Radiation pneumonitis causing death in leukemia patient.
At age 41, the patient was properly diagnosed with a relapse of his acute myelogenous leukemia, confirmed by bone marrow biopsy, after failing chemotherapy.
He was fully informed of the risks of a bone marrow transplant, which was donated by his compatible sister. He received total body irradiation of 1200cGy (rads) to try to kill all of the leukemia tumor cells as well as his bone marrow, in order for his body to readily accept this transplant. Radiation of his lungs was reduced by the use of "50% transmission lung blocks". In that area he received "2 fractions of 300 cGy" of electron beam therapy to those shielded areas. All of this care given at the Hospital #1 was proper.
He was taking immunosuppression drug therapy to prevent rejection of the bone marrow transplant. This significantly increases his risk for infection and he received appropriate antibiotic therapy.
Ten months later he began to feel poorly and had a fever, and a chest x-ray and CT Scan of his chest revealed a change showing pleural effusions (fluid in both chest cavities) and a large pericardial effusion (fluid around the heart contained by the heart sac). He also had a mediastinal mass (a tumor like growth in the central part of his chest, adjacent to his heart, major blood vessels and trachea (windpipe) and its major bronchial tube branches leading to his lungs). This involved his 2/1 to 2/2 admission to the Hospital #2. He received good care there, and was stabilized.
Because he would need thoracic (chest) surgery he was correctly transferred to the Hospital #3 where Dr. #1 performed the needed chest surgery 2/5. He cut two large holes in the pericardium so that the fluid would not further compress his heart, like a vise. He drained the left chest and its contiguous pericardium with a chest tube, and also biopsied the mediastinal mass.
The Pathologist noted that the mediastinal mass were lymph nodes invaded by this blood cancer, his myelogenous leukemia, which recurred. Also the pericardium (heart sac) was involved with this cancer, too. In addition, the pleural (chest cavity) fluid contained this same myeloid leukemia type cells. He was incurable.
Because of this ominous finding he was transferred to the Hospital #4 where he was evaluated by a Radiation Oncologist, Dr. #2. He discussed this case with the patient's physicians, and the patient and his wife on 2/12. He noted in his report that because the tumor extended into the pericardium, that the field of the radiation therapy would have to include that entire area. He said: "I have also discussed this with the patient and his wife regarding increased side effects, and they would like to have the field as large as possible to encompass as much of the disease". He discussed the numerous potential risks, which included "radiation pneumonitis". The dose selected by Dr. #2, in consultation with Dr. #3 was 2000 cGy, given in 10 divided doses (fractions).
In my opinion this was a reasonable dose, considering the previous radiation therapy he had to that area prior to the bone marrow transplant. Their radiation summary shows that he received the 2000 cGy dose from 2/18 to 3/3.
He developed shortness of breath and fever, and was hospitalized at the Hospital #1from 4/2 to 4/30, when he died. Despite proper medical therapy, his lung condition worsened where with the use of a non-rebreathing mask and 100% oxygen, his body was not able to get enough oxygen into his blood from his damaged lungs. He and his family refused the use of a ventilator.
His Physicians believed that the lung (pulmonary) problem was related to the radiation therapy (radiation pneumonitis).
His clinical course and chest x-rays were consistent with that diagnosis. The autopsy, limited to the "chest and lungs only," confirmed that diagnosis. There was extensive scar tissue caused by the radiation therapy, which killed cancer cells. They are replaced by scar (fibrous) tissue. Radiation also kills healthy tissue, and in this case, caused unpreventable damage to his lungs. With some differences in the facts, there could be negligent care.
His care at all his hospitals, based upon by review of all of these voluminous records, was good. When his disease recurred, it was fatal. His radiation therapy was for palliation, because the tumor would grow and choke off his trachea (windpipe) and major bronchial tubes, causing a death similar to what he unfortunately experienced.
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