Pathologist sued - Patient receives $1 million settlement

[coroner]

https://valawyersweekly.com/2023/12/10/pathologist-misinterpreted-patients-biopsy-specimen-1m-settlement/

I'm guessing the bx. of the plaintiff looked like a pretty funky reactive atypia. Good morphologists usually don't rely on IHC for bladder bxs., but at the very least he should've gotten a second opinion before sign out. Some pathology groups require a second opinion/sign-off from another pathologist before signing out a new malignancy, others don't, particularly if it's a slam dunk breast or colon ca. Either way, anybody can have an off-day and miss a dx., but maybe it was an obvious miss and his morphology skills are in need of improvement.

I also wonder if the pathologist was solo, which might make it a hassle to send-out the case, or there's no policy for showing other patholgists first-time malignancies and he was over-confident was a slam dunk ca. and signed it out, or he did show it to another colleague who hastily agreed without paying much attention. Regardless, a miss is a miss in the eyes of the judge, no matter what the circumstances.

I have heard of similar lawsuits before, but $1 million is a pretty steep settlement for pathology. Lawsuits this big can also result in immediate termination and possibly getting blackballed from getting hired at future jobs due to the size of the settlement. Be careful out there folks...

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[cmz]

What struck me was the initial diagnosis of low-grade with subsequent amendment to high-grade/cis. This should have definitely gone for review to an outside consultant or someone within the group (unless they are a local cowboy). I wonder if the Uro pressed for a more aggressive dx based on cytoscopy findings... it just doesn't make sense. Either way, call what you see. If there is a doubt in your mind, especially when you have a colleague nudging you to take another look at a case... for the love of God send it the eff out.

Most low-grade lesions left alone with surveillance, right? This should go down in the books as, "We cured your cancer!! You are now cancer free!" I don't think I've ever had to use IHC on bladder. I think the sneaky biopsies are the "clinging cis" that I've seen called "B9 denuded urothelium." What also strikes me as odd is the aggressive initial diagnosis somehow looked worse than the subsequent cytologies and maybe biopsies(?) after BGC therapy. If I see atypia on cytology, UroVysion is a must. Backseat pathology reads are the best, especially when it's not my case and I have no liability

 

[SunBakedTrash]

What struck me was the initial diagnosis of low-grade with subsequent amendment to high-grade/cis. This should have definitely gone for review to an outside consultant or someone within the group (unless they are a local cowboy). I wonder if the Uro pressed for a more aggressive dx based on cytoscopy findings... it just doesn't make sense. Either way, call what you see. If there is a doubt in your mind, especially when you have a colleague nudging you to take another look at a case... for the love of God send it the eff out.

Most low-grade lesions left alone with surveillance, right? This should go down in the books as, "We cured your cancer!! You are now cancer free!" I don't think I've ever had to use IHC on bladder. I think the sneaky biopsies are the "clinging cis" that I've seen called "B9 denuded urothelium." What also strikes me as odd is the aggressive initial diagnosis somehow looked worse than the subsequent cytologies and maybe biopsies(?) after BGC therapy. If I see atypia on cytology, UroVysion is a must. Backseat pathology reads are the best, especially when it's not my case and I have no liability

I assumed the urologist wanted to know if it was low-grade noninvasive or low-grade invasive with the pathologist ultimately calling low-grade noninvasive. The person who wrote the article called it carcinoma in situ, likely not understanding that flat urothelial CIS is a separate diagnosis we make from noninvasive papillary urothelial carcinoma . It probably was a papilloma or papillary cystitis that he over called. It happens but the fact he was not definitive even in the initial read makes me question that standard of care was being followed. Maybe im way off, who knows?

Not really sure why he received intravesical therapy for low-grade unless it was actually changed to CIS, the patient demanded it or the urologist is unusually aggressive.

 

[ScubaV]

What struck me was the initial diagnosis of low-grade with subsequent amendment to high-grade/cis. This should have definitely gone for review to an outside consultant or someone within the group (unless they are a local cowboy). I wonder if the Uro pressed for a more aggressive dx based on cytoscopy findings... it just doesn't make sense. Either way, call what you see. If there is a doubt in your mind, especially when you have a colleague nudging you to take another look at a case... for the love of God send it the eff out.

Most low-grade lesions left alone with surveillance, right? This should go down in the books as, "We cured your cancer!! You are now cancer free!" I don't think I've ever had to use IHC on bladder. I think the sneaky biopsies are the "clinging cis" that I've seen called "B9 denuded urothelium." What also strikes me as odd is the aggressive initial diagnosis somehow looked worse than the subsequent cytologies and maybe biopsies(?) after BGC therapy. If I see atypia on cytology, UroVysion is a must. Backseat pathology reads are the best, especially when it's not my case and I have no liability

Yeah changing low-grade to CIS is very strange, assuming the terminology in the article is being used accurately. Flat, low-grade lesions are very, very rarely diagnosed in my experience. If it's low-grade, it's >99% papillary and if it's flat and neoplastic, it's >99% high-grade / CIS. Overcalling a papilloma as low-grade carcinoma is not super terrible as it should just prompt more surveillance urine cytologies / cystoscopies, not definitive therapy. Overcalling reactive atypia as CIS is definitely worse, but at least the patient got BCG and not cystectomy.

When in doubt, show it around and/or send it out.

 

[DoctwoB]

Uro here. Surprising that he got a million bucks as the "harm" was minimal.

If the diagnosis was in fact CIS, then the BCG was appropriate for the diagnosis. We don't give BCG for non invasive low grade disease. Whether there is such a thing as invasive low grade disease is debatable, most would argue by definition if invasive then it is high grade.

However, he kept his bladder and ended up with some extra cystoscopies and some bcg. Hardly a million bucks worth in my view.

 

[WEBB PINKERTON]

Hopkins gave the second opinion huh.
Weren't they just in the news because of an overcall that caused a bladder removal and some bullying allegations?

 

[coroner]

I have heard of similar lawsuits before, but $1 million is a pretty steep settlement for pathology.

However, he kept his bladder and ended up with some extra cystoscopies and some bcg. Hardly a million bucks worth in my view.

Agree. I heard of a female patient getting a radical mastectomy over a misdiagnosis of breast ca. and the settlement was under around $75K, this was around ten years ago though.

I assumed the urologist wanted to know if it was low-grade noninvasive or low-grade invasive with the pathologist ultimately calling low-grade noninvasive.

Yeah changing low-grade to CIS is very strange, assuming the terminology in the article is being used accurately. Flat, low-grade lesions are very, very rarely diagnosed in my experience. If it's low-grade, it's >99% papillary and if it's flat and neoplastic, it's >99% high-grade / CIS.

That's what I don't get either from the story. Low grade urothelial ca. is almost always papillary, so why would the pathologist change the dx to CIS? As mentioned, if it's low grade, it's 99% papillary. And, low grade papillary urothelial ca. is 99% non-invasive. So he might have forgot to put the +/- invasion in the report, but if you don't, guaranteed, you'll get a phone call from the urologist asking whether or not it's invasive, leading to an amendment. Maybe the article forgot to put the word "papillary", but that's less likely if the dx. was changed by the pathologist to CIS, which by definition is not papillary.

 

[Med Director New England]

Uro here. Surprising that he got a million bucks as the "harm" was minimal.

If the diagnosis was in fact CIS, then the BCG was appropriate for the diagnosis. We don't give BCG for non invasive low grade disease. Whether there is such a thing as invasive low grade disease is debatable, most would argue by definition if invasive then it is high grade.

However, he kept his bladder and ended up with some extra cystoscopies and some bcg. Hardly a million bucks worth in my view.

Seriously ^
What would the patient gotten if a cystectomy had happened - 10 M ??

1 M just for Unnec BCG therapy seems really high

 

[Alteran]

This is such an unusual scenario to the point to being absurd, but not implausible.

My take on this is the following:

The pathologist likely overcalled reactive type atypia in a bad cystitis which is why it was initially classified as low-grade. The urologist then called and said "how can it be low-grade, the bladder looks so bad it has to be cancer, blah, blah blah". The "clarification" is likely the pathologist being bullied into changing the diagnosis so the urologist can treat the "bladder cancer" and likely because the patient is one of those hyper neurotic sue happy types who is absolutely convinced of having something wrong with them - the kind of patient most docs don't want to deal with and would rather just fire them. Of course, when subsequent cytology studies came up negative, the patient being one of those types starts asking questions and almost certainly was the one driving the second opinion which is why the pathology re-review was triggered. When the original biopsy report was revised as "negative", the urologist throws the pathologist under the bus because he/she certainly isn't going to be holding the legal grenade when it goes off.

That's why folks it's important to QA most if not all of your first time malignant diagnoses, even the obvious ones. If you practice solo, be super liberal in the ancillary studies (like IHC, molecular, etc.). All the academics tell you that IHC and molecular isn't necessary in most cases, you just need morphology...except when they get consulted in medical legal cases. Then they'll tell you that you should have ordered readily available ancillary testing and not doing so was not in keeping with standard of care.

 

[ChicagoPath]

That's why folks it's important to QA most if not all of your first time malignant diagnoses, even the obvious ones. If you practice solo, be super liberal in the ancillary studies (like IHC, molecular, etc.). All the academics tell you that IHC and molecular isn't necessary in most cases, you just need morphology...except when they get consulted in medical legal cases. Then they'll tell you that you should have ordered readily available ancillary testing and not doing so was not in keeping with standard of care.

Good advice. Like my previous boss said, “when in doubt send it out.” Even if the other pathologists in your group agree on a certain diagnosis but you still have doubts, send it out.