Misdiagnosis of pancreatic cancer

Presentation

The patient, a 36-year-old woman, had a 10-year history of a pancreatic cyst. She had two fine needle aspiration (FNA) biopsies in the previous year. The first FNA was reported as “no malignant cells identified.” The second FNA of the cyst — done three months later — was reported as “these findings suggest the possibility of a pseudocyst; however, malignancy cannot be totally excluded.”

A month after the second FNA, it was noted that cyst continued to grow, now at 7.5 cm. General Surgeon A recommended surgery to remove the pancreatic pseudocyst and a left ovarian mass. After obtaining informed consent, the patient was taken to surgery for a distal pancreatectomy with splenectomy and left oophorectomy. Multiple surgical specimens were sent to Pathologist A, the defendant in this case.

Four days after surgery, the pathology finding on the ovary was cystic follicles. The pathology finding on the spleen was congesting and capsular adhesions containing foreign body giant cells and chronic inflammation. The pancreatic pseudocyst was reported as having histiocytic and chronic inflammatory infiltrates and fibrosis; it was reported negative for malignancy.

Almost two years later, the patient returned to General Surgeon A complaining of symptoms consistent with cholelithiasis. A cholecystectomy was scheduled. Upon entering the abdomen, the surgeon encountered “multiple metastatic deposits on the peritoneum, some on the liver surface, in the pelvis and primarily on the right side of the abdominal cavity.”  Multiple biopsies were obtained before removing the gallbladder. Pathologist B reported the specimens were poorly differentiated carcinoma. Subsequently, a medical oncologist diagnosed pancreatic cancer with abdominal carcinomatosis.

Pathologists at an oncology center reviewed the previous pathology slides — that were initially interpreted by Pathologist A — and reported that they showed “undifferentiated carcinoma with osteoclast-like giant cells, arising in a mucinous cystic tumor with high grade dysplasia.”

The patient was referred to an oncology center for treatment, but she died 14 months after being diagnosed.

Allegations

The plaintiffs alleged that Pathologist A was negligent in misinterpreting pathology tissue slides made from the pancreas following a partial pancreatectomy.

Legal implications

There was no indication in the medical record or during the investigation of this claim to indicate that Pathologist A deviated from her normal routine when handling, processing, and reviewing the patient’s specimen. However, when Pathologist A re-examined the slides, she stated that she believed the wall of the cyst did contain cancer cells. Additionally, the slides were sent out for a “blind review” and that reviewer diagnosed “malignant neoplasm.”

Medical oncologists consulted by the defense asserted that the patient’s presentation was unusual for pancreatic cancer and questioned whether the delay in diagnosis altered the patient’s outcome.
 

Disposition

This case was settled on behalf of Pathologist A.

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