Now for a serious comment: Where I trained (thankfully I don't do these anymore) indeed it was standard practice even for us to review the intraop imaging ourselves to make sure we could see whatever seeds/clips/wires were reported to be in the specimen prior to touching it. We even had our own little x-ray machine to take our own images of the specimen before grossing to again confirm everything is there because it has happened that things fall out between radiology and the gross room.
Depending on the setup, if the pathologist didn't have access to the EMR, this must have been an absolute nightmare of a case because they've been told the specimen has a clip and cancer in it and then they can't find it. At what point were they finally confident enough that it simply wasn't there? What a phone call that must have been to the surgeon and/or radiologist.
You nailed it that while the patient did suffer some harm, the harm that was *avoided* was potentially devastating and fatal.
Or more common than falling out, mislabeled specimens in cases where there was a bilateral mastectomy with one breast having cancer and one prophylactic.
Maybe in the hustle and bustle of multiple cases and phone calls, the radiologist relayed the wrong report to the surgeon. Just a thought, but it's easy to imagine.
In any case, this poor patient benefited from an effective mammogram screening and an expert conversation about surgical options, which probably all seemed very reassuring, and then ended up with a significantly more burdensome and complicated course than expected. It worked out well oncologically, but not in terms of confidence and tissue loss as well as two exposures to anesthesia and surgery and the concomitant extra post-op hassles and potential change in future options. There was a lack of built-in double-checks, and the patient paid the price.
I hadn't thought about that explanation for the radiologist's mistake, but it's definitely plausible. I think most physicians know how it feels to work with unsafe volumes.
it strikes me that “a poor cosmetic outcome” relative to missed breast cancer may be, for some women, as untenable as metastases. thank you for this substack!
I don't know if the defense statement was written by a lawyer, but it is... awkward.
"localized the needle" ? You localize the thing being targeted with the needle and then slide a hooked wire through the needle which anchors in place and remove the needle. The wording seems to convey a misunderstanding of this basic concept.
"He appeared to hone in on the mass as opposed to the clip" um, it's under ultrasound - unless it's something like a twirl I wouldn't count on seeing it very well, and certainly not as well as the mass itself.
Granted, a full field CC and LM mammogram needs to be performed to show where the wire is before they leave the department. Under US the needle is easy to see, but the wire is not so making sure that the wire is as far past the target as you think is important. Also the way the breast compresses on US can have some surprising ramifications. I've bracketed a finding with 2 wires under US and thought I was in the back of the finding on the second wire... the mammogram showed that wire no where near the target. I'd put it into some breast parenchyma that was just draped over the target. So, back to the room, put in another wire (sigh).
Both the radiologist and the surgeon should be insisting on a mammogram that shows the wires. This should be a system in place.
The surgeon is bringing the pt to the OR without knowing where the wire is? They don't know how deep the target is or how far the tip of the wire is past the target? No wonder they are doing an 8cm lumpectomy for a 6mm cancer.
In this day and age any place doing breast surgery should have a specimen imager in the OR. There is no reason to leave the pt on the table while someone runs the specimen to radiology, they image it, send the images, get the rads attention, they call a report...
This case is just embarrassing for everyone involved.
One thing that needs to be mentioned is the role of adjuvant treatment. For patients getting breast conserving surgery with lumpectomy, most (if not all) would be recommended to received post-lumpectomy radiation therapy and endocrine therapy (there is emerging data on omission of RT and even endocrine therapy, in the right patient).
In this particular patient, I would recommend adjuvant whole breast radiation therapy. This patient would be a candidate for whole breast irradiation (WBI) or partial breast irradiation). Partial breast irradiation is emerging as the ideal radiation strategy to reduce the side effect profile from whole breast irradiation, while maintaining excellent local control. It is my preferred strategy for early stage breast cancer these days.
If the patient received whole breast radiation therapy, with a T1, receptor positive cancer in a 51 year old woman, I would consider the addition of a tumor bed boost to improve local control. Local recurrence risk increases with younger age patients, and multiple studies have demonstrated a benefit to the radiotherapy boost. Certain guidelines exist to provide guidance on such situations, and for a 51 year old with a grade 2 tumor (based on initial biopsy but unclear grade on final path), a reasonable recommendation is a shared discussion on the benefits and risks of a tumor bed boost.
If the initial decision is to pursue PBI or a tumor bed boost in this particular patient, it is very possible that the mastopexy caused enough local tissue rearrangement that the tumor bed may not be able to be identified, and therefore, PBI or a tumor bed boost may not be able to be administered if the patient desired the treatment, a choice that is now not available for the patient because of the need for the second surgery.
Excellent comment, thanks for the clarification! I did not realize the downstream treatment implications secondary to the surgery/mastopexy. The attorney did not delve into this at all, just goes to show the importance of having domain experts giving good advice in an understandable format.
I will accept said christmas gift on behalf of my colleagues
Now for a serious comment: Where I trained (thankfully I don't do these anymore) indeed it was standard practice even for us to review the intraop imaging ourselves to make sure we could see whatever seeds/clips/wires were reported to be in the specimen prior to touching it. We even had our own little x-ray machine to take our own images of the specimen before grossing to again confirm everything is there because it has happened that things fall out between radiology and the gross room.
Depending on the setup, if the pathologist didn't have access to the EMR, this must have been an absolute nightmare of a case because they've been told the specimen has a clip and cancer in it and then they can't find it. At what point were they finally confident enough that it simply wasn't there? What a phone call that must have been to the surgeon and/or radiologist.
You nailed it that while the patient did suffer some harm, the harm that was *avoided* was potentially devastating and fatal.
Or more common than falling out, mislabeled specimens in cases where there was a bilateral mastectomy with one breast having cancer and one prophylactic.
Hadn't even considered that, that makes it even more complicated and confusing.
Maybe in the hustle and bustle of multiple cases and phone calls, the radiologist relayed the wrong report to the surgeon. Just a thought, but it's easy to imagine.
In any case, this poor patient benefited from an effective mammogram screening and an expert conversation about surgical options, which probably all seemed very reassuring, and then ended up with a significantly more burdensome and complicated course than expected. It worked out well oncologically, but not in terms of confidence and tissue loss as well as two exposures to anesthesia and surgery and the concomitant extra post-op hassles and potential change in future options. There was a lack of built-in double-checks, and the patient paid the price.
I hadn't thought about that explanation for the radiologist's mistake, but it's definitely plausible. I think most physicians know how it feels to work with unsafe volumes.
it strikes me that “a poor cosmetic outcome” relative to missed breast cancer may be, for some women, as untenable as metastases. thank you for this substack!
Yes, the psychological and cosmetic downsides shouldn't be overlooked. Very tough to deal with. Thanks for reading!
I don't know if the defense statement was written by a lawyer, but it is... awkward.
"localized the needle" ? You localize the thing being targeted with the needle and then slide a hooked wire through the needle which anchors in place and remove the needle. The wording seems to convey a misunderstanding of this basic concept.
"He appeared to hone in on the mass as opposed to the clip" um, it's under ultrasound - unless it's something like a twirl I wouldn't count on seeing it very well, and certainly not as well as the mass itself.
Granted, a full field CC and LM mammogram needs to be performed to show where the wire is before they leave the department. Under US the needle is easy to see, but the wire is not so making sure that the wire is as far past the target as you think is important. Also the way the breast compresses on US can have some surprising ramifications. I've bracketed a finding with 2 wires under US and thought I was in the back of the finding on the second wire... the mammogram showed that wire no where near the target. I'd put it into some breast parenchyma that was just draped over the target. So, back to the room, put in another wire (sigh).
Both the radiologist and the surgeon should be insisting on a mammogram that shows the wires. This should be a system in place.
The surgeon is bringing the pt to the OR without knowing where the wire is? They don't know how deep the target is or how far the tip of the wire is past the target? No wonder they are doing an 8cm lumpectomy for a 6mm cancer.
In this day and age any place doing breast surgery should have a specimen imager in the OR. There is no reason to leave the pt on the table while someone runs the specimen to radiology, they image it, send the images, get the rads attention, they call a report...
This case is just embarrassing for everyone involved.
One thing that needs to be mentioned is the role of adjuvant treatment. For patients getting breast conserving surgery with lumpectomy, most (if not all) would be recommended to received post-lumpectomy radiation therapy and endocrine therapy (there is emerging data on omission of RT and even endocrine therapy, in the right patient).
In this particular patient, I would recommend adjuvant whole breast radiation therapy. This patient would be a candidate for whole breast irradiation (WBI) or partial breast irradiation). Partial breast irradiation is emerging as the ideal radiation strategy to reduce the side effect profile from whole breast irradiation, while maintaining excellent local control. It is my preferred strategy for early stage breast cancer these days.
If the patient received whole breast radiation therapy, with a T1, receptor positive cancer in a 51 year old woman, I would consider the addition of a tumor bed boost to improve local control. Local recurrence risk increases with younger age patients, and multiple studies have demonstrated a benefit to the radiotherapy boost. Certain guidelines exist to provide guidance on such situations, and for a 51 year old with a grade 2 tumor (based on initial biopsy but unclear grade on final path), a reasonable recommendation is a shared discussion on the benefits and risks of a tumor bed boost.
If the initial decision is to pursue PBI or a tumor bed boost in this particular patient, it is very possible that the mastopexy caused enough local tissue rearrangement that the tumor bed may not be able to be identified, and therefore, PBI or a tumor bed boost may not be able to be administered if the patient desired the treatment, a choice that is now not available for the patient because of the need for the second surgery.
Excellent comment, thanks for the clarification! I did not realize the downstream treatment implications secondary to the surgery/mastopexy. The attorney did not delve into this at all, just goes to show the importance of having domain experts giving good advice in an understandable format.