I need an initial opinion on what Procedure was performed on a patients Vocal Cord Tumor. It is NOT a “Standard of Care” type opinion right now (a medical malpractice opinion will be needed later). I don’t care what “should” have been done. I need to know what Procedure was done.

Currently, I need you to tell me:

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

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

OR

2) Biopsy or similar procedure (0-10% removed, most of Tumor remains)

This will be more of a review of Laryngoscopy and Stroboscopy images/videos rather than written medical records.

The probability of your opinion will need to be considered.

1) Definitive, 2) Highly Probable, 3) More Likely Than Not.

Or a Percentage such as 51%, 70%, 95% can help us determine the legal standard.

It does NOT need to be absolutely 100% certain and in most civil cases, the legal requirement for stating an expert opinion is “more than 50% probability.”

Medical Records Included on This Page (Click Document to Download as PDF)

1) – Images from each Scope Before and After to give you an idea. Procedure was on 1/5/15. Scopes were done 10/30/14, 5/27/15, 5/10/18, 6/4/18.
2) – 4 Images After Procedure where portion of Tumor removed is noticeable and does not appear to grow back
3) – Images from a Scope on 9/12/2013, Tumor first diagnosed
3.1) – 9/12/13 Scope Notes
3.2) – 9/17/13 CT Scan Notes
4) – Images from a Scope on 10/30/14, 2 months, 6 days Before Procedure
4.1) – 10/30/14 Scope Medical Notes and 10/30/14 Scope Video
5) – Images from a Scope on 5/27/15, 4 months, 22 days After Procedure
5.1) – Images from Scope on 5/10/18, 3 years, 4 months After Procedure
6) – Images from Scope on 5/10/18, 3 years, 4 months After Procedure
6.1) – 5/10/18 Scope Medical Notes and 5/10/18 Scope Video
7) – Images from Scope on 6/4/18, 3 years, 5 months After Procedure
7.1) – 6/4/18 Scope Medical Notes and 6/4/18 Scope Video
8 – 8.1) – Pathology Report
8.2) – 5/31/18 CT Scan Notes
9) – Layman’s Observation
10) – Important Questions
11) – Questions for Opinion
12) – Burden of Proof for Legal Opinion

Medical Records Summary

The Procedure in question was on 1/5/2015.

MEDICAL RECORDS: If you click on a Document Image, it will open Full Size in a new Internet Tab where you can scroll if more than 1 page.

REDACTED INFO: Any info not related to the Scopes or Tumor has been redacted. The physician and patient info has been redacted as well. This info will be disclosed as needed for opinion.

1) – Images from each Scope Before and After to give you an idea. THE PROCEDURE WAS ON 1/5/2015.

10/30/14 – 2 mos, 6 days Before Proc.

5/27/15 – 4 mos, 22 days After Proc.

5/10/18 – 3 yrs, 4 mos After Proc.

6/4/2018 – 3 yrs, 5 mos After Proc.

It appears the Mass or Tumor does not change much after Procedure.

2) – 4 Images at varying times After Procedure where it seems you can see where a portion of Tumor was removed, mostly on the lower half. From the first images post-surgery on 5/27/15 to 3 years later on 5/10/18 and 6/4/18, the area removed is easily noticeable. Regrowth in this area is NOT noticeable.

5/27/2015, 4 mos, 22 days after Proc.

5/10/2018, 3 yrs 4 mos after Proc.

5/10/2018, 3 yrs 4 mos after Proc.

6/4/2018, 3 yrs 5 mos after Proc.

THE PROCEDURE WAS ON 1/5/15.

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3) – Images from a Scope on 9/12/2013, Tumor first diagnosed.

3.1) – 9/12/13 Scope Notes

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3.2) – 9/17/13 CT Scan Notes

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

4.1) – 10/30/14 Scope Medical Notes and 10/30/14 Scope Video

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Recording of Scope – can increase to full screen by clicking arrows on bottom right

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

5.1) – 5/27/15 Scope Medical Notes and 5/27/15 Scope Video

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Recording of Scope – can increase to full screen by clicking arrows on bottom right

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6) – Images from Scope on 5/10/18, 3 years, 4 months After Procedure

6.1) – 5/10/18 Scope Medical Notes and 5/10/18 Scope Video

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Recording of Scope – can increase to full screen by clicking arrows on bottom right

7) – Images from Scope on 6/4/18, 3 years, 5 months After Procedure

7.1) – 6/4/18 Scope Medical Notes and 6/4/18 Scope Video

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Recording of Scope – can increase to full screen by clicking arrows on bottom right

8 – 8.2) – Pathology Reports and 5/31/18 CT Scan Notes

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8) – 2/6/15 Pathology Report

8.1) – 6/22/18 Pathology Report

8.2) – 5/31/18 CT Scan Notes

9) – My Non-expert Observations

1) Based on images from 5/27/15 which was 4 months and 22 days after Procedure, the Tumor still covers the left vocal cord and a good portion of airway, and the size and appearance appears largely unchanged from before the Procedure on 1/5/15.

2) The Tumor has shown no signs of growing Before or After Procedure as shown by:

- Based on images Before Procedure, no noticeable change occurred during over a year from 9/12/13 to 10/30/14. The 10/30/14 medical notes state as much, “It is unchanged from previous.”
- Based on images from 5/27/15 to 5/10/18 and 6/4/18, no noticeable change occurred during over 3 years after the Procedure.

3) From the images after the Procedure, it appears you can see where the tissue was removed on the lower portion where it curves in. This area did not grow back or fill in to the same thickness Before the Procedure in over 3 years as shown in images on 5/10/18 and 6/4/18.

- Based on images from 5/27/15 to 5/10/18 and 6/4/18, no noticeable change occurred during over 3 years after the Procedure.

4) 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 with other opinions sought. It seems the Pathology does NOT point to a fast growing Tumor.

10) – My Non-expert Opinion

Based on 1) the Tumor showing NO signs of growing, including no noticeable growth even in the area where tissue was removed, 2) Pathology Reports that show NO sign of cancer except for “infiltration,” 3) Tumor of similar size and appearance on images from 5/27/15:

The probability that the Tumor was removed on 1/5/15 appears significantly low.

Do you agree that it is very highly probable that a biopsy or similar was done, maybe at most 10% removed. The Tumor was definitely not removed close to the 95-100%.

The probability of your opinion will need to be considered.

1) Definitive, 2) Highly Probable, 3) More Likely Than Not.

Or a Percentage such as 51%, 70%, 95% can help us determine the legal standard.

It does NOT need to be absolutely 100% certain and in most civil cases, the legal requirement for stating an expert opinion is “more than 50% probability.”

11) – By reviewing the Images and medical records, what was the closest outcome of the surgery:

the Surgeon removed 95-100% of the tumor, or
the Surgeon performed what looks like a biopsy (0%-10%), as most of the tumor remains on patients vocal cord, or

If you agree: I will have other questions to address in your opinion.

- Based on Pathology Report and imaging over 4+ years, in your experience have you seen a low malignant tumor like this grow back in 4.5 months?
- Based on the Pathology Report and imaging over 4+ years, can you give an opinion on likely Re-growth rate?
- Based on Pathology Report and imaging over 4+ years, and based on any research if necessary, do low malignant tumors of this nature grow back in 4.5 months?
- If YES to 3 or 4, how do those compare to this tumor? What are the chances it grows back in 4.5 months

If you can answer these questions, that would help too. But I just need the basic ones answered for now.

- - Are there any known cases where a Mesenchymal Tumor that does not appear to be growing before or after surgery with low or inconclusive malignancy grew back in just over 4.5 months? Why do the surgery?
  - Based on the Pathology report findings only, have you seen any cases where a Mesenchymal Tumor of low or inconclusive malignancy like this grew back in just over 4.5 months?

If yes in either 5 or 6, can you describe a specific case, why it grew back so fast and compare to the circumstance in this case. Why would the operation even be performed if this was a possibility? If you believe he DID remove the tumor like alleged, why do the images from the 5/27/15 scope show what appears to be a tumor that is covering my left vocal cord and is blocking a good portion of my airway.

If this was likely to regrow after not growing for over a year prior to Procedure, wouldn’t he tell me that???
I mean if you say removal, low grade… grew back in 4.5 month except for what looks like a cut, then remained unchanged for several years.
Have u ever seen a tumor grow back so fast.

The probability of your response will need to be considered. 1) Definitive, 2) Highly Probable, 3) More Likely Than Not. Or a Percentage such as 51%, 70%, 95% can help us determine the legal standard.

These legal standards will be used:

1) Preponderance of the Evidence – “more likely than not” that the fact is true. This is the typical 51% standard for civil cases often expressed, “based on a reasonable degree of medical certainty” by an expert.

2) Clear and Convincing Evidence – a higher burden of proof. Must be ” highly probable” or “substantially more likely than not that it is true.” This is less strict than the burden of proof in criminal cases.

Obviously, it does not need to be absolutely 100% certain and in most civil cases, the legal requirement for stating an expert opinion is generally “more than 50% probability.”

I need an initial opinion on what Procedure was performed on a patients Vocal Cord Tumor. It is NOT a “Standard of Care” type opinion right now (a medical malpractice opinion will be needed later). I don’t care what “should” have been done. I need to know what Procedure was done.

Currently, I need you to tell me:

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

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

OR

2) Biopsy or similar procedure (0-10% removed, most of Tumor remains)

This will be more of a review of Laryngoscopy and Stroboscopy images/videos rather than written medical records.

The probability of your opinion will need to be considered.

1) Definitive, 2) Highly Probable, 3) More Likely Than Not.

Or a Percentage such as 51%, 70%, 95% can help us determine the legal standard.

It does NOT need to be absolutely 100% certain and in most civil cases, the legal requirement for stating an expert opinion is “more than 50% probability.”

Medical Records Included on This Page (Click Document to Download as PDF)

Medical Records Summary

The Procedure in question was on 1/5/2015.

MEDICAL RECORDS: If you click on a Document Image, it will open Full Size in a new Internet Tab where you can scroll if more than 1 page.

REDACTED INFO: Any info not related to the Scopes or Tumor has been redacted. The physician and patient info has been redacted as well. This info will be disclosed as needed for opinion.

1) – Images from each Scope Before and After to give you an idea. THE PROCEDURE WAS ON 1/5/2015.

10/30/14 – 2 mos, 6 days Before Proc.

5/27/15 – 4 mos, 22 days After Proc.

5/10/18 – 3 yrs, 4 mos After Proc.

6/4/2018 – 3 yrs, 5 mos After Proc.

It appears the Mass or Tumor does not change much after Procedure.

5/27/2015, 4 mos, 22 days after Proc.

5/10/2018, 3 yrs 4 mos after Proc.

5/10/2018, 3 yrs 4 mos after Proc.

6/4/2018, 3 yrs 5 mos after Proc.

THE PROCEDURE WAS ON 1/5/15.

Click the documents to Enlarge to Full Size in a New Internet Tab.

3) – Images from a Scope on 9/12/2013, Tumor first diagnosed.

3.1) – 9/12/13 Scope Notes

3.2) – 9/17/13 CT Scan Notes

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

4.1) – 10/30/14 Scope Medical Notes and 10/30/14 Scope Video

Click the document to Open Full Page in New Internet Tab

Recording of Scope – can increase to full screen by clicking arrows on bottom right

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

5.1) – 5/27/15 Scope Medical Notes and 5/27/15 Scope Video

Click the document to Open Full Page in New Internet Tab

Recording of Scope – can increase to full screen by clicking arrows on bottom right

6) – Images from Scope on 5/10/18, 3 years, 4 months After Procedure

6.1) – 5/10/18 Scope Medical Notes and 5/10/18 Scope Video

Click the document to Open Full Page in New Internet Tab

Recording of Scope – can increase to full screen by clicking arrows on bottom right

7) – Images from Scope on 6/4/18, 3 years, 5 months After Procedure

7.1) – 6/4/18 Scope Medical Notes and 6/4/18 Scope Video

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Recording of Scope – can increase to full screen by clicking arrows on bottom right

8 – 8.2) – Pathology Reports and 5/31/18 CT Scan Notes

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8) – 2/6/15 Pathology Report

8.1) – 6/22/18 Pathology Report

8.2) – 5/31/18 CT Scan Notes

9) – My Non-expert Observations

1) Based on images from 5/27/15 which was 4 months and 22 days after Procedure, the Tumor still covers the left vocal cord and a good portion of airway, and the size and appearance appears largely unchanged from before the Procedure on 1/5/15.

2) The Tumor has shown no signs of growing Before or After Procedure as shown by:

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

Based on images from 5/27/15 to 5/10/18 and 6/4/18, no noticeable change occurred during over 3 years after the Procedure.

3) From the images after the Procedure, it appears you can see where the tissue was removed on the lower portion where it curves in. This area did not grow back or fill in to the same thickness Before the Procedure in over 3 years as shown in images on 5/10/18 and 6/4/18.

Based on images from 5/27/15 to 5/10/18 and 6/4/18, no noticeable change occurred during over 3 years after the Procedure.

10) – My Non-expert Opinion

Based on 1) the Tumor showing NO signs of growing, including no noticeable growth even in the area where tissue was removed, 2) Pathology Reports that show NO sign of cancer except for “infiltration,” 3) Tumor of similar size and appearance on images from 5/27/15:

The probability that the Tumor was removed on 1/5/15 appears significantly low.

Do you agree that it is very highly probable that a biopsy or similar was done, maybe at most 10% removed. The Tumor was definitely not removed close to the 95-100%.

The probability of your opinion will need to be considered.

1) Definitive, 2) Highly Probable, 3) More Likely Than Not.

Or a Percentage such as 51%, 70%, 95% can help us determine the legal standard.

It does NOT need to be absolutely 100% certain and in most civil cases, the legal requirement for stating an expert opinion is “more than 50% probability.”

11) – By reviewing the Images and medical records, what was the closest outcome of the surgery:

the Surgeon removed 95-100% of the tumor, or

the Surgeon performed what looks like a biopsy (0%-10%), as most of the tumor remains on patients vocal cord, or

If you agree: I will have other questions to address in your opinion.

The probability of your response will need to be considered. 1) Definitive, 2) Highly Probable, 3) More Likely Than Not. Or a Percentage such as 51%, 70%, 95% can help us determine the legal standard.

These legal standards will be used:

1) Preponderance of the Evidence – “more likely than not” that the fact is true. This is the typical 51% standard for civil cases often expressed, “based on a reasonable degree of medical certainty” by an expert.

2) Clear and Convincing Evidence – a higher burden of proof. Must be ” highly probable” or “substantially more likely than not that it is true.” This is less strict than the burden of proof in criminal cases.

Obviously, it does not need to be absolutely 100% certain and in most civil cases, the legal requirement for stating an expert opinion is generally “more than 50% probability.”