In February 2014 a 60 y.o. woman with h/o hypertension and hepatitis C presents to the ED with abdominal pain and gross hematuria.
CBC shows normal WBC, PLT 54.
A CT abdomen/pelvis without contrast is obtained, and is reported as: bilateral kidney stones with left hydronephrosis, gallstones, splenomegaly, diverticulosis.
A U/A is consistent with UTI. Cultures will grow E. Coli. The patient is prescribed antibiotics for the UTI, and sent home with the recommendation to follow up with a urologist.
Exactly one year later, in February 2015, a CT abdomen/pelvis is obtained for different reasons. The radiologist finds a 3.6-cm live lesion located in segment IV/VIII. The radiologist also reports a cirrhotic liver with splenomegaly, peri-gastric, peri-esophageal, and peri-splenic varices. There are prominent peri-portal and porto-caval lymph nodes, up to 1.4 cm in size. There is a small degree ascites.
AFP is 146.
An MRI of the liver confirms the findings, which are consistent with HCC.
A review of the prior CT obtained in 2014 reveals that the liver lesion was in fact obviously visible, despite the lack of IV contrast. At that time the lesion was about 2.5 cm in size.
In March 2015 the patient undergoes TACE, which is followed by percutaneous ablation.
Unfortunately, in 2016 new hepatic lesions consistent with metastatic disease are detected, and the patient dies in 2017.
Had the radiologist detected the lesion in 2014, would treatment options and prognosis have been any different?
Files:
No questions yet!
Do you believe there might have been medical error?
According to consensus guidelines and US standards of care, if HCC was confirmed back in 2014, the patient should have been offered definitive treatment. This may have included resection (if technically feasible) or locoregional therapy which may include ablation, XRT, or arterial directed therapy. Imaging would have been done every 3-6 months thereafter with also serial tumor markers. The delay in diagnosis for 12 months was certainly a miss since the tumor grew in the interval without treatment. The patient was at high risk for HCC given the longstanding Hep C history
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As stated above, the delay in diagnosis of the HCC led to the tumor growing unchecked for a year. It is unknown, but likely, that the outcome for this patient would have been better had the tumor been treated aggressively when first detected in 2014.
What makes you a good expert for this case?
I am a medical oncologist. I have seen previous patients with HCC in my practice when I was on staff at Columbia Presbyterian Medical Center in NYC.
How often do you encounter cases similar to this one in your practice?
yes, I have seen previous patients with HCC in my practice when I was on staff at Columbia Presbyterian Medical Center in NYC.
Do you believe there might have been medical error?
I would have to see the images before being certain that there was an error. Although I am not a radiologist, I require in such cases that I can be clearly convinced that a finding was missed. Then it must be considered that it can be much easier to see a lesion in retrospect. Still, it seems likely that the radiologist in 2014 missed the liver tumor because he/she was distracted by the stones, hydronephrosis, splenomegaly, gall stones, and diverticulosis. (I wonder subtle varices were also present, given the splenomegaly and thrombocytopenia.) This seems to be the easy part of this case.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
At first blush it seems obvious that this patient would have done better with earlier treatment in 2014. However, that would require a significantly better therapy than the transarterial chemoembolization (TACE) than she received in 2015. TACE is a palliative treatment for hepatocellular carcinoma, with little chance for cure or prolonged survival. In my opinion, it is unlikely that, had the tumor been detected in 2014, this patient would have been a candidate for curative therapy, i.e. resection or transplantation. Although varices were not mentioned in the original CT report from 2014, they were undoubtedly present, given that they were extensive a year later. The location of the tumor in the central part of the liver, segments IV/VIII in this case, make surgical resection difficult in a patient with cirrhosis, because of the amount of liver that must be removed without extraordinary techniques, which may not have been readily available or perfected in 2014, now 8 years ago. Her platelet count of 54,000 would make any surgeon think twice before undertaking a surgery with significant risk of bleeding as is hepatic resection in a cirrhotic patient. Transplantation could have been be considered, but the low platelet count could also make that risky as well; the extent of metastases a year later make it hard to postulate that she could have been cured with transplantation a year earlier. Localized non-surgical therapies often seem to slow the growth of hepatocellular caricnoma, particularly if done early. This tumor was of only moderate size in 2014 (2.5 cm), so such therapies would certainly have been employed, but in my opinion it is not likely that the patient would have lived past 2017.
What makes you a good expert for this case?
I have extensive experience over the past 30 years in treating patients with cancer and thrombocytopenia. I am board certified in oncology and hematology. I work in close collaboration with surgeons and radiologists.
How often do you encounter cases similar to this one in your practice?
I see patients frequently with thrombocytopenia, cirrhosis, and varices. I see patients occasionally with hepatocellular carinoma. I do not specialize specifically in liver tumors.
Do you believe there might have been medical error?
In 2014, the size of the lesion was 2.5 cm. typically it would be amenable to surgical resection if the cirrhosis was not advanced like in 2015. I did not see any comments on the liver in the CT scan without contrast. If there was advanced cirrhosis, then she would be eligible for a liver transplant. based on the guidelines, she would be a top priority due to HCC.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
she would be amenable to surgical resection or liver transplant.
What makes you a good expert for this case?
I have been on 4 cases on a trial stand and 3 depositions. I have done HCC reviews on 3 occassions.
How often do you encounter cases similar to this one in your practice?
i have reviewed cases on HCC on 3 occassions
Want to open a case or submit response?
Comments are accepted only from Medical Oncology experts.