Delayed Diagnosis of Thyroid Cancer
A significant percentage of women and many men will develop a thyroid nodule over their lifetime. Nodules may be diagnosed during a routine physical examination for an enlarged thyroid, known as goiter, or by chance during an imaging study ordered to investigate other medical issues. Unfortunately, many thyroid nodules will go unnoticed by both the patient and their physician.
The vast majority of thyroid nodules are harmless. If caught early, even cancerous nodules can be surgically removed with little long-term threat to the patient. But for some, thyroid nodules can represent potentially harmful cancer which can lead to the unfortunate loss of life.
Once a thyroid nodule is identified, we rely on our doctors to take the required steps to find out whether the nodule is harmless, potentially cancerous, or cancer.
When a primary care physician encounters a patient with a thyroid nodule, they should follow a systematic approach to rule-out cancer and make sure the patient receives proper diagnosis and treatment. The critical question to answer for any patient with a thyroid nodule is whether to perform a biopsy of the nodule, called a fine need aspiration (FNA). During a FNA, a needle is used to draw cells from a thyroid nodule. These cells are submitted to a laboratory for evaluation by a pathologist trained in the microscopic detection of cancer and other diseases.
Not every patient with a thyroid nodule needs an FNA with its related emotional and physical costs. Nevertheless, patients rely on their physicians to determine when the risk of a thyroid nodule being cancer is high enough to justify the performance of an FNA.
Investigating the Case of a Delayed Diagnosis of Thyroid Cancer –The Duty of Care for Evaluation of a Thyroid Nodule
When investigating a lawsuit based on a delayed diagnosis of thyroid cancer, we must determine whether a physician had a “duty” to perform testing necessary to make the diagnosis. Physicians confronted with a patient who has a newly identifying thyroid nodule are expected to meet this duty by taking specific steps which doctors in our community recognize as essential steps to investigate the possibility of thyroid cancer:
Obtain a History and Physical Examination Specific to the Risk of Thyroid Cancer:
- History: First, a physician evaluating a patient with a thyroid nodule should obtain a detailed medical history, including answers to the following questions:
- How long has the patient noticed the nodule?
- Has the nodule rapidly grown in size?
- Does the patient have symptoms such as difficulty swallowing, hoarseness, or breathing difficulties?
- Is there a family history of thyroid disease or cancer?
- Was this patient exposed to radiation to the head or neck in their past?
- Physical Examination: Perform a thorough neck examination to assess:
- The size, texture, and mobility of the nodule or nodules.
- Whether there are multiple nodules (suggestive of multinodular goiter).
- Whether the patient has enlarged lymph nodes in the neck region (which could suggest cancer).
Obtain a TSH (Thyroid-Stimulating Hormone) Level:
The TSH (Thyroid-Stimulating Hormone) level can provide important information about the risk of thyroid cancer. If a patient with a thyroid nodule has low TSH levels, this suggests that the thyroid is producing too much hormone (hyperthyroidism). In this scenario, the nodule may be a “hot” nodule, which is typically non-cancerous. The next step often involves a radioactive iodine uptake scan to determine whether the nodule is functioning (producing thyroid hormone), which could explain the low TSH levels. If the nodule is confirmed to be “hot,” it is usually not biopsied since hot nodules are rarely malignant.
When TSH levels are within the normal range or elevated, it indicates that the thyroid gland is not producing excessive thyroid hormone. Nodules in patients with normal or elevated TSH levels are more likely to be malignant. The next step typically includes an ultrasound to assess the nodule’s characteristics, such as size, composition, and the presence of suspicious features (e.g., microcalcifications, irregular margins). Depending on the ultrasound findings, a fine-needle aspiration (FNA) biopsy may be performed to evaluate the nodule for cancer.
Obtain a Thyroid Ultrasound
Thyroid ultrasound is the primary imaging test to evaluate a thyroid nodule for warning signs of thyroid cancer. Certain ultrasound features are associated with a higher likelihood of malignancy.
The findings on thyroid ultrasound can be critical to the evaluation of a lawsuit based on the delayed diagnosis of thyroid cancer. This is because doctors rely on the radiologic findings when deciding whether to obtain a FNA biopsy.
Radiologists are trained to recognize features of a thyroid nodule which raise the suspicion of thyroid cancer. If a radiologist fails to report such concerning features, it may lead to false assurance that the nodule is likely benign. This false assurance may discourage the patient’s doctor from ordering a FNA biopsy of a potentially cancerous thyroid nodule, and lead to the delay in diagnosis of thyroid cancer.
A few of the most common features of thyroid nodules which raise the likelihood of cancer include the following:
- Hypoechogenicity – A hypoechoic nodule appears darker than the surrounding thyroid tissue on ultrasound. Hypoechogenicity is associated with an increased risk of malignancy, particularly when combined with other suspicious features.
- Microcalcifications – Tiny, punctate echogenic foci within the nodule, which can appear as small, bright spots on ultrasound. Microcalcifications are a strong indicator of papillary thyroid carcinoma, the most common type of thyroid cancer.
- Irregular or Lobulated Margins – The edges of the nodule are not smooth but irregular or spiculated, sometimes with projections into the surrounding tissue. Irregular or lobulated margins suggest invasive growth and are associated with a higher likelihood of malignancy.
Additional warning signs of thyroid cancer include when a nodule has a more solid as opposed to fluid-filled composition, the absence of cystic or spongiform appearance to the nodule, extension of the nodule outside the thyroid gland into adjacent tissues, and the presence of enlarged or abnormal lymph nodes in the neck region.
Fine-Needle Aspiration (FNA) Biopsy
Once a physician has obtained the history and physical and obtained the results of diagnostic testing with TSH and thyroid ultrasound, the question becomes whether or not to perform an FNA biopsy.
Doctors and scientists who study thyroid cancer developed scoring systems to help identify which patients should have an FNA biopsy and which patients likely have a benign thyroid nodule which can be watched without testing. The presence of suspicious ultrasound features and the size of the nodules, or some combination of these factors, drives the decision whether to perform an FNA. In some situations, the patient’s history may be another important factor for doctors to consider in the decision to perform an FNA.
If a physician does not stay up-to-date on the current recommendations for when to biopsy a thyroid nodule, patients who require FNA for a thyroid nodule may be deprived of the essential test to diagnose thyroid cancer. When a physician fails to order an FNA biopsy for a thyroid nodule despite signs which raise the suspicion for thyroid cancer, that physician may be held responsible to the patient.
Interpretation of FNA Results
Pathologists perform microscopic evaluation of biopsies taken by FNA of thyroid nodules. Just like radiologists who evaluate the radiologic features of thyroid nodules, pathologists are trained to identify cellular features which are more likely cancerous versus those typical of normal or benign thyroid tissue.
Most thyroid nodules are benign based on pathologic evaluation. A benign FNA biopsy result in a thyroid nodule is reassuring, but it does not completely eliminate the need for ongoing monitoring. Proper follow-up and patient education are essential to ensure that any future changes in the nodule are detected early and managed appropriately.
In the case of a biopsy interpreted as malignant or suspicious for malignancy patients will be referred to an endocrinologist or a surgeon specializing in thyroid surgery for further evaluation and management, which may include surgery.
Common Reasons for the Delay in Diagnosis of Thyroid Cancer
Delays in the diagnosis of thyroid cancer can occur due to various factors related to clinical evaluation, diagnostic procedures, and follow-up care. Here are some common examples of how doctors might inadvertently delay the diagnosis of thyroid cancer:
Failure to Recognize or Address Patient Symptoms
- Overlooking Symptoms: Not paying attention to or properly investigating symptoms such as a rapidly growing neck mass, hoarseness, difficulty swallowing, or breathing difficulties, which could indicate thyroid cancer.
Inadequate Physical Examination
- Incomplete Neck Examination: Failing to conduct a thorough physical examination of the neck, which might miss a palpable thyroid nodule or enlarged lymph nodes.
- Assuming a Nodule is Benign: Assuming that a nodule is benign based solely on its size or consistency without further evaluation, especially in patients with risk factors for thyroid cancer.
Improper Use or Interpretation of Diagnostic Tests
- Not Ordering a Thyroid Ultrasound: Failing to order an ultrasound for a thyroid nodule can lead to a missed opportunity to uncover radiologic features concerning for thyroid cancer;
- Overlooking Suspicious Ultrasound Features: If a doctor overlooks or fails to properly consider concerning features on thyroid ultrasound, they may mistakenly believe thyroid nodules are benign and deprive the patient of FNA biopsy;
- Misunderstanding of the Need for Fine-Needle Aspiration (FNA) Biopsy: When doctors fail to stay current in their knowledge and skills, they may not order a FNA biopsy for a patient who has a history and signs concerning for thyroid cancer. Not performing an FNA biopsy on a suspicious nodule can delay the diagnosis and treatment of thyroid cancer.
Mismanagement of Biopsy Results
- Not Following Up on Indeterminate or Suspicious FNA Results: FNA results may not be clearly cancerous or benight. In some cases, the results are “indeterminate” or “suspicious” for malignancy. Doctors who evaluate patients for thyroid cancer are expected to take appropriate action for these results, such as repeating the biopsy, ordering molecular testing, or referring the patient to a specialist.
Inadequate Follow-Up and Monitoring
- Not Monitoring Benign Nodules Appropriately: The evaluation of a thyroid nodule does not end after a FNA biopsy comes back as benign. Doctors should re-evaluate benign nodules for changes in size or characteristics that could indicate malignancy, or new symptoms associated with the nodule. Depending on any changes which occur, a doctor may be expected to re-biopsy the nodule or refer the patient for surgical excision of the nodule.
Case Examples
Examples of medical malpractice verdicts or settlements based on the delay in diagnosis of thyroid cancer include the following:
- $1 million-dollar settlement on behalf of a 69-year-old woman who died from complications of stage IV thyroid cancer after her primary care physician failed to recognize and appropriately evaluate symptoms of persistent difficulty breathing and throat pain, a lump in her throat, and chronic cough. Despite multiple visits over two years, the physician and a consulted ENT did not identify the underlying cause, instead attributing her symptoms to acid reflux and sleep apnea. This delay in diagnosis allowed undiagnosed thyroid cancer to progress unchecked. The patient developed respiratory complications related to her cancer which ultimately led to cardiopulmonary arrest. https://www.lubinandmeyer.com/cases/thyroid-cancer-lawyer.html
- A $1,175,000 settlement was reached after a patient who underwent a thyroidectomy had his pathology misread as benign. Following the surgery, he was monitored by his physicians, but fifteen years later, he was diagnosed with metastatic thyroid cancer. The initial misreading of the pathology report meant that he never received the necessary treatment, allowing the cancer to spread to multiple organs, ultimately leading to his death. https://www.breslinlawyers.com/resources/1-175-000-for-delay-in-diagnosis-of-thyroid-cancer/
- A $1 million-dollar settlement for a man who died after the delayed diagnosis of thyroid cancer. The man sought care for goiter at a Veterans’ medical center from 2011 to 2013. In early 2012, a thyroid scan revealed a large “cold nodule,” which can sometimes indicate cancer. Despite this finding, his doctors did not order a biopsy, instead managing him for hyperthyroidism for 15 months. In May 2013, the patient presented with a rapidly growing thyroid mass and was diagnosed with metastatic thyroid cancer of an aggressive type with high mortality rates. By then, he was no longer a surgical candidate and received only palliative care until his death at age 49. https://valawyersweekly.com/2016/11/28/man-died-after-delayed-diagnosis-for-thyroid-cancer-1-million-settlement/
Delays in the diagnosis of thyroid cancer can occur at various stages, from initial clinical evaluation to follow-up care. The proper diagnostic work-up of a thyroid nodule is critical to ensuring timely and accurate identification of thyroid cancer. Physicians must carefully assess patient history, clinical presentation, and TSH levels, followed by appropriate imaging and, when necessary, a fine-needle aspiration biopsy.
Delays in diagnosis of thyroid cancer, often due to the failure to follow established guidelines or misinterpretation of test results, can lead to the progression of cancer to more advanced stages, reducing treatment options and negatively impacting patient outcomes. The lawyers of Lupetin & Unatin can gather the medical evidence necessary to understand whether a lawsuit is warranted, and if so, help recover compensation for the physical, emotional, and financial harms a delayed diagnosis of thyroid cancer can cause not only the patient, but their loved ones.