This case takes place in Iowa and involves a female patient who was under the care of a specialist physician at a hospital, where she tested for elevated levels of a particular hormone. Some time later, the specialist wrote a clinical note to the referring primary care physician, stating that he had her complete some lab tests as part of the pituitary hormone workup and those lab tests were all normal. Despite the elevated hormone levels, neither physician ordered more tests. The patient experienced a range of symptoms from the time the hormone imbalance was first detected, however the plaintiff’s elevated hormone levels was not tested again. These hormone levels were initially tested on multiple occasions, and at no point were they addressed, nor was a referral to a specialist made for any other diagnostic testing of the thyroid. The plaintiff sought the care of an endocrinologist who diagnosed the plaintiff with right sided pituitary adenoma. It was eventually determined that her thyroid was cancerous and had to be removed.
Question(s) For Expert Witness
- 1. How often do you treat patients with thyroid cancer?
- 2. Is an elevated prolactin level of 83 not normal for a non-pregnant patient? Could it have been a clinical presentation of prolactinoma?
- 3. With the symptoms listed, should medication intervention have been prescribed as a therapeutic first line of intervention?
- 4. Does earlier intervention generally yield a more desirable outcome?
Expert Witness Response E-008239
I have expertise in both pituitary disease and thyroid cancer. I manage about 400 patients with thyroid cancer. I am a referral site for complicated thyroid cancer cases. I am an expert in thyroid nodule and cancer diagnosis and management. An elevated prolactin level of 83 is not normal for a non-pregnant patient and could have been a clinical presentation of prolactinoma. Given the patient’s symptoms, an MRI should have been ordered. If a mass is present, then a consideration for either a prolactinoma or stalk torsion from a large non-secreting adenoma should be made. If the mass was small, then medication is always the first line therapy for prolactinomas. If the mass was large, and likely a non-secreting adenoma, then surgery should be considered. Other causes of high prolactin should be excluded, including liver and kidney dysfunction, certain medications and local nipple stimulation. Delayed diagnosis would lead to more bone loss from estrogen deficiency and possibly result in a larger tumor. Delay in treatment may allow the pituitary mass to grow larger and allow damage to the optic nerves which are just superior to the pituitary.