On January 8, 2021, a 52-year-old male patient underwent a screening colonoscopy that found 7 polyps, which were all benign. (Procedure report w/ photos uploaded.) One year later, he underwent a TURP for what was thought to be just an enlarged prostate. Histopathology of the tissue removed was consistent with metastatic adenocarcinoma with signet ring cell features. Colonoscopy on 2/16/2022 found a "large infiltrative & polypoid mass with central deep ulcer... away from the IC valve" in the cecum, which was biopsied and described as "moderately differentiated adenocarcinoma with signet ring cell features." The patient also had peritoneal metastases.
Can we say, more likely than not, that the tumor must have been present and missed on the colonoscopy one year earlier?
If so, can we say, more likely than not, that the patient would have survived if it had not been missed?
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Do you believe there might have been medical error?
It's nearly impossible for a colon cancer which is "large" (will need details) to develop in 1 year - this was likely missed; and the colonoscopy report photo labeled "cecum" does not show the appendiceal orifice, thus the cecum was likely not reached. I'm unclear how a prostate biopsy however would find metastatic colon ca - colon cancer does not metastasize to the prostate..
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above; if pt had a colon cancer on the second colonoscopy, it was likely missed on the first one. IF that is truly the cause of the nodes and metastases, it was initially missed and led to the current situation.
What makes you a good expert for this case?
See C.V.; full time GI practice for 26 years, 25,000 endoscopic procedures performed.
How often do you encounter cases similar to this one in your practice?
We do colonoscopies daily, and find polyps/cancers regularly. We abide by current quality guidelines including withdrawal time, monitoring ADR's etc to ensure quality colonoscopies. Those guidelines will be a factor in this case as well, as to whether it's documented they were followed.
Do you believe there might have been medical error?
Signet cell carcinoma of the colon is extremely rare (about 1%). It is also not the type of cancer in the colon that screening programs (colonoscopy, fecalimmunochemical tests [FIT], or Cologaurd) for average risk colon cancer were designed to detect. Lastly the signet cell carcinoma found in the colon may have been metastatic (ie not the primary cancer)..
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Colon cancer screening is not designed for signet cell cancer. This signet cell may have been metastatic from another organ (stomach).
What makes you a good expert for this case?
I am a practicing gastroenterologist over 10 years with active colon cancer screening program.
How often do you encounter cases similar to this one in your practice?
I have never seen signet cell carcinoma in the colon.
Do you believe there might have been medical error?
This matter has several facets and technical components which should be understood if not by a judge or jury than by plaintiff's (and maybe defense) counsel in order to best strategize/approach. Will summarize these herein: It takes on the order for years for a colonic adenocarcinoma, even if with signet ring cell features (a cytopathological feature which can sometimes confer more aggressive tumor biology), to form and thereafter metastasize, as was found to be the case in this matter. Therefore, it seems at least "very likely" that the cecal lesion identified on colonoscopy on 2/16/2022, namely the "large infiltrative & polypoid mass with central deep ulcer... away from the IC valve" was already present and of a size that should be readily visible colonoscopically. The colonoscopy procedure repot from January 8, 2021 does have a photo to document visualization of the cecum (an important quality metric); however, i) it is not clear that this photo is in fact depicting the inside of the cecum and ii) does not guarantee that the cecal exam was adequate. This patient also seems to have a tall ileocecal valve per se, which can conceal neoplasms just behind (i.e. proximal to) it. While it may be admissible that a small polyp in the cecum could thus be missed, one that only a year later has become metastatic adenocarcinoma with peritoneal carcinomatosis is very difficult to justify and suggests negligence/performing below the standard of care. Moreover, the photos in the original colonoscopy report do not really capture the area in reference in the subsequent colonoscopy, i.e. the part "away from the IC valve"; therefore, it's difficult to say if there was nothing there. Having photos from the subsequent colonoscopy may be helpful in this regard.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Granted there was indeed a medical error, it seems at least " very likely" that it resulted in injury (the formation of metastatic disease that is no longer curable, as opposed to a localized pre-malignant or malingnant polyp that can be curatively resected) . A potentially useful piece of data, if available, would be abdominal/pelvic imaging from around the time of the initial colonoscopy showing that there is no (occult/subclinical) peritoneal carcinomatosis/metastasis at that time (if such imaging exists and there was no metastasis, even more reason to believe in the likelihood of resulting in injury)
What makes you a good expert for this case?
I'm the a Health Sciences Clinical Professor in the Geffen School of Medicine at UCLA and an Advanced Therapeutic Endoscopist and Director of Endoscopy at Olive View-UCLA Medical Center. I have published extensively in the field of endoscopy and also specifically in the area of colonoscopy, colon cancer, colonoscopic resection, and so forth. I'm a certified medical expert in Gastroenterology for the Medical Board of California. I have served as an expert medical witnesses--both for defense as well as plaintiff-- in select cases, including at the federal level. I am committed to completing professional expert services promptly, collaboratively, and effectively.
How often do you encounter cases similar to this one in your practice?
It's somewhat difficult to say how often since it's not clear what aspect of this case the question is referring to, but granted it is referring to missed colon polyps that are subsequently detected, I would say approximately once every 6 months (at least for the past 5+ years)
Do you believe there might have been medical error?
There is 5% cancer miss rate (esp right sided lesions) even with high quality colonoscopy, this exam appeared to be complete to the cecum, in a well prepped colon and the recall interval based on findings and path was appropriate. The photos seem to support a complete exam. It is plausible the cancer was already metastatic at the time of the scope, or that there was an unrecognized and accelerated carcinogenesis pathway (genetic) in play.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above. There is 5% cancer miss rate (esp right sided lesions) even with high quality colonoscopy, this exam appeared to be complete to the cecum, in a well prepped colon and the recall interval based on findings and path was appropriate. The photos seem to support a complete exam. It is plausible the cancer was already metastatic at the time of the scope, or that there was an unrecognized and accelerated carcinogenesis pathway (genetic) in play.
What makes you a good expert for this case?
I have performed over 10,000 colonoscopies and my expertise is GI cancer detection.
How often do you encounter cases similar to this one in your practice?
Once a year on avg, it is a limitation of the procedure itself even under the best of circumstances. See: https://www.gastrojournal.org/article/S0016-5085(04)00924-2/fulltext
Do you believe there might have been medical error?
The cecal ulcerated malignant polypoid lesion is likely missed during the previous colonoscopy on January 8, 2021.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Although it is undiagnosed malignant lesion caused any metastases on January 8, 2021, colonic adenocarcinomas with signet ring cell features are very aggressive cancer type, 13 months delayed diagnosis may play a role for this advanced situation.
What makes you a good expert for this case?
I am in academic medicine since my training at the University Pennsylvania, PA in 1979. As seen details in my CV, I have been clinical investigator and educator in various medical schools in leadership positions in the US and I am a professor of medicine since 1982. I have over 190 published articles in peer review journals and served important advisory/executive committees as a chair and/or member at the American Gastroenterological Association, College of American Gastroenterology (ACG) and beyond. I am master in gastroenterology by the ACG and various other prestigious awards by the other organizational
How often do you encounter cases similar to this one in your practice?
There is probably an unfortunate delay for the advanced cecal adenocarcinoma with signet cells nearby the ICV, possibly due to flat lesion at the hidden area of cecum.
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