In October 2012 the patient was seen in the emergency room for suspected kidney stones, and a CT of the abdomen was obtained. The radiologist reported: “Mildly increased fat containing hernia inferior to the umbilicus. Stable right nephrolithiasis. Stable retroperitoneal adenopathy. Diverticulosis.”
In August 2017 (5 years later) the patient presented again to the emergency room with complaints of abdominal fullness for one week.
An abdominal and pelvic CT with contrast was obtained, and the impressions were: “Lobulated heterogeneous lobular lesion abutting the stomach with multifocal areas of hypodensity surrounded by peripheral hypervascularity, abutting the greater curvature of the stomach, measuring approximate 6.0 x 7.3 x 5.7 cm. The lesion is increased in size compared with the prior study from 2012 (2.2 x 3.1 x 2.6 cm). Given the interval growth from 2012, malignant etiology cannot be excluded.”
In retrospect, a 2.6-cm tumor of the stomach was therefore already evident in the 2012 CT scan.
Given those findings, a partial gastrectomy was performed in September 2017.
The pathologic examination revealed a gastrointestinal stromal tumor (GIST), greatest dimension 7.0 cm, high grade, mitotic rate > 5/50 HPF, negative margins. Stage pT3, pN0.
The patient was started on Gleevac treatment 400 mg. /day. A recent CT (March 2019) shows no evidence of disease.
Has the 5-year delay in diagnosis affected the patient risk of recurrence?
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Do you believe there might have been medical error?
A 2.6-cm lesion should have been identified by the radiologist in 2012. From your summary it sounds like at that time the radiologist missed the GIST, which allowed the tumor to grow without treatment for 5 years.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Gastrointestinal Stromal Tumors (GIST) are malignancies of the gastrointestinal tract, typically found in the stomach and small intestine. Prognosis is based on size, location and mitotic rate (duplication rate of the tumor cells). The smaller the size of the tumor when treated, the more likely the patient will be cured or survive longer. Treatment is surgical removal of the tumor with clear margins. Depending on the stage of the cancer adjuvant therapy may be prescribed. In my opinion, had the GIST tumor been diagnosed and treated in 2012, prognosis would have been better. Based on available GIST tumor nomogram, in 2012 the patient would have had a 63% chance to be cancer free in two years and a 41% chance to be cancer free in 5 years. She would not have required adjuvant therapy had she been treated at that time.
What makes you a good expert for this case?
While not a medical oncologist I am trained in surgical oncology and I see patients with GIST quite frequently. Surgery is typically the initial treatment modality for GISTs.. I also routinely discuss multi-disciplinary treatment of sarcomas at tumor boards.
How often do you encounter cases similar to this one in your practice?
GIST are relatively rare tumors. Because I work in a tertiary referral academic center I see at least 10 GIST each year.
Do you believe there might have been medical error?
he is already on Gleevec to reduce his risk of recurrence. if his cancer will recur in 3 yrs, there is a chance that he could have benefited from earlier result however, its not always the case. a lot of these cases take a long time to go for trial.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If his cancer will recur in 3 yrs, there is a chance that he could have benefited from earlier result however, its not always the case. a lot of these cases take a long time to go for trial. I do not any other causation
What makes you a good expert for this case?
I have done a similar case. if his cancer will recur in 3 yrs, there is a chance that he could have benefited from earlier result however, its not always the case. a lot of these cases take a long time to go for trial. I do not any other causation
How often do you encounter cases similar to this one in your practice?
2-3 times in my practice to understand how GIST are treated.
Do you believe there might have been medical error?
There wasn't no indication on the 2012 CT scan of a gastric (Stomach) mass. The patient had kidney stones and diverticulosis. The symptoms were most probably related to the nephrolithiasis. Absence of a defined gastric mass or the measurement of such a "mass" in the 2012 report does not lend itself to a causal inference of negligence per se. The comparator cannot be in retrospective analysis. Hence the difficulty in establishing causality of a missed diagnosis. Small GIST tumors rarely cause symptoms since they are very slow growing. However with the mitotic rate noted in this tumor, it is possible it acquired a more aggressive growth phase (which happens during the biological life of GIST) These tumors are c-KIT gene mutated tumors and respond excellently to Imatinib and Sunitnib. The patient was treated with Imatinib and most likely will have to stay on the drug for the foreseeable future. GIST also can develop resistance to Imatinib and the Sunitnib can be substituted at that time."
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
No diagnostic error with the initial CT scan. The only question here is the term "stable retroperitoneal lymphadenopathy"; the size of the nodes is not mentioned. Larger nodes need to be investigated to rule out disease. Patient apparently remained symptom free for 5 years (that equates to the slow progression of disease and the tumor's biological life).
What makes you a good expert for this case?
Experience with treating GIST in the past.
How often do you encounter cases similar to this one in your practice?
GIST is a modestly Rare disorder and occurs in the late years of life. It is common in the GI tract and mostly in the Stomach area. It remains a diagnosis of exclusion.
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