The patient is a 23-year-old white female, gravida O who presented acutely to the emergency room two days ago and was identified on CT scan to have a complex pelvic mass which measured 10 cm x 12 cm x 3.8 cm in size. Her presentation was with acute pain and ultimately she elected to proceed with a laparoscopic evaluation of the pelvic mass .
March 9, operative laparoscopy and then laparotomy for right salpingo-oophorectomy.
Please see attached for OP notes and summary.
**Later notes from a different facility state the mass “ruptured during surgical extirpation”.**
Pathology yielded an Immature Teratoma high grade 3.
She was seen for initial gynecologic oncology consultation on 4/10/2023 and tumor markers on 4/10/2023 showed her AFP to be slightly elevated at 10.8, quantitative hCG was less than 5 and LDH was normal at 114.
4/17 PET Scan: revealed a hypermetabolic soft tissue nodule abutting the posterior right lobe of the liver, posterior and superior to the right kidney measuring 2.4 x 1.6 cm.
There was a similar small hypermetabolic nodule posterior to the descending colon.
There were multiple intensely hypermetabolic soft tissue nodules in the right pelvis abutting the uterus and more anteriorly, the largest measuring 3.9 x 1.9 cm with 2 adjacent hypermetabolic nodules in the left pelvis in the region of the left ovary/adnexa along the left external iliac vessels. Incidentally, there was a peripheral pulmonary micronodule in the right lower lobe felt to likely be benign.
These were not present prior to March mass removal.
4 cycles of Chemotherapy were now ordered. Completed between May and July 2023.
CT abdomen pelvis done on 9/6/2023 showed reduction in pelvic midline mass with multiple peritoneal nodules and masses new from prior study. Findings and options for management have been explained in full she wishes to proceed with exploratory laparotomy, tumor debulking, omentectomy, possible bowel resection if indicated.
Approx 15 new masses found. Pathology with teratomas (no immature elements) suggesting growing teratoma syndrome.
2 days later, admitted to a new facility for increased shortness of breath. Found to have bleomycin pulmonary toxicity. She declined severely during the admission and required transport to a larger hospital for ECMO and possible lung transplant.
October-January: Very complicated and extended admission for the bleomycin pulmonary toxicity. Included ECMO, long term intubation. She did undergo a successful lung transplant and is improving.
Our question concerns the original treatment and operative intervention by the OB provider. Is it possible the rupture of the mass could cause the subsequent complications and potential spreading of teratoma cells? The recurrent disease led to chemotherapy which led to chemo-toxicity which resulted in the lung transplant. Additionally want to confirm the overall care plan for a patient of this nature form an OB GYN/Onc perspective.
Please let us know if you need any further info.
Files:
Q: What was the preop workup and counseling prior to 3/9 surgery?
A: Yes both were performed
Q: Not whether they were performed, but the details. Specifically, if the imaging was of high concern for malignancy, and whether the imaging was consistent with more of a cystic appearance than solid as was seen intraoperatively
A: —
Q: , and counseling wise would like to know if counseling was for attempted ovarian cystectomy first and possible risks of ovarian cystectomy attempt. Or if decompression was always planned, and if so, if the risk of that was discussed
A: —
Do you believe there might have been medical error?
Potential error in question is dissemination of malignant immature teratoma (or perhaps the mature components within) at time of laparoscopy on 3/9. Based on the operative report, there was spillage of immature teratoma content as the surgeon initially used endoshears to try to decompress the mass, and noting the internal structure was solid - therefore it seems like the mass was indeed ruptured. The description of the size and complexity of the mass potentially may have prompted the surgeon to have assumed this was mature teratoma and thus an initial attempt at ovarian cystectomy. However, whether presumed dermoid or not, if there were no clear planes to have been found to attempt ovarian cystectomy upon exploration (there’s no description in the op note of starting with decompression to facilitate cystectomy, or identifying a plane between ovary and cyst and attempting cystectomy but incidentally rupturing the cyst), I believe decision should have been made to proceed with salpingo-oophorectomy rather than attempt decompression. If the only point of decompression was to allow it to be delivered through incision, the decompression could/should have been done in a contained manner *after* (salpingo-)oophorectomy and the ovary being in a bag with the neck of the bag outside the peritoneal cavity to avoid spillage. Would like a bit more information on preop workup and counseling, but based on the available information, I do not see a clear reason why the decompression was done from the get-go, and the decompression potentially led to the hypermetabolic (presumed metastatic) lesions seen on PETCT. However, given the patient had grade 3 immature teratoma, even if it had been contained at stage IA, adjuvant BEP would have been recommended, with resultant pulmonary toxicity which is a known side effect of bleomycin unfortunately.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
While the initial surgical management may have resulted in the initial spread of the immature teratoma, the injury in the case is noted to be the pulmonary toxicity of bleomycin, which would have been recommended/given as part of BEP for grade 3 immature teratoma even if it had been removed contained and were the earliest stage. If the injury/complication in contention were that the patient required additional debulking procedure after the initial surgery and BEP, that contention could be medically supported - the decompression likely led to spread of disease and while BEP treated the immature components, mature components would not have been treated and on imaging was seen and led to the debulking surgery
What makes you a good expert for this case?
I am a gynecologic oncologist in practice for 11 years, with focus on surgical treatment of gynecologic cancers. I have treated both mature and immature teratomas in my practice and am comfortable discussing treatment of them as well as potential complications of surgical and chemotherapeutic treatment of them
How often do you encounter cases similar to this one in your practice?
Mature teratomas once every month or so, immature teratomas every couple of years
Do you believe there might have been medical error?
Based on the available information, it is not clear how suspicious the providers were of a potential malignancy. This could have been assessed preoperatively with tumor markers. In the absence of reassuring information planned drainage would not be advised. While the mass might have ruptured during removal, even at laparotomy, planned drainage would be in advisable in my opinion
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Depending upon the preoperative extent of disease evaluation, one could hypothesize that the metastatic disease might be related to the intraoperative rupture and seeding of the perineal cavity.
What makes you a good expert for this case?
My training and expertise are aligned with the nature of this case.
How often do you encounter cases similar to this one in your practice?
The pathology is uncommon, but this is the type of case if you want oncologist would tend to see.
Do you believe there might have been medical error?
Patient was a young woman with excessive pain and required prompt intervention. While germ cell tumor should be considered in this situation, the appropriate treatment initially is to remove the mass and examine for any other obvious disease. The rupture of the tumor would not alter the treatment as Grade 3 immature teratoma requires chemotherapy even if apparent stage Ia. The appropriate treatment of BEP chemo was given and the later pulmonary toxicity is a known consequence of this therapy. The subsequent development of teratoma syndrome is a rare event and appears to be a consequence of the chemotherapy rather than due to some tumor spill. This is a very unfortunate case but I don’t see any evidence of mismanagement.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As above. The chemotherapy was necessary for this tumor and caused the pulmonary damage. The teratoma syndrome appears to also be a consequence of the chemotherapy.
What makes you a good expert for this case?
33 years experience as a gyn oncologist with treatment of germ cell malignancies both surgically and with chemotherapy.
How often do you encounter cases similar to this one in your practice?
About 1-2 germ cell malignancies per year.
Do you believe there might have been medical error?
I do not believe there was a medical error: 1) appropriate to change from laparoscopy to laparotomy once mass seen. Appropriate to call refer to gyn onc. 2) if rupture occurred, that is not an error. It is an unfortunate but common occurrence. 3) appropriate number of cycles of chemo(4) (assume BEP) given based on data from MDACC (Gershenson et al.) because of residual disease.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Changing from laparoscopy to laparotomy was appropriate for a complex mass. A complex mass should NOT be drained and removed if there is a likelihood of malignancy. Even if mass ruptured in the operation, that is not an error, it is an unfortunate occurrence. No problems with Gyn Onc care. Growing Teratoma Syndrome is a known complication when treating immature teratoma. Pulmonary fibrosis (along with retroperitoneal fibrosis) is a known toxicity of bleomycin.
What makes you a good expert for this case?
I am a gyn oncologist and have published on growing teratoma syndrome.
How often do you encounter cases similar to this one in your practice?
Uncommon. Germ cell tumors make up a small proportion of ovarian cancers.
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