One of the defense experts also stated there is no data to suggest that early lung cancer detection efforts have made any difference in outcomes, and that no one can say if the patient would have had a better outcome with an earlier diagnosis. It was the expert’s opinion that the patient likely had metastatic disease for months or years prior to the chest x-ray at the ED.
Resolution:
This case resulted in a defense verdict.
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