A 53 year old Caucasian female presented to an urgent care center with bloody diarrhea and vomiting. She was a UK resident visiting Key West. The family medicine physician ordered a CT abdomen/pelvis with contrast. The radiologist failed to identify an approximately 1 x 3 cm upper pole renal mass resulting in a 1 year delay in diagnosis.
The UK oncologists initially treated with Ipilumimab and nivolumab, but the patient failed therapy due to severe colitis. The patient was then placed on corticosteroids and ustekinemab, followed by cabozantinib.
She travelled to Tampa for a second opinion who noted the following:
The timeline shows a rapid natural history with growth from the small mass not identified in 2019 to the much larger mass and associated adenopathy. The adenopathy does run along the margin of the aorta for at least 10 cm. This certainly makes consideration of resection problematic. The primary itself is relatively isolated and conceivably a nephrectomy for debulking might be a consideration but the amount of disease left behind would be the majority.
The Tampa oncologist noted that there was neither regression nor tolerability to the initial treatment (although he agreed with the initial plan once the cancer was identified).
The patient died, while on palliative care, on 5/17/23.
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Do you believe there might have been medical error?
Even though the case mentions that the mass was seen during the patients original presentation. per the 2nd opinion note, they mention- "The timeline shows a rapid natural history with growth from the small mass NOT identified in 2019 to the much larger mass and associated adenopathy" If the mass was originally present and missed by radiologist, it is a medical error But if it was not seen on original CT, that it is likely not an error
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again, If the mass was originally present and missed by radiologist, it is a medical error. Renal cancers are curable when non metastatic with surgery. If her mass was missed and she became inoperable, we can consider causation Also, it is important to know what happened in UK. Why did she get Ipi, Nivo, when she was someone who was prone to diarrhea But if it was not seen on originally CT, the above holds untrue
What makes you a good expert for this case?
I have experience treating RCC in early stage and advanced stage. Besides I am familiar with side effects of the medications and the current/prospective research in the field. Non clear cell kidney cancers unfortunately can behave aggressively and there are not many new trials focusing on this histology
How often do you encounter cases similar to this one in your practice?
I encounter 5-10 new cases a year and have managed multiple cases over the years
Do you believe there might have been medical error?
The patient had a nonclear cell type. It depends on the type of non-clear cell. Clear cell renal carcinoma (ccRCC) is the most common histopathological subtype and accounts for approximately 75–80% of all cases. Papillary renal cell carcinoma (pRCC) in the non-clear cell type, the second most common subtype after ccRCC, accounts for 10–15% of all cases. The pRCC in the non-clear group was found to be differentiated into two prognostically divergent subgroups: an organ-confined / localized subgroup with a significantly better prognosis and a metastatic subgroup with a worse prognosis than the clear cell reference group. Several studies have found that non-metastatic pRCC showed a significantly reduced risk of cancer-specific death when compared to ccRCC. See: “The outcome of papillary versus clear cell renal cell carcinoma varies significantly in nonmetastatic disease,” N. Wagener et al., PLoS ONE (2017) 12(9): e0184173; and “Incidence and long-term prognosis of papillary compared to clear cell renal cell carcinoma – A multicentre study”, S. Steffens, et al., European Journal of Cancer (2012) 48, 2347-2352. Patients with papillary renal cell carcinoma face low tumor re-occurrence and cancer-related death rates, based on the peer-reviewed article “Prognostic factors in a large multi-institutional series of papillary renal cell carcinoma,” A. Zucchi et al., BJU International (2011) 109, 1140-1146. Since this patient has a unique TFE3+ mutation, it is aggressive in the metastatic setting rather than an early-stage disease.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If it were diagnosed in the early stage, he would have a better 5 yr OS.. It is my opinion, to a reasonable degree of medical certainty, that the radiologist significantly deviated from the standard of care in 2022 when he reviewed the CT scan. He would be having a better 5 yr OS
What makes you a good expert for this case?
I have testified in 8 trials and done 4 depositions for the defense. I have done plaintiff's work and have opined a similar case of RCC which was settled.
How often do you encounter cases similar to this one in your practice?
This is a rare mutation. Non-clear cells are rare, and we do not encounter them routinely. When we see one, we remember one.
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