MEDICAL MALPRACTICE – CASE #74355

Opinion Requested and Observations to Review

Case Summary:

This case is based in California on a patient who has a Vocal Cord Tumor, and the treatment he received. A Standard of Care opinion will be needed LATER.

FIRST, I need a short Expert Opinion that helps establish, What Procedure Was Performed on the patients Vocal Cord on 1/5/15.

IMPORTANT:

Standard of Care has NOTHING to do with this initial opinion I need.  This page should clarify exactly what I am requesting.

Based on your review of images/video and related medical records,

What Procedure Was Most Likely Performed on 1/5/2015?

1) Biopsy or similar procedure (5-25%+ removed, Most of Tumor remains)

                                            OR

2) Tumor Removal (95-100% of Tumor removed)

In most civil cases, the legal requirement for stating an Expert Opinion is only “more than 50% probability.” 

Your review will consist of mostly imaging, rather than written medical records. Here is whats included on this page:

1) – Images from Stroboscopy on 9/12/13
2) – Images from Stroboscopy on 10/30/14
3) – Images Stroboscopy on 5/27/15
4) – Images from Stroboscopy on 5/10/18
5) – Images Stroboscopy on 6/4/18.
6) – CT Scan Notes Excerpt from 9/17/13
7) – 2 Pathology Reports 

After your initial review, I will provide the Medical Records page which has Images, Videos, and all the Paper Records.

OBSERVATION #1

Based on images Before Procedure, no noticeable change occurred during Over 1 year from 9/12/13 to 10/30/14. The 10/30/14 medical notes below state as much, “It is unchanged from previous.” 

Images from a Scope on 9/12/2013, when Tumor was first diagnosed.

        (If you click the image, a larger view will open in a new internet window)

Images from a Scope on 10/30/14, 2 months, 6 days Before Procedure

           (If you click the image, a larger view will open in a new internet window)

Excerpt below from 10/30/14 Scope Medical Notes, saying Tumor was unchanged from previous Scope on 9/12/13.

Excerpt from CT Scan on 9/17/13 describing Size and Appearance of Tumor

Do You agree with OBSERVATION #1?

The Procedure was performed on 1/5/2015

The full Procedure Report will not be provided for this initial opinion. If you need this Report, you Do Not understand the opinion being requested.

OBSERVATION #2

Based on these images from 5/27/15 that are only 4 months and 22 days after Procedure, the Tumor still covers the left vocal cord and a good portion of patients airway.  The size and appearance is not much different from the images above from before the 1/5/15 Procedure.  If tumor was removed 95-100%, it appears to regrow very rapidly. (see below)

Images from a Scope on 5/27/15, 4 months, 22 days After Procedure

        (If you click the image, a larger view will open in a new internet window)

Do You agree with OBSERVATION #2?

OBSERVATION #3

Based on images from 5/27/15 and 5/10/18, NO noticeable growth occurred during a 3 Year period after the Procedure. (see below)

Comparison of Scope images almost 3 years apart After Procedure

        (If you click the image, a larger view will open in a new internet window)

THIS COLUMN –  Scope images from 5/27/15, LESS than 5 months after Procedure

THIS COLUMN – Scope images from 5/10/18, OVER 3 years after Procedure

Do You agree with OBSERVATION #3?

OBSERVATION #4

From the first images post-procedure on 5/27/15 to 3 years later on 5/10/18 and 6/4/18, what looks like the incision area (bottom portion) does not grow back or fill in to the same thickness after over 3 years. The area removed is still easily noticeable, while regrowth in this area is NOT.  It seems more consistent with a biopsy type Procedure and very little regrowth, if any. 

        (If you click the image, a larger view will open in a new internet window)

From Scope on 5/27/2015, Less than 5 months After Procedure

From Scope on 5/10/2018, 3 years 4 months after Procedure

From Scope on 5/10/2018, 3 years 4 months after Procedure

From Scope on 6/4/2018, 3 years 5 months after Procedure

Do You agree with OBSERVATION #4?

OBSERVATION #5

On the Pathology Reports, it states No/Negative/Zero for dysplasia, carcinoma, mitoses, necrosis, atypia, mitotic figures. Based on “degree of infiltration” ONLY, it was described as “low malignant potential” and diagnosed low grade malignancy by one pathologist. Additional opinions were sought and no definitive diagnosis was made. From review of Pathology alone, regrowth potential of this tumor appears very low and/or very slow-growing. (see Pathology below)

        (If you click on Document Image, a larger view will open in a new internet window)

Original Surgical Pathology Report

Emory Pathology Report

Do You agree with OBSERVATION #5?

OBSERVATION SUMMARY:

#1) The Tumor showed NO signs of growing before Procedure.

#2) 4 months and 22 days after Procedure, Tumor still covered vocal cord and the size and appearance is NOT much different than Before Procedure.

#3) NO noticeable signs of growth during the over 3 years After Procedure.

#4) The incision area is still noticeable After Over 3 years, while regrowth in the area is NOT noticeable. Regrowth that is disproportionate to one side, where you can still see the incision area seems unlikely. Images are more consistent with a biopsy type Procedure with NO or little regrowth.

#5) Pathology Reports indicate an inconclusive or low grade malignancy with the ONLY sign of cancer being “infiltration,” so growth and regrowth potential is very low or very slow-growing.

MY LAYMAN OPINION

It seems highly unlikely the Tumor was removed and then grew back in LESS than 5 Months to appear close to the same size as Before the Procedure, when NO other signs of growth are present for an extended period of time Before (over 1 year) and After (over 3 years) the Procedure.

The observations above seem more consistent with a Biopsy type Procedure with NO or very little regrowth for Over 3 years. 

It DOES NOT appear to be a Tumor Removal procedure on 1/5/15.  That would mean a tumor with NO dysplasia, carcinoma, mitoses, necrosis, atypia, mitotic figures – grew back to a similar size in LESS than 5 MONTHS (Scope 5/27/15) and then DID NOT change for OVER 3 YEARS (Scopes 5/10/18 and 6/4/18)? 

And if it was removed, why would the regrowth of the bottom portion be so much slower and indented to resemble an incision area? And then this rapid regrowth just stopped growing Less than 5 Months After Procedure?

YOUR PRELIMINARY OPINION:

Based on your review of #1-5 above (full scope videos will be provided),

What Procedure Was Most Likely Performed on 1/5/2015?

1) Biopsy or similar procedure (5-25%+ removed, Most of Tumor remains)

                                    OR

2) Tumor Removal (95-100% of Tumor removed)

Medical opinions do not require 100% certainty and in most civil cases, the legal requirement for stating an expert opinion is just “more than 50% probability.”

1) IF YOUR OPINION IS: 1) Biopsy or similar procedure,

What is the current MEDICAL PROBABILITY of your OPINION?

  A) Almost 100% Certainty

  B) Highly Probable or Substantially More Likely Than Not.

  C) More Likely Than Not (51%)

Or use a Percentage: 95%, 75%, 51%.

2) IF YOUR OPINION IS: 2) Tumor Removal,

What Specifically have YOU OBSERVED that SUPPORTS THIS?

Please provide your experience or research where a tumor like this grew back in Less than 5 Months when it:

1) Showed no noticeable change in size over 4+ years Before and After Procedure.
2) Had NO common signs of cancer ie. dysplasia, carcinoma, mitoses, necrosis, atypia, mitotic figures.
3) Regrowth was disproportionate to one side of a tumor, where you can still see the incision area on bottom portion and NO regrowth in this area is noticeable from 4 Months 22 days After Procedure to over 3 years After Procedure.

So it grew back in Less than 5 Months to resemble the same tumor prior to Procedure, except for the bottom portion, where it grew back back to look like an incisional biopsy was done? Then remained the same with no or very little growth for Over 3 years later?

What is the probability it grew back in under 5 months?

NEXT STEPS – If you are supportive of my position:

– I will have a few “general knowledge” vocal cord treatment/care related questions for you.

– I will need the Declaration Template edited with your info and any other edits.

– In the near future, I will need a Standard of Care Expert Opinion based on the Procedure that was performed.