Rad Onc Medical Malpractice Case

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Fascinating but unfortunate case: Carotid Blowout Syndrome [Oncology]

Patient in late 40s diagnosed with SCC.
Surgical resection incomplete due to bleeding complications (not communicated well).
Pt receives 60Gy over 30 treatment days.

Patient ultimately dies of carotid blowout syndrome.

Sues the hospital, asks for >30 million to settle the case. Patient was highly-paid insurance executive.

Exact settlement is confidential but likely was in the low 8 figure range.

 

[Gfunk6]

I've never heard or read about a carotid blowout at such a low dose and in a scenario that didn't involve re-irradiation. I wonder if surgery weakened the carotid wall and radiation finished it off?

 

[medgator]

Sometimes it's not about whether an intervention is at fault or whether malpractice was committed. It's about the outcome in front of a jury. In this case though, looks there were clear errors in the case, even if it didn't directly cause the syndrome.

Guessing they wanted risk avoidance and just settled

 

[Burt Radnolds]

Was an interesting read, nice nightmare fuel. The case was much more complicated than the above brief summary. HPV+ tonsil cancer with retropharyngeal node, had what sounds like large biopsy of tonsil. They suggest there was a miscommunication and oncology team thought he had undergone full oncologic resection. Patient was treated "adjuvantly" to 60Gy without chemo. Recurred at retropharyngeal node, got re-irradiated, subsequently had a blow out.

Crux of case stated is that patient was treated inadequately for gross residual disease. They state he should have received 70Gy + chemo and then would have not recurred and not subsequently required re-irradiation.

 

[fiji128]

I've never heard or read about a carotid blowout at such a low dose and in a scenario that didn't involve re-irradiation. I wonder if surgery weakened the carotid wall and radiation finished it off?

"Operating under the assumption of complete surgical resection, the treatment recommendation was for radiation therapy but no chemotherapy. He underwent radiation therapy to a dose of 60Gy over 30 treatment days. Biopsy confirmed recurrent squamous cell carcinoma. This time he underwent chemotherapy and radiation treatments."

The lawsuit was filed against the Ivy League hospital.

The accusations against the doctors are described here:

• Head and neck oncologist
  • Failed to communicate that the cancer was not completely resected
  • Failed to bring the patient back for a repeat operation
• Radiation oncologist
  • Failed to realize that the tumor had not been completely resected
  • Gave radiation dose of 60Gy (only appropriate if completely resected)
  • Failed to give 70Gy (appropriate dose for remaining tumor)
• Medical oncologist
  • Failed to give chemotherapy when indicated

Very interesting how something like this could be missed especially with what was probably some sort of vip patient.

 

[CptCrunch]

Sometimes it's not about whether an intervention is at fault or whether malpractice was committed. It's about the outcome in front of a jury. In this case though, looks there were clear errors in the case, even if it didn't directly cause the syndrome.

Guessing they wanted risk avoidance and just settled

Yeah, it sounds like the carotid blowout was more caused by progressive tumor infiltrating into the carotid than caused by the re-irradiation. Despite being HPV/p16 positive, the tumor was behaving aggressively and the ultimate outcome may have been the same even without the mistakes that occurred.

"An autopsy was performed and the cause of death was an acute massive bleed secondary to perforation of the right carotid artery which was encased by a partially necrotic poorly differentiated squamous cell carcinoma."

 

[DrZap]

Sounds like a miss but sometimes VIPs are the biggest obstructions in their own care

 

[communitydoc13]

Very interesting how something like this could be missed

This was a bad cancer. (I know nothing about the case other than the link.) Look at that MRI. Nasty, infiltrative thing not typical of HPV positive disease. (But I have seen it before.)

After tonsillectomy, microscopic positive margins at the carotid space are common and not necessarily representative of the positive margins that drove our adjuvant chemo/rt trials. Can't tell enough from the screen grabs, but ipsilateral RP node could be mistaken for contiguous tonsillar disease.

Could have fairly easily interpreted as "focal positive margin after tonsillectomy at carotid space (probably scraped tumor off of this area)" in an HPV positive setting and gone with 60 post-op. (This is the wrong interpretation of course, significant ear pain without exophytic mass on exam and deep seated tumor concerning.) Also, dental artifacts didn't help.

Pre-surgical MRI would have fixed everything IMO. I don't always have these and don't order standard in the post-op setting.

VIPs are the biggest obstructions in their own care

VIPs should always go out of their own system. Not sure if applicable in this case.

 

[w00tz]

Probably would not have happened if treated today, when PET scans are more commonly used in staging. Would have picked up that RP node easily and staged correctly.

 

[medgator]

Probably would not have happened if treated today, when PET scans are more commonly used in staging. Would have picked up that RP node easily and staged correctly.

Missed that, not sure why he would have gone to surgery if they had done an initial pet

 

[fiji128]

Even though 60 Gy with no chemo is technically inadequate I would bet it would take care of p16+ disease most of the time given that initial imaging. Above imaging does include PETs.

 

[evilbooyaa]

Patient had a PET/CT. WHy the **** did he undergo surgery with a RP node clearly visible on PET?

Re-chemoRT 6 months after initial 60Gy is a bad idea even when you **** up. Put em on IT or EXTREME and kick that can down the road as much as you can.

This guy got treated at an Ivy League institution? Woof.

 

[deleted1111261]

Big name institution doesn't mean anything.

I am very curious what institution this was at and what their peer review process is.

(I'd be surprised if this was MDACC, the head and neck peer review and tumor board are incredible.)

 

[RickyScott]

Patient had a PET/CT. WHy the **** did he undergo surgery with a RP node clearly visible on PET?
This guy got treated at an Ivy League institution? Woof.

Could have been Columbia?

 

[elementaryschooleconomics]

This guy got treated at an Ivy League institution? Woof.

Probably by a faculty member who tries to be in clinic no more than 1-2 days a week and tries to cap at 2-3 consults on each of those days so they can spend more time on their "groundbreaking" research figuring out who to omit radiation in, while their residents write the notes, do the volumes, and do the statistical analysis on the research.

 

[deleted1111261]

Probably by a faculty member who tries to be in clinic no more than 1-2 days a week and tries to cap at 2-3 consults on each of those days so they can spend more time on their "groundbreaking" research figuring out who to omit radiation in, while their residents write the notes, do the volumes, and do the statistical analysis on the research.

DING DING DING

 

[StIGMA]

I am very curious what institution this was at and what their peer review process is.

Can find his obit searching in the time window- I won’t link out of respect.
He lived very close to Yale. Of course this doesn’t mean he was necessarily treated there.

 

[RickyScott]

I have seen some cases where tumors behave very badly following a gross cut through. Person most at fault is ent for trying to remove tumor with obvious retro node.

 

[BobbyHeenan]

I have seen some cases where tumors behave very badly following a gross cut through. Person most at fault is ent for trying to remove tumor with obvious retro node.

I had a very similar case of an “excisional biopsy” of a tonsil cancer which was really a non oncologic tonsillectomy with just a little bit of gross disease left.

I gave it 70 with chemo and he recurred with a carotid blowout, nearly fatal at recurrence. IR able to embolize. It was ugly.

clearly there were some issues with the original poster med mal case but locallly progressive tonsil/retro pharyngeal cancer does some awful things. Even if you do everything right.

 

[Neuronix]

They reference in that document a "Radiology and Mammography center".

There's basically only one of those that pop up on Google in Norwalk, CT.

Yale is Ivy League... Maybe he drove into Manhattan though who knows.

 

[Lamount]

This is a scary story to read because I am sure we can all think of a few times we thought raise a concern with a surgeon, radiologist, or pathologist when things just didn't add up... and it turned out to be a really good thing that we did. It only takes one time not being on your game.

 

[deleted1111261]

What tumor board would have been agreeable to surgery in this case? After that took place, and consult sent to RO, what sort of peer review takes place? Case discussion? Contour/dose review?

A lot of hubris … dump trucks full of them. Probably same dump trucks that KHE/Turaco used for their earnings.

 

[BobbyHeenan]

What tumor board would have been agreeable to surgery in this case? After that took place, and consult sent to RO, what sort of peer review takes place? Case discussion? Contour/dose review?

A lot of hubris … dump trucks full of them. Probably same dump trucks that KHE/Turaco used for their earnings.

If the treating rad onc thought GTR then he or she presents it for case review as 60 Gy it would look ok. You likely won’t pick up a RTP node on a non contrasted post op CT sim, especially if dental artifact.

You know this, but even at some academic centers cases go to surgery first prior to any tumor board discussions. You know the drill - “we talked to him about surgery or radiation and he wanted surgery.”

 

[RickyScott]

I have seen some cases where tumors behave very badly following a gross cut through. Person most at fault is ent for trying to remove tumor with obvious retro node.

Dealing with case now where some idiot oral surgeon/dentist fulgurated out/piecemeal resected a maxillary tumor. Within 2 weeks of the operation it has exploded into cheek, orbit and down the buccal mucosa.

 

[deleted1111261]

If the treating rad onc thought GTR then he or she presents it for case review as 60 Gy it would look ok. You likely won’t pick up a RTP node on a non contrasted post op CT sim, especially if dental artifact.

You know this, but even at some academic centers cases go to surgery first prior to any tumor board discussions. You know the drill - “we talked to him about surgery or radiation and he wanted surgery.”

Still curious to know how the PET-CT report read.

 

[Gfunk6]

After reading through all the comments, I just realized that the OP embedded a hyper-link that I missed. Read through the whole case, very sad.

 

[temujim]

If the treating rad onc thought GTR then he or she presents it for case review as 60 Gy it would look ok. You likely won’t pick up a RTP node on a non contrasted post op CT sim, especially if dental artifact.

You know this, but even at some academic centers cases go to surgery first prior to any tumor board discussions. You know the drill - “we talked to him about surgery or radiation and he wanted surgery.”

Always get contrast on your sims in H&N, unless contra-indicated. PMH and Fox chase have reported up to 15-30% (IIRC) rapid early recurrences on sim CTs for post op cases. Definitely a situation to have your antennas up and be careful with the review of the CT sim, no matter what your H&N surgeon says.

 

[gmsquid]

Most blowouts are a result of tumor, even in the rexrt setting. If you treat enough HN, you’ll eventually have a patient that has a blowout. The surgery didn’t help the situation, but this very well could’ve happened regardless. Still, things missed along the way and what may have been an oncologic inevitability became malpractice.

 

[seper]

Very sad. It could be anyone.

 

[deleted1111261]

Most blowouts are a result of tumor, even in the rexrt setting. If you treat enough HN, you’ll eventually have a patient that has a blowout. The surgery didn’t help the situation, but this very well could’ve happened regardless. Still, things missed along the way and what may have been an oncologic inevitability became malpractice.

I don’t know… I have a feeling that RP node wasn’t contoured at all, and it wasn’t failure - it was missed.

70 Gy definitive hardly ever leads to blowout.

 

[deleted1111261]

Always get contrast on your sims in H&N, unless contra-indicated. PMH and Fox chase have reported up to 15-30% (IIRC) rapid early recurrences on sim CTs for post op cases. Definitely a situation to have your antennas up and be careful with the review of the CT sim, no matter what your H&N surgeon says.

Do you have the reference for this? Would be very helpful.

 

[elementaryschooleconomics]

Do you have the reference for this? Would be very helpful.

I would also really like the reference for this!

 

[RickyScott]

I would also really like the reference for this!

I always try to get contrast on def cases, but never postop. I would worry about reactive nodes etc.

 

[temujim]

Do you have the reference for this? Would be very helpful.

15-20%

Rapid recurrence in head and neck cancer: Underappreciated problem with poor outcome - PubMed

Rapid recurrence occurs at an underappreciated rate and is associated with poor survival outcomes. Patients with ENE are at highest risk and may benefit from diagnostic imaging evaluations immediately prior to PORT.

pubmed.ncbi.nlm.nih.gov

Predictors of Early Recurrence Prior to Planned Postoperative Radiation Therapy for Oral Cavity Squamous Cell Carcinoma and Outcomes Following Salvage Intensified Radiation Therapy - PubMed

Early recurrences are not uncommon in patients with high-risk features, Further study is required to improve prediction and outcomes of this very high-risk group.

pubmed.ncbi.nlm.nih.gov

 

[gmsquid]

I don’t know… I have a feeling that RP node wasn’t contoured at all, and it wasn’t failure - it was missed.

70 Gy definitive hardly ever leads to blowout.

Thats true that 70 Gy doesn’t lead to blowout if disease is controlled. But in the setting of persistent disease, blowout is the result of the tumor and not the rexrt. if tumor wasn’t encasing the artery, retrospective data suggests there likely wouldn’t have been a blowout even with the rexrt.

As for dose, there’s decent data that even 60 Gy rt alone leads to decent control in low risk HPV positive HNSCc (if this patient was low risk) from HN002. (2 year LRF of only 9.5% albeit accelerated over 5 weeks) and from the retrospective PMH series that formed the basis for the rt alone arm of HN002. It’s a valid point that this node may not have been included in the 60 Gy volume though I don’t know how it would’ve been missed covering the postop bed for the tonsil.

 

[fiji128]

If you look at the imaging that carotid blow out was almost certainly due to the aggressive nature of the residual/progressive disease and not the cumulative RT dose delivered.

 

[RickyScott]

Thats true that 70 Gy doesn’t lead to blowout if disease is controlled. But in the setting of persistent disease, blowout is the result of the tumor and not the rexrt. if tumor wasn’t encasing the artery, retrospective data suggests there likely wouldn’t have been a blowout even with the rexrt.

As for dose, there’s decent data that even 60 Gy rt alone leads to decent control in low risk HPV positive HNSCc (if this patient was low risk) from HN002. (2 year LRF of only 9.5% albeit accelerated over 5 weeks) and from the retrospective PMH series that formed the basis for the rt alone arm of HN002. It’s a valid point that this node may not have been included in the 60 Gy volume though I don’t know how it would’ve been missed covering the postop bed for the tonsil.

In some hpv cancers 30gy and chemo is enough per mskcc protocols. Definitely bad luck here. My guess is the pt would still have failed w/70 gy and chemo.

 

[deleted1111261]

15-20%

Rapid recurrence in head and neck cancer: Underappreciated problem with poor outcome - PubMed

Rapid recurrence occurs at an underappreciated rate and is associated with poor survival outcomes. Patients with ENE are at highest risk and may benefit from diagnostic imaging evaluations immediately prior to PORT.

pubmed.ncbi.nlm.nih.gov

Predictors of Early Recurrence Prior to Planned Postoperative Radiation Therapy for Oral Cavity Squamous Cell Carcinoma and Outcomes Following Salvage Intensified Radiation Therapy - PubMed

Early recurrences are not uncommon in patients with high-risk features, Further study is required to improve prediction and outcomes of this very high-risk group.

pubmed.ncbi.nlm.nih.gov

Misunderstood
Thought you meant not using CT contrast was associated with recurrence

 

[elementaryschooleconomics]

Misunderstood
Thought you meant not using CT contrast was associated with recurrence

Ah yeah me too. I was about to use that paper to beat admins over the head for expanded sim capabilities,,,

 

[madchemist89]

Where are the letters from experts for the defense?

 

[jondunn]

as a famous man once said 'maybe Paul Wallner was on to something!!!!!'


in all serioiusness, I take no joy or enjoyment reading this story. mistakes happen often in a rad onc center somewhere. most mistakers are small, won't be noticed by anyone, and do not result in catastrophe. lots of times people chalk it up to 'radiation didn't work'. but it happens and can happen to any of us.

this particular mistake was bad of course. but to the poster who asked about peer review - unless you are at one of the centers (and there are some) where they have a dedicated head and neck chart rounds and review every single single slice as well as the diagnostic imaging, the chance that a small RP node gets missed at chart rounds is pretty high.

in this case the only way I would see it clearly being caught is if it is part of your practice to look at the PET/CTs in a group setting before contouring. and like i said this defintely happens, in both academic and private settings. but most of us don't have the luxury of that kind of time or organization or man power.

 

[seper]

I also wonder if treating docs were deep in the de-escalation mindset. This shows you, it is a dangerous place to be in

 

[RickyScott]

I doubt I would have caught this on a peer review because you are "pre-conditioned" not to look for gross disease when it is presented as margin negative resection. Same for unlucky attending and resident dealt this case. once the surgeon/pathology says all disease removed, very difficult to avoid this outcome.

 

[deleted1111261]

as a famous man once said 'maybe Paul Wallner was on to something!!!!!'


in all serioiusness, I take no joy or enjoyment reading this story. mistakes happen often in a rad onc center somewhere. most mistakers are small, won't be noticed by anyone, and do not result in catastrophe. lots of times people chalk it up to 'radiation didn't work'. but it happens and can happen to any of us.

this particular mistake was bad of course. but to the poster who asked about peer review - unless you are at one of the centers (and there are some) where they have a dedicated head and neck chart rounds and review every single single slice as well as the diagnostic imaging, the chance that a small RP node gets missed at chart rounds is pretty high.

in this case the only way I would see it clearly being caught is if it is part of your practice to look at the PET/CTs in a group setting before contouring. and like i said this defintely happens, in both academic and private settings. but most of us don't have the luxury of that kind of time or organization or man power.

Maybe so, maybe not. We caught a LN node out of field in a head and neck case that wouldn’t have been treated in our pre planning contour review. We are pretty into peer review. It’s always “we don’t have time or luxury”. We didn’t but now we do, because it’s important to me and my vision for the department.

I’m also curious if there was pre-treatment tumor board and what the actual PET-CT report says. If they had tumor board and the report mentions it, then multiple people just plain screwed up.

 

[jondunn]

I also wonder if treating docs were deep in the de-escalation mindset. This shows you, it is a dangerous place to be in

hmm this does not seem relevant to this case.

 

[jondunn]

Maybe so, maybe not. We caught a LN node out of field in a head and neck case that wouldn’t have been treated in our pre planning contour review. We are pretty into peer review. It’s always “we don’t have time or luxury”. We didn’t but now we do, because it’s important to me and my vision for the department.

I’m also curious if there was pre-treatment tumor board and what the actual PET-CT report says. If they had tumor board and the report mentions it, then multiple people just plain screwed up.

that is great you guys have that. key for head and neck.

the ENT screwed up here too. took a patient to surgery with a PET-positive RP node.

 

[RickyScott]

Maybe so, maybe not. We caught a LN node out of field in a head and neck case that wouldn’t have been treated in our pre planning contour review. We are pretty into peer review. It’s always “we don’t have time or luxury”. We didn’t but now we do, because it’s important to me and my vision for the department.

I’m also curious if there was pre-treatment tumor board and what the actual PET-CT report says. If they had tumor board and the report mentions it, then multiple people just plain screwed up.

I can’t imagine a pre-treatment tumor board took place here, even at manhattan’s worst. Radiologist would point out the rp node and dipsht ent would say: I am going to get that?

 

[communitydoc13]

Radiologist would point out the rp node and dipsht ent would say: I am going to get that?

Honestly, looking at the screen captures, this whole thing could have been contiguous. Right tonsil, lateral pharyngeal wall, RP node and parapharyngeal infiltration all one big glob on the post failure MRI. In fact, looks like there is infiltration posterior to right longus colli (this is the RP space, even though RP nodes are typically anterolateral to longus colli) and I don't see a discrete node, just infiltrative tumor in the parapharyngeal space. If you treat enough head and neck, you will occasionally see these super infiltrative lesions (progressing along nerve paths, vascular sheaths, fascial planes, even intramuscular invasion).

The PET screen captures I see are not so revealing to me. This person just may have had much more significant disease than apparent on scope or PET.

Most good ENTs will not go after deeply infiltrative lesions in this location. If surgery aborted early and just debulking, key to case may be path report and surgeons narrative.

Many community radiologists are quite good but delineating parapharyngeal, retropharyngeal, carotid spaces (all contiguous BTW) not usually strong suit in my experience.

 

[seper]

hmm this does not seem relevant to this case.

Oh I’ve seen this movie before. “Maybe just a bit of cancer left? p16 positive? Won’t you guys stop at 60 Gy. That NRG study looked pretty good for 60”

 

[Palex80]

Most good ENTs will not go after deeply infiltrative lesions in this location. If surgery aborted early and just debulking, key to case may be path report and surgeons narrative.

It seems that this is the point the whole case got out of hand. Every surgeon would have described that is his operation report. Now, either he never wrote one or noone cared to read it?