Failure to Identify Left Kidney Mass Claimed in Delayed Renal Cell Carcinoma Diagnosis

Allegation:

Failure to identify left kidney mass, resulting in a two-and-a-half year delayed diagnosis of renal cell carcinoma.

The Case:

A 53 YOF (5’3”, 222 lbs.) underwent a CT of the abdomen and pelvis (CTAP) with contrast in June 2012. The defendant radiologist interpreted the CTAP as diverticulosis without evidence of acute diverticulitis and no other significant abnormality.

In December 2014, the patient underwent a CT of the abdomen and pelvis (CTAP) with contrast as a follow up to malignant endometrial cancer. Treatment for the endometrial cancer included a robotic laparoscopic total abdominal hysterectomy and salpingo-oophorectomy with bilateral pelvic lymph node sampling in September 2010. Post-surgery pathology revealed a moderately differentiated endometrioid adenocarcinoma of the endometrium superficially. The patient also had a history of diabetes, hypertension, hypercholesterolemia, hypothyroidism, obesity, diverticulosis, and colon polyps.

The December 2014 CTAP was interpreted by the defendant radiologist as spleen and pancreas showing no focal abnormalities; adrenal glands unremarkable; kidneys demonstrating no focal lesions with no hydronephrosis. The final impression stated stable appearance of the abdomen and pelvis, with no evidence of significant abnormality. When the defendant intended to compare the 2014 images to the 2012 images, she inadvertently brought up the 2012 images on both monitoring screens resulting in a comparison of the 2012 images to themselves.

In May 2017, the plaintiff was seen for gynecological follow up and a CTAP with contrast was ordered and performed during that same month. These images were compared with the prior studies. The study was interpreted by the radiologist as showing an enlarged spleen, with normal appearance of pancreas, gallbladder, bile ducts, and liver. A 4.2 cm heterogeneously enhancing mass lesion exophytic anteriorly from the upper anterior cortex of the upper pole of the left kidney was noted. Additional interpretations in the report included normal renal vein, no adenopathy, kidneys elsewhere normal, and collecting structures not dilated.

The patient consulted with a urologist in May 2017 for follow up of the 4.2 cm mass. A surgical robotic partial nephrectomy was recommended. The plaintiff underwent the procedure the following month in June 2017. Pathology revealed renal cell carcinoma into the perinephric adipose tissue. Surgical resection margins were negative for carcinoma. Angiolymphatic invasion was present. The patient did not require chemotherapy or radiation treatment, and no recurrence was noted during the timeline of the claim.

The plaintiff’s pre-suit affidavit alleged that the defendant radiologist deviated from standard of care by failing to note a mass in the reading of the December 2014 CTAP, resulting in a delay in diagnosis of renal cell carcinoma. Plaintiff further alleged that the delay in diagnosis of the mass allowed the renal carcinoma to double in size, requiring a more significant surgery and worsening carcinoma from a stage I to a stage III cancer, significantly decreasing the survival rate.

Expert Testimony

The defense expert opined that there was a mass visible on the December 2014 CTAP interpreted by the defendant radiologist; however, it would have been acceptable to treat the tumor by monitoring the growth of the mass, given that kidney cancer has a growth rate of 0.6 cm to 0.8 cm per year. By 2017 the tumor had increased to roughly 4.2 cm and became a stage IIIA tumor. The defense expert also stated there is no difference in treatment between a stage IA tumor and a stage IIIA tumor with the treatment continuing to be observation.

Of note, both plaintiff and defense experts agreed that treatment for the condition remained unchanged between tumor stages. The partial nephrectomy was appropriate for both stage IA and stage IIIA tumors. Therefore, the surgery performed was the same surgery the plaintiff would have had in 2014 had it been diagnosed then. One defense expert stated there was no need for post-surgery radiation or hormonal treatment. Although there was an unknown decrease of five-year survival in 2017, the plaintiff still had a greater than 50% chance of five-year survival.

Plaintiff alleged that damages were emotional based on her fear of recurrence which is considered a cause of action within the state where this case occurred.

The Verdict

Based on the considerations of alleged damages, the medical prognosis of the plaintiff, the expert testimony for both plaintiff and defense, and the discovery of a verification process error that resulted in the failure to properly identify the imaging dates, this case was settled for a reasonable amount.

Risk Reduction Strategies

This case study demonstrates the importance of protocols to avoid both systems and personal process errors (e.g., interruptions, distractions, etc.) that could result in a claim alleging delayed diagnosis or misdiagnosis. 

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