Delayed Diagnosis of Cervical Cancer, Patient Sustains Ureter Damage

This case involves a fifty-eight-year-old female patient, an adamant user of adult baby powder and other talc-based products, who underwent an ultrasound for complaints of increasing pelvic pain. The ultrasound revealed a large ovarian mass that was suspicious for malignancy. This prompted the physician to order blood work for CEA and CA 125 tumor markers. The CEA level returned in the high range of 5+ and the CA 125 was high at a level of 90. The patient was referred for surgical intervention and underwent a total abdominal hysterectomy that was reported to be performed without complication. Unfortunately, the patient demonstrated some urinary retention and difficulty passing urine post-operatively. Also, the patient’s BUN/Cr continued to rise dramatically and she had a persistent fever with leukocytosis. The patient was taken back into surgery after a CT of the abdomen showed fluid buildup in the pelvis. Further workup revealed evidence of ureteral injury during the first resection procedure and the patient required re-implantation of the ureters to avoid a permanent nephrostomy tube placement. Furthermore, the patient was inadequately staged after her primary resection procedure required an additional resection of the cervix that was only partially successful due to extensive scarring and fibrosis. The patient had a poor overall prognosis after her care at this institution and the chance of recurrence after her treatment was significant.

Question(s) For Expert Witness

1. What is the proper protocol for early staging to prevent recurrence in ovarian and uterine cancer?

Expert Witness Response

A complete lymph node dissection would prevent the need to return to the operating room for lymph node staging or use of unnecessary radiation therapy. One recent study found that almost 20% of patients with grade 1 disease who underwent routine staging, avoided whole-pelvic radiation based on pathologic findings. Also, a small percentage of patients with grade 1 disease required whole-pelvic radiation that they would not have received based on uterine and adnexal pathology. Although, controversy exists as to whether lymph node sampling is adequate or if more extensive full lymphadenectomy might offer a survival advantage.