Patient Receives Unnecessary Lobectomy

This case involves a male patient in his early sixties who underwent a routine chest x-ray. The x-ray revealed an area of density and a subsequent CAT scan was performed. The CAT scan revealed a nodular opacity in the right upper lobe and a PET scan was recommended. Following the PET scan, the comment was made that the lesion should be diagnosed as malignant if the patient’s history correlated due to “FDG activity” in the right upper lobe and some surrounding lymph nodes. The patient was advised that due to the location of the lesion, a biopsy of the lung lesion to rule out infection would not have been possible. The patient informed the treating physician that he had recently moved from an area of the country where Cocci, also known as “valley fever” is endemic. The patient underwent a biopsy of the involved lymph nodes through bronchoscopy needle aspiration. The pathology report stated that the specimen was “scanty.” However, no evidence of malignancy was found and some white blood cells were seen. Twenty days later, the patient underwent mediastinoscopy in order to obtain better lymph node samples. The pathology report from the second lymph node biopsy initially reported no finding of microorganisms. (This was later amended.) The patient underwent a right upper lobectomy and lymphadenectomy. Postoperatively, the surgeon commented that the lung lesion did not look malignant, as it was soft and gelatinous in nature. A biopsy of the extracted lobe revealed Coccidimyocosis. It is alleged that the patient should have been treated for suspected Cocci to rule it out before the invasive lobectomy, given the inconclusive lymph node biopsy.

Question(s) For Expert Witness

1. What is the relationship between the pathologist and surgeon in terms of proceeding with invasive surgeries?

2. Was surgery premature given the history of the presenting complaint?

Expert Witness Response E-000214

The surgeon should not proceed with any invasive procedure until the information from any previous biopsies is obtained. It is the surgeon's responsibility to have all the information. The crucial question is the timing of the aggressive procedures and whether he had any previous films for comparison. Doing an excisional biopsy is not necessarily inappropriate, but I don't understand why they did the lymphadenectomy if the lesion was not malignant. I would be happy to look at it further.