Age: 66-year-old female
Primary Diagnosis: High-grade metastatic endometrial carcinoma
Harm: ?? Misdiagnosed spinal metastasis → Inappropriate radiation → Permanent paraplegia
Cause: ?? Immune-related demyelinating disease from Jemperli (dostarlimab)
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Timeline of Key Events
2020–2023: Cancer History
• 2020: Diagnosed with high-grade endometrial carcinoma.
Treated with surgery (TAH/BSO), chemotherapy (Carbo/Taxol), and vaginal brachytherapy.
• 2023: Cancer recurrence with malignant ascites and omental caking. Started Jemperli immunotherapy.
• December 2023: Declared cancer-free by Florida Cancer Specialists.
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February 2024: Misdiagnosis and Radiation
• Feb 8: Sudden onset of bilateral leg weakness and numbness. Goes to hospital #1.
• Feb 15: MRI showed brain and spinal lesions; interpreted as metastases. Radiologist recommended biopsy/further investigation to determine exact etiology.
• Feb 17: Oncology/Radiologist initiated emergent spinal radiation based on imaging alone. No CSF confirmation or biopsy obtained before radiation. Biopsy considered, considered too high risk.
• Feb 19: First lumbar puncture: lymphocytic CSF, no malignancy.cRadiation continued despite this.
• Feb 23: Completed 5 rounds of radiation. No neurologic improvement.
• *** LP notes are attached as screenshot ***
• Feb 28:Second LP again showed no cancer. Concern raised for immune-related demyelination.
Tumor board note March 10, 2024: "LP completed with CSF analysis, findings are not suggestive of malignancy. Had an extensive discussion with IP following our multi- disciplinary Tumor Board and it was recommended that she undergo thorough work-up for possible demyelinating conditions due to the presence of the long segment T2 thoracic intramedullary hyperintense signal thoracic intramedullary enhancement, again grossly spanning from T9 through T12. Spinal cord biopsy was discussed with Neurosurgeon who requested alternative work-up due to risk of procedure. We had a very thorough discussion with IP and her son regarding the risks of this procedure due to the location of the mass. From a Neuro- Oncology standpoint, we are recommending re consultation of neurology to facilitate any additional work-up while inpatient for possible demyelinating conditions as well as a consultation with a Neuro- Immunologist outpatient. We will plan to see Ms. Taylor in our clinic with follow-up imaging in about 2 months time.
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March 2024: Second opinion from different facility: Correct Diagnosis and Irreversible Injury
• Mar 14–16: Transferred to new hospital: MRI: lesions consistent with demyelinating disease, not cancer. Diagnosis: Jemperli-induced immune-mediated CNS demyelination Started IV steroids, Jemperli discontinued, Paraplegia now permanent.
D/C to rehab
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April–June 2024: Complications from Care
• Stage 4 pressure ulcer developed from inadequate turning.
• E. coli sepsis from fecal contamination at SNF.
• GI bleeding from radiation enteritis.
• Multiple hospitalizations, debridement, and rehab setbacks.
• Still paraplegic. Wound unlikely to heal. No cancer recurrence noted.
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Current Status
• Paraplegic, no functional recovery of legs.
• Recurrent sacral and heel ulcers.
• Requires special bed, full-time care.
• Cancer remains in remission.
• Under Neurology follow-up for long-term care and monitoring
Questions to consider:
Was the IPs lack of neurological function upon initial presentation to hospital #1 already too late for reversal of demyelinating disease if recognized early?
Was the radiation that was emergently ordered appropriate despite lack of available lumbar puncture results and/or biopsy?
Despite the difference in treatment plans, would anything have changed the overall outcome of IPs mobility dysfunction/progress of symptoms despite delay and recognizing the less than 1% chance of Jemperli-related complications?
Any other observations or insights would be appreciated.
Files:
No questions yet!
Do you believe there might have been medical error?
While it is difficult to ascertain not knowing the radiation dose and field design, assuming standard dosing the risk of myelitis or myelopathy in this setting should be less than 5%. Ideally biopsy would have been obtained but depending on the patient's clinical condition it is not unusual to treat without biopsy in the emergent setting, especially in the setting of a previously diagnosed cancer and radiographic concern for progression. Now, if the radiation field or dosing was inappropriate that may change my perspective. I would be happy to review these in further detail to provide a more nuanced opinion.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As above, without evaluating the specific radiation dosing and field, it is difficult to make this assessment. But assuming standard design and dosing, the risk should be less than 5%.
What makes you a good expert for this case?
I am a third generation, board certified radiation oncologist. My family and I have been practicing in the state of Florida since 1957. I have the benefit of running a long term follow up clinic and fully understand and can easily explain in the layman/s terms the long term expected effects of radiotherapy. I also have impeccable and unimpeachable credentials, having graduated from Princeton, the University of Florida College of Medicine, and the Mayo Clinic for my residency. I hold academic appointments at the University of South Florida and the University of Central Florida as well, and teach residents and medical students.
How often do you encounter cases similar to this one in your practice?
I see this type of clinical scenario on a weekly basis, working in a high volume tertiary care hospital.
Do you believe there might have been medical error?
This is an unfortunate case, but the Patient likely underwent standard palliative radiation to a radiation dose that would have no chance of causing paraplegia. Radiation to the spinal cord is commonly prescribed and because its given over several days it does not cause paraplegia.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I dont believe the radiation caused her injury. Standard radiation to the spinal cord does not cause spinal cord toxicity beacuse its given over several days. Her paraplegia was almost certainly due to her underlying demyelinating disorder.
What makes you a good expert for this case?
Am in expert in central nervous system tumors and palliative radiation.
How often do you encounter cases similar to this one in your practice?
I often treat cancers that have spread to the spinal cord
Do you believe there might have been medical error?
this type of side effect from dostarlumab is very uncommon, and using imaging alone to diagnose a recurrent cancer is a common standard of care. if the radiology report indicate spinal metastases and the patient had neurologic symptoms, urgent treatment with radiation would have been medically justified. one key is to better understand the radiology interpretation.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
it is possible that the radiation accelerated or worsened the neurologic condition, but, the patient seems to have had these issues even before radiation. the cause of the outcome cannot be solely pinned on the radiation.
What makes you a good expert for this case?
i have ~20 years experience as a radiation oncologist and have 10 years experience serving as the quality chair of our department
How often do you encounter cases similar to this one in your practice?
this is a very rare situation and i have not heard of any similar case in our hospital's practice as long as i have been here
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Comments are accepted only from Radiation Oncology - includes all subspecialties experts.