74 y/o with PMH HTN, CVA 2019, mild cognitive impairment with memory deficits, EGD x2, watchman procedure, knee surgery. 50 pack year per CT scan history (Dietrich’s note says less than 5 years), family history-mother with breast and colon cancer, brother with lung cancer, Vietnam veteran.
09/05/2024 Dr. Allan Powell at Viera Imaging-CT scan low dose of the lung for routine cancer screening 2/2 history of smoking . Impression: Lung RADS category 1- negative-recommend annual screening.
06/26/2025 Peter Koretsky-EGD with biopsy-no procedure records- referenced in Dr. Dietrich note
07/03/2025 EGD/Dilatation and EUA performed by Ji Young Bang, MD [pathology only]- Pathology tissue exam: ESOPHAGUS, DISTAL MASS, BIOPSY:- MODERATELY DIFFERENTIAUD ADENOCARCINOMA.- BACKGROUND OF BARRETT ESOPHAGUS WITH HIGH-GRADE DYSPLASIA.
07/09/2025 Dr. Allan Powell at Viera Imaging-CT chest without contrast-has esophageal cancer, compare last year. Impression: Distal esophageal wall thickening, consistent with esophageal cancer. No lung nodules or adenopathy appreciated.
07/15/2025 Cancer Care Center of Brevard-Martin Dietrich, MD-initial visit: referred by Peter Koretsky, MD. 74 year-old patient with adenocarcinoma of the GE junction. He has been undergoing EGD for difficulties swallowing with worsening food caliber, He has lost 15 lbs of weight . He had EUS on 07/03/2025 demonstrating two abnormal lymph nodes in the lower paraoesophageal mediastinum in addition to severe stenosis. His biopsy demonstrated adenocarcinoma, PD-Ll missing with pMMR and Her2 non amplified disease,06/26/2025 Esophageal biopsy .FINAL DIAGNOSIS, Esophagus,.Distal, Biopsy: • ADENOCARCINOMA MODERATELY DIFFERENTIATED-Dr. Karotsky's office notified on 06/30/2025 immunohistochemistry performed. A/P: adenocarcinoma with one positive lymph node, significant dysphagia recommend PEG but he is hesitant. CT PET for staging. Dr Shankar for consideration of concurrent chemotherapy/radiation
08/01/2025 staging PET scan performed: impression: Hypermetabolic distal third esophageal mass extending to at least GE Junction. Cannot exclude gastric involvement. Correlation with endoscopy.
08/04/2025 Cancer Care Center of Brevard-Martin Dietrich, MD-follow-up visit. CT/PEt showed large primary tumor-no lymphadenopathy- plan for XRT/Chemo
08/21/2025 Cancer Care Center of Brevard-Martin Dietrich, MD-follow-up visit-port has been placed. He had the feeding tube replaced as it was pulled out. ECOG performance status Is O, Treatment plan: . concurrent chemo/XRT Cl 08/25/2025 C2 09/02/2025 (planned)
09/09/2025 Cancer Care Center of Brevard-Martin Dietrich, MD-follow-up visit-He lost his feeding tube due to accidental removal, replacement was recommended but he is hesitant due
to pain sensation, I did explain It may be needed again in the future. He will start chemo/radiation next Monday-asking for a referral to Health First for PEG placement.
09/26/2025 Cancer Care Center of Brevard-Martin Dietrich, MD-follow-up visit-Dr Velarde has placed a PEG tube. He has continued with weight loss, neck has not been particularly symptomatic,a/p: continue XRT/chemo with carboplatin/paclitaxel.
10/10/2025 Cancer Care Center of Brevard-Martin Dietrich, MD-follow-up visit-He has been able to swallow and pass solid foods.He has completed chemotherapy and radiation. He has a PEG tube in place that he Is using. ECOG performance status is 1. Repeat assessment is due with EGO, would also obtain CT C/A/P prior to next visit.
10/23/2025 EGD report by Peter Koretsky, MD-The proximal and mld-esophagus were unremarkable. There appeared lo be gross tumor Involving the entire circumference of the
• esophageal lumen in the distal esophagus, 41-43 cm. From the incisor. The tissue was firm and friable. The lumen was patent, however, and the gastroscope passed through it without resistance (Biopsy).The stomach was unremarkable. However a retroflexed view revealed marked thickening of the mucosa on the gastric side of the• GE Junction (see photo). This was biopsied. (Biopsy).Per pathology report, these specific biopsies were negative for malignancy.[ p 115-116]
10/24/2025 Dr. Allan Powell at Viera Imaging-CT scan abd and pelvis with contrast-recently finished radiation-impression: Mass versus focal wall thickening In the gastric cardia adjacent to the GE junction.
11/17/2025 Cancer Care Center of Brevard-Martin Dietrich, MD-follow-up visit-. He has been doing well, weight gain, He has a feeding tube In place that Is bothering him, no infection or other concerns. ECOG performance status Is 1, CT scans with persistent mass were reviewed. Has completed xrt/chemo: A/P He will see Dr Koretzky for repeat assessment of tumor viability, if residual tumor Is seen would proceed with consideration of esophagectomy plus consideration of immunotherapy. Referred to Dr Herrera at Orlando Health for consideration of resection. He will likely need another endoscopy In light of his CT persistence of distal disease.
01/06/2026 Pathology report from esophagectomy-showed invasive metastatic adenocarcinoma
01/29/2026 Cancer Care Center of Brevard-Martin Dietrich, MD-follow-up visit- s/p Esophagectomy with pull through, lymphadenectomy 01/06/2026 (Dr Herrera, Orlando Health) with l lymph node Involved, +residual tumor, Adjuvant nivolumab 02/2026 - ongoing. He has undergone surgery with residual disease. discussed pathology. Findings and treatment Implications. We reviewed his nutritional status, going well. He has maintained weight and is eating well with a mechanical soft diet. ECOG performance status is 1.
03/10/2026 Cancer Care Center of Brevard-Martin Dietrich, MD-follow-up visit-He has been doing well. No side effects to immunotherapy, ECOG performance status is 0. He still has difficulty with larger meals, discussed nutritional strategies. He is at elevated risk of recurrence with lymph node Involvement and extra nodal extension, as well as residual disease In the primary tumor. PD-Ll is CPS 22 which would portend a more favorable response to immunotherapy-prescribed subcutaneous nivolumab for management.
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Do you believe there might have been medical error?
Low dose CT scan screening are primarily designed to detect lung cancer, but they can occasionally identify esophageal cancer as an incidental finding. While not a dedicated, highly sensitive diagnostic tool for esophageal cancer, the scan covers the entire chest cavity and may catch abnormal esophageal thickening or masses. his LDCT done on 09/05/2024 needs to be seen whether we can see esophageal thickening or mass
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
if scan shows esophageal thickening, then definitely yes. It would have be diagnosed at Stage I where in we could go directly for surgery without chemorad.
What makes you a good expert for this case?
I have done trial work mainly defense. testified on trial 11 times - all defense. done 12 depo- 10 defense/ 2 plaintiffs
How often do you encounter cases similar to this one in your practice?
i do encounter for missed lung nodule
Do you believe there might have been medical error?
For a lower esophageal or GE junction cancer patients who are surgical candidate, the new standard of care is to do chemotherapy + immunotherapy (Matterhorn trial) for 4 cycles followed by surgery followed by 4 more cycles of chemo immunotherapy. If patient is not a surgical candidate or not a candidate for chemotherapy, then we do chemo radiation. The note says ECOG 0, so I am not sure why this patient did not get chemoimmunotherapy. Regarding missing esophageal cancer on prior CT (9/5/24) is concerned, ct scans are not best at picking up early esophageal cancers as subtle thickening can be easily missed. The ct which reported possible mass in July 2025 was probably after the endoscopy which showed cancer.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again, the same explanation as before- CT generally doesn’t pick up esophageal cancers unless it is a large mass or associated with lymph node or distant metastases. One can argue that the cancer developed in the 10 months between the 2 scans
What makes you a good expert for this case?
Medical oncologist with 13 years of experience and managing multiple patients with esophageal and GE junction cancers over the time. I also see patients for second opinion for such cancers
How often do you encounter cases similar to this one in your practice?
Yes. We typically have multi specialty conference discussion on such patients. We typically see 4-5 patients every month.
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