CT guided biopsy right upper lobe lesion in April 2024 consistent with adenocarcinoma, moderately differentiated, TTF
1 positive, CK7 positive, CK20 negative consistent with lung primary with PDL1 expression of 40%. Pathology revealed 4/4 station 4R lymph nodes negative for metastatic carcinoma. Pt's thoracic surgeon also consulted with thoracic tumor board. Due to lymph node involvement present on PET scan N1 and consensus from tumor board, the recommendation is for the patient to proceed with neoadjuvant chemotherapy rather than post op treatment. Creatinine 1.07 and EGFR 56.3 on 4/11/24.
On 7/3/24, started chemo with Carbo/Pemetrexed/Keytruda. Creatinine level after initial chemo 3.71 & eGFR = 12.6. In spite of decreased renal function, on 7/25/24, Carboplatin dose reduced to 351 from 438 d/t diffuse rash but client still received Carbo/Alimta/Keytruda. Renal function worsened. Dx'd with Tubulointerstitial nephritis. She remains on dialysis 3x/week.
Client believes she was given improper chemotherapy which caused her kidneys to fail.
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Do you believe there might have been medical error?
It depends on whether she was appropriately treated for autoimmune nephritis. if not, there is a case.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
We do not have enough information with regard to her immune-mediated nephritis
What makes you a good expert for this case?
i have tesfied in 9 cases on trial
How often do you encounter cases similar to this one in your practice?
rarely. we do not see that often
Do you believe there might have been medical error?
Need more information about the size of the cancer and lymph node status to stage the cancer and understand why chemo immunotherapy was used. But side effects can happen with treatments and although rare nephritis can happen from keytruda.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As long as there was a clear indication for using chemoimmunotherapy, the use seem appropriate. Besides, the oncologist appropriately reduced tue dose of Carboplatin. The rate of nephropathy from keytruda is rather low and only way to know is biopsy or rule out other causes
What makes you a good expert for this case?
Medical oncologist with over 10 years of experience and busy lung cancer practice
How often do you encounter cases similar to this one in your practice?
I see lung cancer and use above regimen multiple times. Rate of nephropathy is 2-14%. I have seen 5-10 cases over the time.
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