This case involves an overweight middle-aged female patient who was diagnosed with an endometrial polyp following a hysteroscopy. She presented to an OB/GYN for a second opinion regarding treatment options. The OB/GYN discussed hysterectomy versus hormonal treatment but the patient chose to undergo a total abdominal hysterectomy. During the procedure, the surgeon realized the uterus had grown too large to be removed from the vagina. It was decided that the uterus would be removed in pieces through an abdominal incision. Surgical pathology later revealed the patient had stage II endometrial cancer. When the patient asked how she could have cancer, the surgeon informed her the physician who performed the hysteroscopy had missed a polyp. Following her surgery, the patient had persistent abdominal pain and was referred for an abdominal CT. The scan showed several masses at the abdominal incision site and a CT-guided biopsy revealed metastatic adenocarcinoma. It was alleged that the tumors were of gynecological origin with endometrial histology. The patient underwent chemotherapy and many sessions of radiation therapy but continues to suffer from recurring fluid collections. An expert in gynecological oncology was sought to discuss how hysterectomies can lead to metastasis.
Question(s) For Expert Witness
- 1. How often do you perform hysterectomies?
- 2. Can the type of approach to a hysterectomy eventually lead to metastasis? Please elaborate.
- 3. How does a delay in cancer diagnosis affect the prognosis of a patient? How does a delay in diagnosis have an effect on metastasis?
Expert Witness Response E-207325
I currently perform approximately 100 hysterectomies via various approaches per year including abdominal, laparoscopic and robotic. While the summary states the patient had a TAH/BSO, it seems more likely that she had a TLH/BSO (a laparoscopic hysterectomy) as there would be no reason to remove the uterus via the vagina for an abdominal hysterectomy. Had the patient had a pre-operative diagnosis of cancer (i.e. if the polyp were removed pre-op), then she should not have undergone a surgery requiring morcellation of her uterus as this would be strictly contra-indicated. Given the size of her uterus, she should have either had an open hysterectomy (a TAH/BSO) or had the uterus morcellated within a containment bag. There is every reason to believe that the morcellation of the uterus caused the spread of her cancer. The real issue is that she had undiagnosed postmenopausal bleeding and therefore underwent a laparoscopic hysterectomy with morcellation which was inappropriate. The red flag is that the only uterine sampling you have shown squamous tissue suggesting it was a cervical specimen and not from the endometrial cavity. Thus there could be no assurance that she did not have endometrial pathology (i.e if the polyp described showed only squamous tissue, it was likely an endocervical polyp and not an endometrial one). According to the narrative, she appears to have had a Stage II grade 1 endometrial cancer which should not have recurred the way that it did. The fact that it recurred within the abdominal wall is extremely suggestive that the morcellation of the uterus caused the recurrence and metastases.