Delayed Diagnosis of Pancreatic Cancer Linked to Inadequate Imaging Studies

This case involves a male patient who was diagnosed with a slow-growing form of cancer in the ducts near his pancreas. The patient was subsequently treated with an ampullectomy, in which the lesion was removed endoscopically.

Wendy Ketner, M.D.

Written by
— Updated on August 24, 2021

Delayed Diagnosis of Pancreatic Cancer Linked to Inadequate Imaging Studies

The margins of the removed lesion were found to be negative for cancerous cells, and doctors believed that the cancer was not invasive to the patient’s pancreas. This result prompted doctors to order a 6-month period of observation of the patient’s condition, primarily through the use of upper gastrointestinal endoscopy as well as ultrasound. Though the course of this observation period, the patient underwent multiple endoscopies, all of which were negative for suspicious lesions, however the doctor did not order any ultrasounds during the observation period. One year after the conclusion of the observation period for the initial lesion, the patient was diagnosed with a mass in the head of his pancreas, which necessitated a Whipple procedure and left the patient with a grim prognosis.

Question(s) For Expert Witness

  • 1. Can you determine whether surveillance of the pancreas by the means described above is the standard of care?

Expert Witness Response E-000029

Surveillance of the pancreas by upper endoscopic ultrasound for total ampullectomy for this type of cancer, which is resected with negative margins indicated is within reasonable practice, which includes blood studies, chest radiograph, and a CT scan of the abdomen and/or pelvis every 6 months. Most of the literature suggests CT scan, not ultrasound, for additional monitoring. The National Comprehensive Cancer Network recommends it on PANC-6 category 2B recommendation, which means there is some disagreement among experts on this topic. I am certainly capable of determining whether the blood tests for the pancreatic enzymes and cancer markers, CEA and CA-19-9 is indicated and is the standard of care in such a patient. The National Comprehensive Cancer Network recommends Ca 19-9 (Panc-6) Category 2B for completely resected cancers. Regarding the percentage of loss of body weight that should have prompted an upper endoscopic ultrasound, literature says that unintended weight loss of 5-10% is an indication for an evaluation. For cancer patients in remission, I would support 5%.

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