This thoracic radiology case involves a patient in North Dakota with a history of smoking who had a chest x-ray that allegedly reflected a mass in the upper portion of the left lung. The study was allegedly of poor quality and no repeat was done, no biopsy was recommended, and no follow-up CT was performed. The patient returned to the physician some weeks later with a complaint of coughing up blood. Another chest x-ray was performed that allegedly showed a considerably larger mass, but still nothing was done to further work up the lesion. The patient presented to various hospitals for follow-up on multiple occasions, however his concerns were evidently dismissed. Eventually, the patient was given a bronchoscopy, which revealed the presence of metastatic cancer; he was placed on the lung transplant list, but his smoking history precluded him from being a priority.
Question(s) For Expert Witness
- 1. Will you be able to determine if the imaging studies were misread and warranted earlier CT and bronchoscopy?
- 2. Will you be able to determine whether or not an earlier CT and bronchoscopy could have revealed the lung cancer at an earlier stage?
- 3. Under what circumstances is a patient with this medical history and comorbidities a candidate for bronchoscopy?
Expert Witness Response E-057628
The patient should have undergone a follow-up CT or at least chest x-ray based on the first report, with the main question being whether the report was sufficiently clear to put the referring physician at fault for not pursuing appropriate follow-up as indicated. In any case, It would have been egregious to have failed to have worked up a growing lesion. This is extremely likely to represent gross negligence in the handling of care. It is overwhelmingly likely that the cancer would’ve been diagnosed many months earlier had more attentive follow-up and work-up been pursued. Any patient who would not likely have required intubation is an appropriate candidate for a bronchoscopy. Small cell lung cancer typically follows a rapid progression consistent with a median survival in the range of months without treatment. It is therefore quite likely that his cancer was localized at the time of his initial presentation but became extensive and therefore incurable by the time of his ultimate diagnosis many months later. I have been a national/international expert in lung cancer for about 15-16 years. I have written book chapters, spoken at national meetings, am on national committees shaping guidelines in thoracic oncology, and care for patients with lung cancer for about two thirds of my extensive clinical practice.