A 52-year-old male patient with a past medical history of celiac disease went to the ED on 8/27/2021 complaining of abdominal pain, sweating, and muscle pain. A CT abdomen pelvis and a small bowel series with gastrografin were done, and the patient was diagnosed with diverticulitis. After several more fruitless ED visits, on 10/3/2021 another CT abdomen/pelvis was done which showed masses in the small bowel and mesentery, possible carcinomatosis, and possible metastasis to the right lung and right third rib. Within a week or so it was confirmed that the patient had Burkitt lymphoma, Stage IVB. He was started on DA-EPOCH treatment.
Apparently, the hospital has admitted that a mass was missed during the first ED visit on 8/27/2021. Before I have a radiologist confirm that, I am wondering what the chances are that the 5-week delay made a difference. Specifically, I assume the lymphoma will probably cause his death; would the same have been true if he had been diagnosed 5 weeks earlier?
If there is other information you need to make a determination, please specify what that is. Thank you!
Files:
Q: Were the labs and chest X-ray totally normal on first er visit ?
A: —
Do you believe there might have been medical error?
Of course review of all the pertinent records is always necessary before rendering a full opinion in a case. Here it is a given that a mass was missed on the CT scan. This was an error, unless perhaps it was very small and a reasonably careful radiologist would only have seen it in retrospect.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Depending on the size of the mass and its location, it may not even have been causing his symptoms, unless it was obstructing his bowel and surgery was needed to relieve the patient's symptoms, but that is not described here. The size and location of the lesion also has bearing on whether CT-guided biopsy was feasible or laparoscopic surgery would have been necessary to make a diagnosis. Had the mass been noticed and reported on the initial CT report, this patient's diagnosis and treatment would have only been accelerated by a few weeks, and that would not have made any difference in the final outcome. Though Burkitt's lymphoma is very aggressive and rapidly growing and needs intense multi-agent chemotherapy, including central nervous system prophylaxis, it should be treated with intent to cure, and hopefully that will be this patient's outcome, There is no indication for surgery or radiation to solitary lesion. It should be regarded as systemic disease from the start, for as this case indicates, it will spread as the work-up is proceeding. The reason the diagnosis would not have been made much sooner is that no reasonably prudent physician would have suspected Burkitt's lymphoma. It is exceedingly rare in adults. It is known as the one disease that almost grows while you watch it, but every other disease that would present as an abdominal mass would grow slowly, providing plenty of time to figure out who should take the lead in this case: GI, general surgery, oncology, and what approach to take. The work-up could have proceeded with biopsy first, or with chest CT, PET CT, or endoscopy. Consultations and scheduling of additional tests would easily have taken several weeks to accomplish. The patient is described as being obese, so decision-making regarding which diagnostic tests to pursue first would have been more complicated. In 99.9% of cases work-up of this problem would have proceeded methodically over the next 4-6 weeks. In this exceeding rare situation, the disease progressed rapidly before the work-up commenced in full, but the treatment and outcome will be the same. Earlier diagnosis would have spared the patient some discomfort and angst, but it would not have increased his chance for cure or prolonged survival..
What makes you a good expert for this case?
I have been practicing clinical oncology for 35 years. I have been a generalist most of that time, though I spent 7 years in academic practice focusing on chest malignancies. My broad experience in treating many malignancies is an asset in understanding this case. Unlike many oncologists, I never took the "call me when you have a tissue diagnosis" approach. I always thought I had something to offer early on in the investigation of presumed cancer, even if there was a chance it would turn out not to be a cancer at all. I did not feel this was wasted time. I learned something and the patient has other physicians often gained by my knowledge of how various cancers presented and progressed.
How often do you encounter cases similar to this one in your practice?
I have treated as many Burkitt's patients as most any other adult oncologist - 2. Pediatric oncologists treat Burkitt's much more commonly, but they are not involved in the initial evaluation of adults with suspected cancer.
Do you believe there might have been medical error?
Yes, if indeed the abdominal mass was missed during the first emergency room visit and scan on 8/27/2021, this 5-week delay would absolutely be a medical error, and it would absolutely impact patient's outcome. Burkitt's lymphoma is a high-grade, highly aggressive lymphoma which can grow extremely rapidly. He was diagnosed with stage IVb lymphoma but it may have only been stage II or III 5 weeks previously. This impacts his disease burden, chance of response to therapy, and potential toxicity of therapy. With respect to its rapid growth, and increased disease burden, he is then at risk for tumor lysis syndrome and organ damage.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Because Burkitt lymphoma is an aggressive and rapidly growing tumor, this patient may very well have been harmed because of missing the diagnosis for several weeks and having a chance for increased disease burden, as reported above.
What makes you a good expert for this case?
I am a hematologist/oncologist who has experience in treating Burkitt lymphoma.
How often do you encounter cases similar to this one in your practice?
I see all types of lymphoma, and have been treating hematologic malignancies for about 30 years. Burkitt lymphoma is not very common, but I see 1 or 2 cases every few years.
Do you believe there might have been medical error?
This type of lymphoma is extremely aggressive. Cure rate with earlier stage disease is HIGHER than if it was caught at stage IVB. This is one of the factors in going into prognosis of Burkitt's Lymphoma (stage). LDH also plays a role - was this high? Catching the mass/masses on the films earlier would have lead to earlier treatment and better prognosis.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Biopsy earlier would have led to earlier diagnosis and treatment. If the mass was missed, this delayed time to diagnosis /treatment.
What makes you a good expert for this case?
I have 17 years of experience BOTH in private practice oncology / hematology as well as a hospital-based position. I have excellent communication skills and devote extensive time to explaining medical terms and issues to laypersons. I conduct extensive clinical research via trials as well.
How often do you encounter cases similar to this one in your practice?
I experience something like this about 3-4 times / year with delay in diagnosis leading to delayed care.
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