Missed Cancer Diagnosis During Appendectomy

Case Summary

The patient in this case is a 37 y.o. male who presented to the hospital in June of 2013 with a perforated gangrenous appendix.  An appendectomy was performed. Post-operative pathology appeared to be normal. Two months after surgery the same patient was admitted with abdominal distention. He was then diagnosed with Stage 4 Adenocarcinoma. Upon testing sample from first visit, June 2013, there were evident signs of adenocarcinoma.

Questions

Did the initial practitioner properly diagnose the patient from the pathology reports? Was the cancer clearly evident in the first sample and or was the diagnosis missed?  Was the standard of care met by the oncologist reviewing initial charts?  Did the delay in diagnosis result in increased complications experienced by the patient?

Expert Findings

AMFS expert (Oncologist) reviewed this matter and provided the following opinion: The pathologist did not identify the malignancy on appendectomy specimen. This resulted in a catastrophic series of events for the patient.  First, had the malignancy correctly been identified, the standard of care would have dictated the performance of a right hemicolectomy, as many studies have shown that there is a clear survival benefit to the addition of this procedure (5-yr survival improved from 44% in the appendectomy group to 77% in the hemicolectomy group). If the tumor was indeed small and had not spread by that time, then the hemicolectomy might in fact have been curative. If, on the other hand, demonstrable advanced disease was found at the time of a hemicolectomy in 6/2013, then at the very least the morbid complications of bowel obstructions may have been avoided, and earlier adjuvant systemic therapies may have been started sooner to improve survival possibility. In summary, a correct diagnosis in June 2013 would have lead the patient to a better immediate surgical procedure – potentially curative-, potentially reduced complications (morbidity) and potentially better overall prognosis.

AMFS expert (Pathologist) provided the opinion that pathology indeed missed the diagnosis at appendectomy which was identified two months after the procedure. This extensive disease was likely present at the time of appendectomy and would have been of best interest to have pre-operation radiology reports at the appendectomy carefully reviewed by the surgeon at the time of procedure.