In July 2021, a 69-year-old patient went to her regular GYN complaining of vaginal bleeding for the past several months. An ultrasound on 8/10/21 showed an enlarged uterus but the rest of the report is illegible to me -- I will upload to see if anyone else can decipher it. Endometrial sampling was done on 8/18/21, which did not find any dysplasia, but the report also says "No endometrium identified." The GYN diagnosed her with fibroids, prescribed Lupron and norethindrone for the bleeding, and did nothing further. On March 11, 2022, the patient sought a second opinion from a doctor who was her former employer, by April, she had been diagnosed with Stage IVB endometrial cancer, Type 2. She passed away in May.
My biggest question is whether the delay in diagnosis was long enough to say that, more likely than not, she would have survived if the cancer had been diagnosed in fall 2021. I also wonder whether the Lupron and/or norethindrone made things worse in any way. Of course, I am also interested in any opinions on the standard of care as well.
Thank you.
Files:
No questions yet!
Do you believe there might have been medical error?
If endometrial sampling is inadequate, there should have been follow up with another method of sampling.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is difficult to tell whether a delay from August 2021 to April 2022 led to upstaging of disease from an earlier stage where survival was more likely, to stage IVB - it is possible that in August 2021 there was either no cancer (type 2 cancers can develop really quickly) or already advanced cancer (survival for advanced/metastatic endometrial cancer is ~12-14 months), both of which would not have made a difference. If one could know/prove that the cancer was indeed in a early stage back in August 2021, such that it could have been diagnosed and treated earlier, then one can say the chances of survival would be better. As it is, I am not sure this scenario is more likely than the other two (where there was no cancer or already metastatic cancer initially) Type 2 cancers don’t tend to be hormone-sensitive. Lupron in a menopausal woman likely doesn’t do anything, as Lupron in premenopausal women puts them into a chemical menopause. Northindrone is a progestin and, as such, would have anti-hormone-sensitive endometrial cancer properties. Therefore, I don’t believe there would be an explanation for either drug to have worsened the cancer outcome in this case.
What makes you a good expert for this case?
I am a board-certified gynecologic oncologist
How often do you encounter cases similar to this one in your practice?
Endometrial cancer - 1-4 cases a week
Do you believe there might have been medical error?
It would be useful to know the endometrial stripe size of the ultrasound that was initially performed. Can a formal report be requested from radiology if what you have is ineligible. Or was it just a bedside US done by the provider? If the EMS was <5mm technically no endometrial sampling would have been considered acceptable. Based on the fact the provider opted to proceed with endometrial sampling suggests the lining was potentially >4mm or bleeding persistent. The lack of endometrial tissue should have prompted further evaluation with strong consideration for a hysteroscopy and D&C for further evaluation.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There is no way to know if the patient had stage IV disease at time of her initial presentation or if the 7 month delay in diagnosis altered the course of her disease. Would be useful to look at symptoms she reported around initial presentation yo get some insight. Type II endometrial cancers (ie serous carcinoma) have a higher propensity to spread quickly and be aggressive. I am assuming the Lupron was given to help shrink fibroids and the norethindrone to help with endometriosis. Neither are standard in my opinion for treatment of PMB. Norethindrone is a low dose progesterone. Higher dose progesterone (Megace for ex) is sometimes used to treat endometrial pre-cancer and type I endometrial cancer, but I don’t suspect this is why the provider was ordering and in this case was likely not helpful as my serous cancer is not hormone responsive. The Lupron was likely protective as it shuts down estrogen and progesterone from being secreted from ovary. Not all Type II endometrial cancers are responsive to estrogen or progesterone, however - many are not. To know if this may have caused harm it would be helpful to look at the ER / PR (estrogen receptor and progesterone receptor) status of the tumor which pathology may have run.
What makes you a good expert for this case?
High volume Gynecologic oncologist. Attention to detail in case review
How often do you encounter cases similar to this one in your practice?
>150 endometrial cases /year with high volume of type II endometrial cancers
Want to open a case or submit response?
Comments are accepted only from Gynecologic Oncology (Obstetrics and Gynecology) experts.