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Assessment of cancer patient’s chest X-ray

Date: 14 Dec 2020
This report concerns the care provided to a man by a radiologist and a district health board. The man was diagnosed with testicular cancer and a right orchiectomy was performed. Following the surgery, there was no evidence of spread of the cancer to the lymph nodes. The man was placed on a high surveillance programme including monthly chest X-rays and tumour markers for at least the first year, and an annual CT scan.
19HDC01606
  • Occupations : Radiologist
  • Group providers : District Health Board

Names have been removed (except the experts who advised on this case) to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.

District Health Board

Radiologist, Dr C

 

 

A Report by the Deputy Health and Disability Commissioner

 

Contents

Executive summary
Complaint and investigation
Information gathered during investigation
Opinion: — Introduction
Opinion: Dr C — adverse comment
Opinion: District health board — no breach
Opinion: Other comment and conclusion
Recommendations
Follow-up actions
Appendix A: Independent advice to the Commissioner
Appendix B: Independent advice to the Commissioner

 

 


Executive summary

  1. This report concerns the care provided to a man by a radiologist and a district health board (DHB). In Month1[1] 2016, the man was diagnosed with testicular cancer and a right orchiectomy was performed. Following the surgery, there was no evidence of spread of the cancer to the lymph nodes. The man was placed on a high surveillance programme including monthly chest X-rays and tumour markers for at least the first year, and an annual CT scan.
  2. Around the end of Month8, the man visited his general practitioner (GP) and complained of back pain. On 13 Month9, he was reviewed by the DHB oncology team and also received his monthly chest X-ray (which had been requested on 16 Month8). The radiologist reported the chest X-ray on 21 Month9 and did not raise any concerns.
  3. On 24 Month9, the man presented to his GP with neurological symptoms. He was referred to the Emergency Department and an MRI of the spine was performed. A metastasised lesion in his T7 vertebrae was identified.
  4. Subsequently, it was found that the spinal lesion had been visible on the chest X-ray performed on 13 Month9, and that the lesion had been overlooked by the radiologist. On 25 Month9, the man underwent spinal surgery, and from Month11 he continued with chemotherapy. Sadly, the man passed away in 2018.
Findings
  1. The Deputy Commissioner was critical that the radiologist missed the T7 compression fracture in his report. The Deputy Commissioner accepted that the error was inadvertent, but considered that the radiologist should have exercised more caution and care when reading the scan.
  2. The Deputy Commissioner found that the oncology care provided by the DHB was appropriate.
Recommendations
  1. The Deputy Commissioner recommended that the radiologist apologise to the man’s father.
  2. The Deputy Commissioner recommended that the DHB review Dr Kingzett Taylor’s advice on possible improvements, and report back to HDC on the result of its review and any improvements it intends to make.
Other comment and follow-up
  1. The Deputy Commissioner noted that his expert advisor and the expert engaged by ACC advised that perceptual errors are known to occur in a proportion of observations made by any human observer. The Deputy Commissioner’s expert advisor also acknowledged that perceptual error is a common part of radiology practice, estimated at 3–5%, and noted that the clinical significance of such errors can vary widely.
  2. While the Deputy Commissioner recognised that such errors may occur and that their impact may vary considerably, those errors create a risk to consumers. He noted that the radiology profession and the services it works with have a clear responsibility to do everything they reasonably can to prevent such errors. The Deputy Commissioner will, therefore, write to the Royal Australian and New Zealand College of Radiologists (RANZCR) to invite it to consider what actions can be taken to minimise the incidence of perceptual error in radiography reports in light of this review of the man’s care.

 

Complaint and investigation

  1. The Health and Disability Commissioner (HDC) received a complaint from Mr B about the services provided by the DHB to his son, Mr A (deceased). The following issues were identified for investigation:
  • Whether the DHB provided Mr A with an appropriate standard of care in 2016 and 2017.
  • Whether Dr C provided Mr A with an appropriate standard of care in 2017.

  1. This report is the opinion of Deputy Commissioner Kevin Allan, and is made in accordance with the power delegated to him by the Commissioner.
  2. The parties directly involved in the investigation were:
Mr B                                                                      Complainant
DHB                                                                       Provider
Dr C                                                                       Provider/radiologist


  1. Also mentioned in this report:
Dr D                                                                       Consultant medical oncologist
Dr E                                                                       Medical oncology registrar

 

  1. Further information was received from:
General practice medical centre
ACC


 

  1. Independent expert advice was obtained from oncologist Dr Richard Isaacs (Appendix A) and radiologist Dr Andrew Kingzett Taylor (Appendix B).

Information gathered during investigation

Introduction
  1. This opinion concerns the care the DHB and Dr C,[2] a consultant radiologist, provided to Mr A, aged in his twenties at the time of events. In particular, the report concerns the oncology care provided to Mr A from Month1 to Month11 and the radiology care provided in Month9.
Oncology care (Month2 to Month8)
  1. In Month1, Mr A was diagnosed with right testicular cancer. On 1 Month2, a right radical orchiectomy[3] was performed, and Mr A was discharged on 2 Month2.
  2. Dr D, a consultant medical oncologist, managed Mr A’s care, and met with Mr A on 21 Month2. Dr D documented:

“I explained to [Mr A] that his testicular cancer appears to have been completely removed but we are concerned about the possibility that some of the glands in the back of his belly may be metastatic[4] from his testicular cancer … if this cancer hasn’t spread then he has a moderately good prognosis … if however there is evidence of metastatic spread then his chances of being cured are a lot lower and he would need chemotherapy and probably surgery or radiation as well.”

  1. Following the meeting, Dr D arranged for a PET-CT scan[5] to look for any indication of metastatic disease. The scan was performed on 23 Month2.
  2. On 29 Month2, Dr D met with Mr A again and informed him that the scan had not shown any evidence of spread of the testicular cancer to the lymph nodes in front of the spine or elsewhere. Dr D documented:

“The recommendation from our Multidisciplinary Meeting was to have him on close surveillance, so the next CT scan will be two months from now. I will see him in a month from now with bloods [tests] a few days beforehand for tumour markers,[6] and a chest x-ray on arrival. He is happy with plan.”

  1. No chemotherapy or radiation was recommended following Mr A’s orchiectomy. The DHB stated:

“[T]here is no evidence that giving such treatment is effective for patients with malignant transformation[7] of testicular teratoma[8] to rhabdomyosarcoma.[9] Surveillance is a recommended option for testicular seminoma.[10]”

  1. On 20 Month3, Mr A attended the Oncology Clinic and saw a medical oncology advanced trainee for Dr D. The trainee noted that Mr A remained well and that tumour markers and the chest X-ray performed on this date were all unremarkable. The trainee documented: “There remains no evidence of disease recurrence [one and a half] months after the radical orchiectomy.”
  2. A CT scan was performed on 16 Month4, and Mr A saw Dr D the following day. It was noted that Mr A remained completely well with no residual pain, and that the CT scan showed no evidence of recurrence of cancer. Dr D gave Mr A a form to have his tumour markers checked monthly, and documented:

“[W]e will see him back in one month with a repeat chest x-ray on arrival. His next CT scan will be 10 months from now unless there are any symptoms of concern in the meantime, or concerns on chest radiology.”

  1. Mr A saw Dr D again on 15 Month5. Mr A’s tumour markers and chest X-ray were “unremarkable with no signs of recurrence of disease”. Mr A was given forms for monthly tumour markers and chest X-rays. Dr D noted:

“We will continue to do monthly chest x-rays and tumour markers for at least the first year and his next CT scan will be nine months from now. [Mr A] is aware to get in touch if there are any new symptoms in the meantime.”

  1. Dr D next saw Mr A on 19 Month6. Dr D noted that Mr A remained well and that there were no clinical signs of recurrence of his testicular tumour. His tumour markers and chest X-rays were unremarkable. Another appointment was arranged for a month’s time.
  2. Dr D met with Mr A on 16 Month7, and documented that he remained well with no symptoms or clinical signs to suggest recurrence of his testicular tumour. The chest X-ray and serum tumour markers were normal.
Month8 to Month9 consultations
  1. On 16 Month8, Mr A attended the Oncology Clinic and saw Dr E, a medical oncology registrar for Dr D. It was noted that Mr A’s chest X-ray and test results were normal, and that his physical examination was unremarkable. Another appointment was arranged for four weeks’ time, and a repeat abdominal CT scan was arranged for two months’ time.
  2. On the same day, Dr E prepared a referral form to the Radiology Department for a chest X-ray in a month’s time (13 Month9). The referral form did not mention back pain, as Mr A did not have this symptom at the time. The referral form stated that the relevant clinical history included non-seminoma[11] stage 1,[12] and active surveillance.
  3. On 29 Month8 and 2 Month9, Mr A visited his GP at the medical centre and complained of back pain. The GP noted that Mr A had an appointment at the Oncology Clinic for blood tests and a chest X-ray the following week.
13 Month9 consultation
  1. On 13 Month9, a chest X-ray was performed by Dr C, and Mr A then saw Dr E. There is no record of any discussion between Dr C and Dr E.
  2. Dr E told HDC: “[B]efore the clinic, I reviewed Mr A’s [chest X-ray] for pulmonary lesions and saw nothing abnormal.”
  3. Dr E stated:

“[Mr A] reported a one–two week history of poorly localised, non-specific middle back pain of a musculoskeletal nature. He attributed the pain to the activities of his employment. Given that he had a high risk non-seminoma and was under surveillance, I was concerned to ascertain whether the pain he described might be attributable to metastasis. I made systematic enquiry for symptoms of skeletal metastasis and related complications. Specific questions were asked … all of my inquiries were answered in the negative.”

  1. Dr E documented:

“[Mr A] reported some muscular back pain but was otherwise completely asymptomatic. His tumour markers were all within normal range. The chest x-ray demonstrated no appreciable lesions[13] as in the previous films. Physical examination today was unremarkable, showing no lymphadenopathy[14] or palpable masses. We will see him again in four weeks with a CT scan.”

  1. In response to the provisional report, Mr B said that he was with his son during Dr E’s review, and told Dr E specifically that his son had had back pain for two to three weeks and that the pain medicine prescribed by the GP on 29 Month8 and 2 Month9 was not effective. Mr B disagreed with Dr E’s statement that Mr A’s back pain had been related to his employment.
  2. Dr E stated:

“[A]s with all my patients, I discussed with [Mr A] the limitations of CXR[15] reviews in the clinic, and explained that my interpretation of the X-ray would be no substitute for the radiology report which would follow. I would have explained too that he would be contacted if any abnormal finding was noted by the radiologist.”

Discovery of spinal lesion
  1. On 20 Month9, Mr A again visited his GP about his back pain. The GP noted that Mr A had been seen in the Oncology Clinic on 13 Month9, and told HDC that at this meeting Mr A told her that he had discussed his back pain with the oncologist. She said that she was reassured by this, and was also aware that Mr A had a CT scan scheduled for the following week.
  2. On 21 Month9, Dr C reported his review of the chest X-ray. The report stated: “Chest: Lungfields are clear. No evidence of any pulmonary nodules. No change.” Dr C did not identify the presence of a spinal lesion.
  3. On 24 Month9, Mr A presented to the medical centre with neurological symptoms. He was referred to the Emergency Department for further investigation.
  4. On 24 Month9, an MRI of the spine was performed. The radiology report documented:

“The body of T7[16] is collapsed … This lesion was not evident on the previous CT even on retrospective analysis. Therefore this would be a relatively aggressive metastatic process … Patient’s symptoms are accounted for by a collapse of the T7 body with associated epidural disease[17] compressing the cord. These features were not present on the CT in [Month4] last year. The appearance is of a metastatic deposit.”

Subsequent events
  1. On 25 Month9, Mr A underwent spinal surgery.[18] On 8 Month10, he was discharged from hospital and referred for radiotherapy and rehabilitation.
  2. On 18 Month10, Dr D met with Mr A and his father. Dr D noted:

“A chest X-ray was reported as showing no lung metastases on films of [13 Month9] but neither the reporting radiologist nor my registrar noticed a new wedge compression[19] at T7 that was clearly related to subsequent events due to his metastatic disease. I have apologised for this and discussed that a diagnosis at that point may have avoided the neurological complications of his spinal cord compression, though it would not have changed the surgical procedure that needed to be undertaken.”

  1. From Month11, Mr A continued to receive courses of chemotherapy. However, his cancer continued to spread further, and he began to experience paralysis and numbness in his limbs. Sadly, Mr A passed away in 2018.
ACC report
  1. ACC engaged a radiologist, Dr David Milne, to provide advice about the radiology care provided to Mr A. ACC seeks to identify retrospectively whether an injury occurred during, or as a result of, treatment provided.
  2. In summary, Dr Milne reported that the chest scan on 13 Month9 showed a wedge compression fracture of the T7 vertebral body. Dr Milne asked three of his radiology colleagues to undertake a blind review of the chest X-ray imaging, and all reported a compression fracture around the thoracic spine. Dr Milne advised ACC:

“[Dr C] has clearly overlooked a fracture of the mid thoracic spine which was present on the imaging on 13 [Month9]. Compression fractures of the spine are frequently overlooked on imaging and this has been well described in the literature both for plain film and CT imaging.

Such mistakes in observation are not uncommon in the practice of clinical radiology and, if such errors are isolated instances, do not raise issues of competence in respect of the reporting radiologist[.] [I]n my opinion … it would be impossible to completely avoid observation errors by Radiologists … due to the complexities of human error.”

Further information
  1. Dr C told HDC:

“It is correct that I had overlooked a fracture of the mid thoracic spine which was present on the image … If I had been alerted to the back pain, I would have looked more carefully at the spine …”

  1. Dr C also stated: “May I take this opportunity to give my condolences and sympathy [to Mr A’s family].”
  2. Dr E told HDC:

“I acknowledge that, regrettably, the T7 compression fracture was not seen on the chest x-ray (CXR), when I reviewed [Mr A] on 13 [Month9]. However … in the circumstances I reviewed it, I do not believe that the compression could have been identified.”

  1. Dr E stated:

“As an oncology registrar my role was to provide clinical review, to conduct a physical examination, discuss relevant findings, and to arrange subsequent investigations and follow-ups, all under the supervision of a consultant oncologist. The formal interpretation of diagnostic images was not part of my role. As oncologists, we have basic knowledge about X-rays and their interpretation. We are not trained in diagnostic radiology.”

  1. Dr E also said: “I wish to express my heartfelt condolences to [Mr A’s] family.”
  2. The DHB told HDC:

“[Dr C] is a highly experienced and well-respected senior radiologist who would not normally miss such a finding but unfortunately he did on this occasion. If he had been asked to review the x-ray regarding the patient’s thoracic back pain then he would certainly have reported the finding.”

  1. The DHB stated:

“It should be noted that the request form was completed a month before that appointment, at the time of the previous clinic review, when the patient had not reported any back pain, as part of ongoing surveillance … [W]hen [Dr E] looked at the chest x-ray he did not identify [the] T7 fracture. He then made the appropriate choice to request a CT scan as the next imaging, which is superior to plain x-ray of the spine.”

Changes made since incident
  1. Dr C told HDC:

“[W]hile we will never be able to completely avoid such errors happening in the future, we can continue to be vigilant. I will discuss the case at my peer group meeting for teaching and learning purposes.”

  1. The DHB told HDC that Dr C has since retired..
  2. The DHB stated:

“[The DHB] has undertaken a review of what occurred and this review included consideration of whether any changes were needed. Based on the findings of this review, the DHB has not been able to identify any changes it needs to make to the service it provides.”

Responses to provisional opinion
Mr B
  1. Mr B was provided with an opportunity to comment on the “Information gathered” section of the provisional report. Where appropriate, his comments have been incorporated into the report. Mr B emphasised his concern that if the spinal lesion had been picked up earlier, then his son may have had opportunities to receive earlier treatment. Mr B stated: “[I]f chemotherapy was done at this early period it would have slowed the spread and growth of any cancer and increased the quality and expected lifetime for [Mr A].”
Dr C
  1. Dr C was provided with an opportunity to comment on the provisional opinion. He told HDC that he had no comment to make on the report.
The DHB
  1. The DHB was provided with an opportunity to comment on the provisional opinion. The DHB told HDC that it shared the provisional report with the relevant individuals, and they had no comment to make.

 

Opinion: — Introduction

  1. This opinion concerns the care provided by the DHB from Month1 to Month11, and the radiology care provided by Dr C in Month9.
  2. First, I would like to acknowledge the traumatic impact these events have had on Mr B and his family. It is understandable that they have sought an independent review from this Office.

 

Opinion: Dr C — adverse comment

  1. In Month1, Mr A was diagnosed with right testicular cancer, and on 1 Month2 he underwent a right orchiectomy. Mr A was placed on a close surveillance programme and was required to attend the DHB’s Oncology Clinic on a monthly basis for tumour markers and chest X-rays to check for any metastases.
  2. Dr C was the radiologist who performed the chest X-ray on 13 Month9. Dr C did not report a compression fracture at T7, and he accepts that he overlooked this. Dr C told HDC that he was not informed of Mr A’s back pain, and that had he known, he would have reviewed the spinal area more carefully. However, the referral form filled in by the Oncology team and sent to the Radiology team was prepared a month prior to the X-ray, and at that time Mr A did not have back pain.
  3. I have carefully considered the standard of care to be expected in a case such as this. Expert advice was obtained from Dr Kingzett Taylor, a radiologist, who was asked to undertake a blind review of the X-ray. Dr Kingzett Taylor identified the compression fracture at T7, but he advised that the radiology care provided by Dr C was appropriate. Dr Kingzett Taylor stated:

“The failure to detect the vertebral fracture is likely to have been a perceptual error … perceptual errors can be confidently expected to occur in a proportion of observations made by any human observer … It is acknowledged that perceptual error is a common part of radiology practice and some errors are inevitable …

Although it is likely that most radiologists would have detected the compression fracture on the [13 Month9] chest radiograph, they would also acknowledge that thoracic vertebral fractures are frequently overlooked on chest radiographs.”

  1. ACC also engaged a radiology expert adviser, Dr Milne. Dr Milne identified the compression fracture of the T7 vertebral body and asked three of his radiology colleagues to undertake a blind review of the chest radiographs, and all three reported the compression fracture. Nevertheless, Dr Milne stated:

“Such mistakes in observation are not uncommon in the practice of clinical radiology and, if such errors are isolated instances, do not raise issues of competence in respect of the reporting radiologist [and] in my opinion … it would be impossible to completely avoid observation errors by Radiologists … due to complexities of human error.”

  1. I note that both Dr Milne and Dr Kingzett Taylor identified the compression fracture in their blind reviews, and that three of Dr Milne’s colleagues also reported the compression fracture when invited to review the chest radiographs. I further note that Mr A was on a high surveillance programme for the purpose of detecting metastases at the time when the scan occurred. A metastasis did appear and was captured on the X-ray, but Dr C did not identify it.
  2. Nevertheless, I also accept that there was no mention of back pain in the Radiology referral from Dr E on 16 Month8 because the referral form had been completed a month in advance, and at that time there is no evidence Mr A reported back pain to Dr E at that time. Dr Kingzett Taylor also advised that thoracic vertebral fractures are frequently overlooked on chest radiographs. I acknowledge that in this case, the main focus of the chest X-ray was on the lung, but unfortunately a metastasis appeared in the spine. Dr C was not aware of Mr A’s back pain symptom and, as a result, Dr C did not focus on the spine. I also note that both Dr Milne and Dr Kingzett Taylor advised that perceptual error is common and some errors are inevitable. They are not critical of the care provided by Dr C.
  3. After careful consideration of the factors discussed above, my opinion is that Dr C should have exercised more caution and care when reading the scan. While I accept that Dr C’s error was inadvertent, I am nevertheless critical that Dr C missed the T7 compression fracture in his report. I note that Dr C has accepted his error and apologised for this.

 

Opinion: District health board — no breach

  1. Mr A’s oncology care was managed by Dr D at the DHB. Following the orchiectomy on 1 Month2, a PET-CT scan was performed in late Month2. The scan did not show any evidence of spread of the cancer, and close surveillance of Mr A was planned.
  2. Mr A visited the DHB Oncology Clinic monthly for tumour markers and chest X-rays. He also had a PET-CT scan on 16 Month4, which reported no evidence of recurrence of the cancer. However, in late Month8 Mr A began to experience back pain.
  3. On 13 Month9, Mr A’s monthly chest X-ray was performed by Dr C, but Dr C did not report the T7 compression fracture. On the same day, Mr A was reviewed by Dr D’s registrar, Dr E, and Mr A advised that he was experiencing back pain. Dr E stated that he made systematic enquiry for symptoms of skeletal metastasis at this consultation, and asked specific questions, but all of his enquiries were answered in the negative. Dr E saw the X-ray prior the consultation, but unfortunately he did not notice that there was a new wedge compression at T7. Dr E arranged for another CT scan to be performed in four weeks’ time.
  4. Mr A continued to experience back pain, and on 24 Month9 he was admitted to the Emergency Department and a spinal MRI was performed. The Radiology report noted that “the body of T7 [had] collapsed” and that “this would be a relatively aggressive metastatic process”.
  5. Expert advice was obtained from a medical oncologist, Dr Richard Isaacs. Dr Isaacs stated:

“It is my opinion that [the DHB] did follow an adequate standard of practice … Resection of the spinal tumour at an earlier stage would sadly not have been curative, as the subsequent early development of lung metastases indicated the presence of micrometastatic disease at the time the spinal cord compression was diagnosed.

In my opinion, [Mr A’s] very difficult disease journey was driven by the nature of his malignancy and not by any deficiency in his care.”

  1. Dr Isaacs also advised that the care provided by Dr E and Dr D was of an appropriate standard.
  2. As discussed above, Dr Kingzett Taylor advised that despite the missed reporting of the compression fracture at T7 by Dr C, other care he provided was appropriate. I also note that Dr Kingzett Taylor advised that the missed reporting was a “perceptual error” by the radiologist. As such, I consider that this was an individual error by Dr C, and not an organisational issue.
  3. I note that Mr A had an “aggressive metastatic process”, and that prior to Month9 all his test results had been normal. It appears that Mr A’s cancer advanced suddenly and unexpectedly, and, despite further treatment, he continued to deteriorate.
  4. Having considered all of the information obtained, including the expert advice, I find that the care provided by the DHB was appropriate.

 

Opinion: Other comment and conclusion  

Other comment
  1. As noted above, my expert advisor and the expert engaged by ACC advised that perceptual errors are known to occur in a proportion of observations made by any human observer. It is also acknowledged that perceptual error is a common part of radiology practice, estimated at 3–5% by my expert advisor, who also noted that the clinical significance of such errors can vary widely.
  2. While I recognise that such errors may occur and that their impact may vary considerably, those errors create a risk to consumers. The radiology profession and the services it works with have a clear responsibility to do everything they reasonably can to prevent such errors. Therefore, I will invite the Royal Australian and New Zealand College of Radiologists (RANZCR) to consider what actions can be taken to minimise the incidence of perceptual error in radiography reports, in light of this review of Mr A’s care.
Conclusion
  1. I note that Dr Isaacs advised:

“[Mr A’s] journey would have been extremely traumatic, not only for [him], but also for his family when such a young man had such morbidity from his disease, with loss of mobility and significant suffering. I believe, however, that his journey was made so difficult not by any deficiency in his oncology treatment, but by the biology of his disease.”

  1. I express my sympathy to Mr B and his family. I acknowledge that this matter continues to cause Mr B significant distress, and I thank him for bringing his concerns to this Office. The complaint has afforded the relevant clinicians an opportunity to reflect on the care they provided. It has also led this Office to invite RANZCR to review the incidence of perceptual error, in light of this case, and to consider what further actions can be taken to minimise such errors.

 

Recommendations

  1. I recommend that Dr C provide a written apology to Mr B and his family for the failing identified in this report. The apology is to be sent to HDC, for forwarding to Mr B and his family, within three weeks of the date of this report.
  2. I recommend that the DHB review Dr Kingzett Taylor’s advice on possible improvements, and report back to HDC on the result of its review and any improvements it intends to make, within three months of the date of this report.

 

Follow-up actions

  1. I will be writing to RANZCR to invite it to review the incidence of perceptual error in radiology reports, in light of this case, and to consider what further actions can be taken to minimise such errors.[20]
  2. A copy of this report with details identifying the parties removed, except the experts who advised on this case, will be sent to the Medical Council of New Zealand, and it will be advised of Dr C’s name.
  3. A copy of this report with details identifying the parties removed, except the experts who advised on this case, will be sent to the Health Quality & Safety Commission and RANZCR, and placed on the Health and Disability Commissioner website, hdc.org.nz, for educational purposes.

 

 

Appendix A: Independent advice to the Commissioner

The following expert advice was obtained from oncologist Dr Richard Isaacs:

“18 March 2020

Health and Disability Commissioner

PO Box 1791

Auckland 1140

Dear Sir

Complaint: [DHB]

Your ref: 19HDC01606

I have been asked to review the case of [Mr A], who died from metastatic rhabdomyosarcoma [in] 2018. I have been asked to specifically comment on:

  1. The appropriateness of the care [Mr A] received from [the DHB] following his orchiectomy at [the public hospital], particularly the complainant’s concern that [Mr A] should have received more frequent CT scans and that no chemotherapy or radiation treatment was given following the orchiectomy.
  2. The appropriateness of care provided by:
  3. [Dr E];
  4. [Dr D].
  5. Any other matters in this case that you consider warrant comment, but limited to the Oncology care of [Mr A].

For each question comment on:

  • What is the standard of care/accepted practice?
  • If there has been a departure from the standard of care or accepted practice, how significant a departure do you consider this to be?
  • How would it be viewed by your peers?
  • Recommendations for improvement that may help to prevent a similar occurrence in future.

Case Summary

[Mr A] was a previously fit [man in his twenties] who presented with a several month history of an enlarging lump in his right testis. This appeared complex and probably malignant on ultrasound and he went forward to right orchiectomy on 1 [Month2], following a pre-operative CT which showed prominent, but normal sized para-aortic and aortocaval lymph nodes.

Histology showed a variety of benign tissues, but a predominant malignant rhabdomyosarcoma, with a mix of low and high grade areas of differentiation and foci of seminoma, occupying 2–3% of the tumour mass. There were no features suggesting high risk of spread, as per standard criteria for a malignant teratoma. It is highly likely that there was a pre-existing mature teratoma that ‘de-differentiated’ into this form of sarcoma, admixed with seminoma.

He was seen by [Dr D] on 21 [Month2], who recommended that, due to the lymph node findings, a post-operative PET/CT should be performed, as this imaging modality is considered highly sensitive for detecting rhabdomyosarcoma spread.

This scan showed no evidence of metastatic disease.

[Dr D] reviewed [Mr A] on 29 [Month2] to confirm those findings and indicated that his case had been discussed at a multidisciplinary meeting with a plan to repeat a CT in 2 months.

He was seen for clinical review on 20 [Month3], when examination and CXR were normal and a CT was booked for 16 [Month4]. This was again normal.

He was next seen by [Dr D] on 17 [Month4], who made a decision to follow [Mr A] with monthly markers, but not to repeat his CT for 10 months, a decision consistent with standard surveillance for seminoma. Instead a decision was made to perform monthly CXR, to monitor for lung metastases from the sarcoma component.

He was seen again on 15 [Month5], 17 [Month6], 16 [Month7] and 16 [Month8]. On each occasion he was said to be well and bloods and repeat CXR were normal on each occasion.

On 13 [Month9] [Dr E] reviewed [Mr A] and reports him having ‘some muscular back pain but was otherwise completely asymptomatic’. A CXR was considered normal and the planned CT scan was booked for 4 weeks.

The next clinic record is on 11 [Month10], after [Mr A] had been diagnosed with a spinal cord compression due to metastatic involvement of the T7 vertebra, requiring surgical fixation. [Dr D’s] record on 18 [Month10], reports [Mr A] had progressive worsening of symptoms after his clinic review on 13 [Month9].

The CXR from 13 [Month9] was ultimately confirmed as showing a new wedge fracture at T7, but this was not reported by the radiologist and was not noted by the Medical Oncology Registrar, [Dr E].

I have reviewed the images and it is my opinion that the fracture is NOT visible on the PA view and only seen on the lateral view, a view that would routinely be performed in many hospitals including my own.

[Dr D] reports that earlier recognition of that change may have ‘avoided the complications of spinal cord compression, although it would not have changed the surgical procedure that needed to be undertaken’. Histology at surgery confirmed rhabdomyosarcoma.

[Mr A] was referred for radiotherapy and was advised that ‘chemotherapy at that time was unlikely to change the potential outcome’. Post-radiotherapy CT surveillance 3 monthly was recommended.

In [Month11] he developed progression locally at T7, causing paraplegia and was found on CT to have developed lung metastases.

He commenced VAC chemotherapy on 25 [Month11], but I understand his disease subsequently progressed further and he died from his disease [in] 2018.

Opinion

  1. The appropriateness of the care [Mr A] received from [the DHB] following his orchiectomy at [the public hospital], particularly the complainant’s complaint that [Mr A] should have received more frequent CT scans and that no chemotherapy or radiation treatment was given following the orchiectomy.

[Mr A] had a very unusual form of testicular tumour, for which there are no clear management guidelines. [Dr D] discussed his care in a multidisciplinary meeting and applied an internationally recognized surveillance program, which is used to follow patients with early stage testicular seminoma.

Another approach would have been to follow the surveillance program for non-seminomatous testicular teratoma, as this would have resulted in a further CT in [Month7].

While this may have identified changes earlier, that is supposition, as [Mr A’s] disease clearly moved very rapidly in [Month9]. Furthermore, the reason for more intense surveillance in non-seminomatous germ cell tumours is that they are very chemo-sensitive and early spread can be treated with curative intent. This is not the case with a rhabdomyosarcoma, which is a relatively chemo-resistant malignancy and tumours that dedifferentiate from teratoma are often particularly resistant to systemic therapies. There is no proven evidence of benefit as adjuvant therapy in this setting and I absolutely support the decision not to proceed with chemotherapy after the spinal surgery, when the only site of known metastatic disease had been treated with radiotherapy.

Furthermore, sarcomas very rarely spread to bone and almost always go to lung as the first site of relapse. This area was being monitored very closely and appropriately with monthly CXR.

[Mr A] was commenced on appropriate chemotherapy when he had more widespread metastatic disease, but the inherent chemo- and radio-resistance of this tumour is confirmed by the failure of [Mr A] to gain significant benefit from either treatment modality.

It is my opinion that [the DHB] did follow an adequate standard of practice. In retrospect, a closer surveillance approach may have identified changes in the spine earlier, but this is most unlikely to have altered [Mr A’s] ultimate survival.

Resection of the spinal tumour at an earlier stage would sadly not have been curative, as the subsequent early development of lung metastases indicated the presence of micrometastatic disease at the time the spinal cord compression was diagnosed.

In my opinion, [Mr A’s] very difficult disease journey was driven by the nature of his malignancy and not by any deficiency in his care.

  1. The appropriateness of care provided by:
  2. [Dr E];

I do not believe [Dr E] should be held responsible for missing the compression fracture on CXR, particularly when it had been missed by the reporting radiologist. The symptoms described in his clinic letter were those of muscular pain and sarcomas very rarely go to bone, so his index of suspicion for bone changes would be appropriately low. In my unit, I would only have looked at the PA view which did not show the fracture.

It is my opinion that [Dr E’s] practice was entirely appropriate for a training Registrar.

  1. [Dr D].

[Dr D] is an experienced clinician, who decided [Mr A’s] treatment plan in consultation at an MDT and then selected an entirely reasonable surveillance program. The option of more frequent CT surveillance is only suggested in retrospect and would have been unlikely to significantly impact on [Mr A’s] survival. The surveillance followed, was indeed more intensive than that used for standard seminoma, with monthly CXR and really reflects an appropriate focus on the high likelihood of lung metastases being the predominant site of relapse.

It is my opinion that [Dr D’s] practice was of an appropriate standard for a senior Medical Oncologist.

  1. Any other matters in this case that you consider warrant comment, but limited to the Oncology care of [Mr A].

[Mr A’s] journey would have been extremely traumatic, not only for [Mr A], but also for his family when such a young man had such morbidity from his disease, with loss of mobility and significant suffering. I believe, however that his journey was made so difficult not by any deficiency in his oncology treatment, but by the biology of his disease.

Yours sincerely

Dr Richard Isaacs MNZM MBChB D.Phil (Oxon) FRACP

Medical Oncologist”

Appendix B: Independent advice to the Commissioner

The following expert advice was obtained from radiologist Dr Andrew Kingzett Taylor:

“MY QUALIFICATIONS

I am a diagnostic radiologist working full-time for the Pacific Radiology Group. I became a fellow of the Royal Australian and New Zealand College of Radiologists in 1996.

I received further subspecialty musculoskeletal radiology training in San Francisco in 1998–9 and have worked since for Pacific Radiology Group or its predecessors in both New Zealand and Australia.

I am registered as a diagnostic radiologist in both Australia and New Zealand.

I am a member of the

American Roentgen Ray Society

Australasian Musculoskeletal Imaging Group

European Society of Skeletal Radiology

Radiologic Society of North America

I participate fully in the RANZCR CPD programme.

CONFLICTS:

I am not aware of any conflicts of interest.

INFORMATION REVIEWED

Letter from HDC dated 3 February 2020

Copy of original requisition form dated 16 [Month8]

CD including examination 13 [Month9]

Subsequent letter from HDC dated 24 April 2020

Letter of complaint dated 30 August 2019

ACC Treatment Injury Report

Response from [Dr C] dated 20 October 2019

Response from [the DHB] dated 29 October 2019 (received by HDC on 4 November 2019)

OPINION

NO DEPARTURE FROM STANDARD OF CARE.

The mid thoracic vertebral compression fracture at T7 was not reported on the chest radiograph performed 13 [Month9].

The failure to detect the vertebral fracture is likely to have been a ‘perceptual error’. Some researchers prefer the term ‘discrepancy’ to ‘error’ but perceptual error is the most frequently used expression. Perceptual errors can be confidently expected to occur in a proportion of observations made by any human observer, including professionally trained observers (such as a diagnostic radiologist) even when operating under ideal conditions. (Pitman)

It is acknowledged that perceptual error is a common part of radiology practice and some errors are ‘inevitable’.

In concluding that there is no departure from the standard of care in this instance I have in particular considered that there was no reference to back pain on the requisition form and it would have been presumed that the examination was being performed for asymptomatic surveillance.

Unfortunately it is very well established that thoracic vertebral fractures are frequently unrecognised on chest radiographs. Although the majority are incidental osteoporotic fractures, researchers have also found that vertebral fractures are also frequently overlooked on imaging performed after minor trauma and (as in this instance) in oncologic patients.

Li, Yizhong, et al. ‘The prevalence and under-diagnosis of vertebral fractures on chest radiograph.’ BMC musculoskeletal disorders 19.1 (2018): 235.

Wild, Melanie, et al. ‘Vertebral body fractures of unknown origin in cancer patients receiving MDCT: reporting by radiologists and awareness by clinicians.’ SpringerPlus 5.1 (2016): 1–6.

Pitman, A. G. ‘Perceptual error and the culture of open disclosure in Australian radiology.’ Journal of Medical Imaging and Radiation Oncology 50.3 (2006): 206–211.

How would it be viewed by peers?

Although it is likely that most radiologists would have detected the compression fracture on the [13 Month9] chest radiograph, they would also acknowledge that thoracic vertebral fractures are frequently overlooked on chest radiographs (see literature review in section above).

In this case there was no reference to back pain on the requisition form and it would have been presumed the chest radiograph was being performed for asymptomatic surveillance.

Recommendations for improvement that may help to prevent a similar occurrence in future.

This case can be usefully discussed at a peer review meeting. Reviewing and learning from cases such as this, radiologists will be able to continue to fine-tune and calibrate/re-calibrate their viewing patterns and reporting techniques throughout their career.

As discussed above, thoracic vertebral fractures are known to be underrecognized on radiographs. It has been proposed that speech recognition software may offer a limited solution as chest radiograph reports routinely omit reference to vertebral column.

Arguably a line referring to presence or absence of a vertebral deformity could be routinely added to chest radiographs in a particular patient population (such as oncologic patients) to trigger an automatic review by the reporting radiologist.

Andrew Kingzett Taylor

Blind report prepared by Dr Kingzett Taylor:

MY QUALIFICATIONS

I am a diagnostic radiologist working full-time for the Pacific Radiology Group. I became a fellow of the Royal Australian and New Zealand College of Radiologists in 1996.

I received further subspecialty musculoskeletal radiology training in San Francisco in 1998–9 and have worked since for Pacific Radiology Group or its predecessors in both New Zealand and Australia.

I am registered as a diagnostic radiologist in both Australia and New Zealand.

I am a member of the

American Roentgen Ray Society

Australasian Musculoskeletal Imaging Group

European Society of Skeletal Radiology.

Radiologic Society of North America

I participate fully in the RANZCR CPD programme.

CONFLICTS:

I am not aware of any conflicts of interest

INFORMATION REVIEWED

Letter from HDC dated 3 February 2020

Copy of original requisition form dated 16 [Month8]

CD including examination 13 [Month9]

CHEST RADIOGRAPH 13 [Month9]

INDICATION

Non-seminoma (mixed rhabdo and seminoma) Stage 1A Active surveillance

COMPARISON
No prior films

FINDINGS

No visible pulmonary mass lesion or consolidation. No pleural fluid. Cardiac size normal

Compression fracture mid thoracic vertebral body — about T7

Elevation right hemidiaphragm

IMPRESSION

No pulmonary mass seen

Compression fracture mid thoracic vertebral body.

Compare with prior imaging if is available. If this fracture is new and/or has not been documented and investigated previously, further imaging is necessary to exclude a pathologic fracture. MRI would probably be modality of choice.

Andrew Kingzett Taylor”

Addendum to Dr Kingzett Taylor’s advice:

“No I would not expect [Dr C] to review [Dr E’s] consultation notes.

In certain circumstances [Dr E] might have chosen to update [Dr C] but he chose an appropriate alternative strategy and ordered a more sensitive test — CT — to further investigate the back pain.

…

The 3–5% figure still seems to be reasonably well accepted. As I said the clinical significance of these errors varies very widely.”[21]

 

 

 

 

[1] Relevant months are referred to as Months 1–11 to protect privacy.

[2] Dr C is a member of the Royal Australian and New Zealand College of Radiologists. The DHB said that he has since retired.

[3] A surgical procedure in which one or both testicles are removed.

[4] Spread from the site of origin to another part of the body.

[5] Positron emission tomography (PET) scans are used to evaluate organ and tissue function. By identifying changes at the cellular level, PET scans may detect the early onset of disease.

[6] Substances, usually proteins, produced by the body in response to cancer growth or by cancer tissue itself. Measurement in blood plasma, urine, or tissue can aid diagnosis of some types of cancer, and predict and monitor response to treatment and detect recurrence.

[7] The process by which cells acquire the properties of cancer.

[8] A type of testicular cancer.

[9] Rhabdomyosarcoma (RMS) is a rare type of cancer that forms in soft tissue — specifically skeletal muscle tissue or sometimes hollow organs such as the bladder or uterus.

[10] A type of testicular cancer.

[11] A type of testicular cancer. Non-seminomas often grow and spread more quickly than seminomas. Non-seminomas also are more likely to spread to the lungs, liver, and brain.

[12] Stage 1 means that the cancer is only in the testicle and has not spread beyond it.

[13] Tumours.

[14] Abnormally enlarged lymph nodes.

[15] Chest X-ray.

[16] The seventh thoracic vertebra (T7), which is located in the mid to lower area of the spine.

[17] Spread of the cancer in the spine, causing compression of the spinal cord.

[18] A corpectomy (removal of all or part of the vertebral body, usually to decompress the spinal cord and nerves).

[19] Pressure on the spinal cord.

[20] In a previous decision by this Office (15HDC00685), Dr Kingzett Taylor advised that perceptual errors are thought to occur in about 3–5% of radiology reports, although their clinical relevance will vary widely. Dr Kingzett Taylor advised that this error rate is still reasonably well accepted.

[21] Dr Kingzett Taylor was asked whether his advice in a previous decision by this Office (15HDC00685) — that perceptual errors are thought to occur in about 3–5% of radiology reports — is still reasonable.