Wrong Site Biopsy Results in Inaccurate Negative Cancer Test

Case Summary

This case involves an adult female with Hashimoto’s Thyroiditis who was under the care of an endocrinologist. The physician noted an enlarged lymph node. However, the endocrinologist didn’t take any action.

The patient also exhibited symptoms of dysphagia and dysphonia. She visited several physicians over the following two years. The patient’s symptoms of dysphagia and dysphonia continued to exacerbate, along with increased lymphadenopathy.

A biopsy of the lesion in the neck was eventually ordered. During the procedure, the surgeon performed a wrong site biopsy. Consequently, the physician examined a smaller left lymph node as opposed to the symptomatic right node. This resulted in a negative cancer test. As time progressed, the patient’s symptoms worsened which led her to seek a second opinion. The patient was subsequently diagnosed with papillary thyroid cancer. The delayed diagnosis resulted in total thyroidectomy with modified radical neck dissections and radioactive iodine treatment.

Case Theory

Papillary thyroid cancer in Hashimoto’s Thyroiditis is an autoimmune lymphocytic disease. It is the most common form of thyroid inflammatory disease. Hashimoto’s thyroiditis patients have a higher risk of developing both thyroid and colorectal cancer. Thyroid cancer prevention is a part of patient care upon the diagnosis of Hashimoto’s Thyroiditis. Papillary thyroid carcinoma is the most common form of malignancy associated with Hashimoto’s.

Here, the failure to identify the cause of the enlarged lymph node, dysphagia, and dysphonia is a violation of the standard of care. The obvious clinical symptoms alone, with a high-risk factor, should have alerted this specialist to the likelihood of cancer. This case is made egregious by the wrong site biopsy that further delayed care in this patient.

Expert Witness Q&A

• What factors are important in determining when to biopsy and what mass to biopsy?
• What effect, if any, can a delay in the diagnosis of papillary thyroid cancer have on the treatment a patient received and a patient’s prognosis?
• What is the standard of care for a dysphagic and dysphonic thyroid patient with Hashimoto’s Thyroiditis and an enlarged lymph node?
• What safety measures should have been taken to ensure a wrong site biopsy is not performed?

Expert Witness Involvement

Endocrinologist

An expert in endocrinology can speak to the standard of care for a similar patient. This expert can also outline the deviations from proper standards. An endocrinology expert can opine on the changes in patient care and prognosis due the thyroid removal, radical neck surgery, and radioactive iodine treatment.

Oncologist

An oncology head and neck surgeon can speak to the prognosis and expected sequelae for this patient. This specific expert can outline what medical consequences resulted from a time delay and wrong site biopsy.