A 69 year old man is diagnosed with urothelial cancer.
On June 2, 2017, he underwent a right nephrectomy and transurethral resection of the right ureter and bladder cuff.
The surgical pathology report reads: high grade papillary urothelial carcinoma with focal squamous differentiation, involving the upper calyx and renal pelvis, measuring 3.5cm in greatest dimension, with invasion of the renal parenchyma at the papilla, Stage pT3Nx
Lympho-vascular invasion was present
He was not prescribed chemo or radiation.
In November of 2019, he experienced excruciating back and abdominal pain and presented to the ED where an abdominal CT revealed a large soft tissue mass in the right aortocaval region measuring 8.6 x 7.7 x 8.4 cm, suspicious for renal cancer, as well as an expansile soft tissue lesion within the right vertebral body of T11 measuring 4.5 x 3.8 cm, suspicious for metastatic lesion, as well as abdominal lymph nodes.
He was diagnosed with metastatic urothelial carcinoma (primary) with bony metastasis.
Should this patient have received adjuvant treatment (chemotherapy and/or radiation) after surgery?
Should the urologist have referred the patient to a medical oncologist?
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Do you believe there might have been medical error?
It is unlikely there was an error. Currently, there is no standard of care, with regard to chemo or radiation therapy for urothelial cancer, however neoadjuvant chemotherapy is commonly used in many cases, as we do so commonly with bladder cancer. If there was known nodal involvement at the time of resection, chemo or radiation or both would have been appropriate. The concern, really is with post op surveillance. I would hope that six months or even nine months CT scans were performed in order to catch this earlier and then prevent by the metastatic disease.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
In the absence of a standard of care, I think it could easily be argued that surveillance postoperatively would benefit this patient more than adjuvant therapy. However, if there was poor postoperative surveillance with imaging, then causation may be possible.
What makes you a good expert for this case?
I am actually published in the medical literature regarding robotic nephroureterectomy for Urothelial carcinoma. In addition I run our urology tumor board on a monthly basis, so I am very familiar with urologic cancers.
How often do you encounter cases similar to this one in your practice?
In our group we probably see 1 to 2 upper tract urothelial carcinoma’s requiring nephroureterectomy a year.
Do you believe there might have been medical error?
From a surgical perspective the treatment was correct and standard of care. Although there is high grade large volume disease there is no standard of care for adjuvant chemotherapy after nephroureterectomy for TCCA of the renal pelvis. There are a number of papers that show some support for additional chemotherapy but they are limited by enrolled patient numbers. other studies have shown little effect. Whether or not the patient should have been referred to an oncologist is a good question. I would have sent this patient to an oncologist within our multispecialty group for an opinion and possible enrollment in a trial if desired but I would be hesitant in claiming there was malpractice in not offering an oncology consultation so less likely a medical error in my opinion.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
With high grade urothelial tumor in upper tracts the outcome is poor in general and adding chemotherapy for curative therapy cannot be proven beneficial except for a few small patient studies in the literature. There is no standard of care for this treatment but trials may be available
What makes you a good expert for this case?
I have been a urologist in practice since 1988. I have given up full time practice as I turn 64 but have seen a lot of patient care action for my entire practice career. I am Board certified .
How often do you encounter cases similar to this one in your practice?
These are not often seen cases I have a couple of recent patients who received neoadjuvant chemotherapy for high grade upper tract tumors with nodal involvement and they did well for a period of time before recurrence of disease
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