This case involves a forty-year-old patient with a past medical history of inactive hepatitis B and hypothyroidism by Synthroid. The patient presented to the treating physician with complaints of pain on her left hip, which she experienced after she had been lying on her side sun-bathing. The patient was able to palpate a bony growth approximately half the size of her thumb on her pelvis. The treating physician reported in her treatment records that the patient’s abdomen was soft, non-tender, with no masses or hepatosplenomegaly and normal bowel sounds. The physician also reported that there was a small mass between the pelvic bone and skin which she diagnosed tentatively as a lipoma. The patient was told that inconsequential and no follow-up was ordered. Over the next several weeks, the pain gradually increased and the mass felt significantly larger. Appearing to her to extend into her abdomen. The patient was examined by a primary care physician at another medical facility 76 days after the initial consultation. On physical examination of the abdomen, a large abdominopelvic mass in the left lower quadrant was found and a CT scan was ordered. The CT scan revealed a probable osteosarcoma measuring approximately 10 cm transversely, 8 cm anteroposteriorly, and 15.5 cm sagittally. There was no evidence of metastases or lymphadenopathy. The patient underwent a left sub-total iliac bone resection to remove the tumor. Based on biopsy samples taken during the procedure, it was felt that the chondrosarcoma most likely arose from pre-existent sessile osteochondroma. The patient was left with a large scar from the surgery and an antalgic gait due to paresthesia in her left thigh. She was no longer able to maintain her previous levels of physical activity.
Question(s) For Expert Witness
1. Was it a departure from accepted standards of medical care for the initial physician to characterize the mass as a lipoma and not order follow-up tests?
2. Had the mass been detected earlier, would the nature of the surgery, resulting scarring and disability have been substantively different?
Expert Witness Response E-007415
A bone tumor and a soft tissue lipoma are very different in nature. They should be easily distinguishable on physical examination of the patient. Had the mass been detected earlier, the nature of the surgery and disability could have been different. Earlier diagnosis could have led to less radical surgery and potentially better outcomes for the patient. The key to curing osteosarcoma is organ preservation and the smaller the cancer, the better is the chance of organ preservation with a more limited and less destructive surgery, and better the chance of cure. Disability and scarring would have been less and the amount of chemo and radiation would also be less. In this case, deciding whether the standard of care was breached really depends upon the initial doctor’s description of the size and consistency of the mass. If this was a large, firm mass, not ordering testing breaches standard of care.
About the author
Dr. Faiza Jibril
Dr. Faiza Jibril has extensive clinical experience ranging from primary care in the United Kingdom, to pediatrics and child abuse prevention at Mount Sinai Hospital, to obstetrics in Cape Town, South Africa. Her post-graduate education centered on clinical research and medical ethics. Dr. Jibril is currently Head of Sales in the US and Canada for Chambers and Partners - a world leading legal ranking and insights intelligence company.
