Spindle cell carcinoma

A 39-year old man was referred to an orthopaedic surgeon, an MDU member, because of continuing pain in his right shoulder. He had already had physiotherapy and a joint injection but neither had been helpful.

The surgeon found the patient had restricted active shoulder movements and his initial diagnosis was a rotator cuff tear. He requested x-rays and an ultrasound scan.

The shoulder x-ray showed subchondral sclerosis of the glenohumeral joint with no narrowing of the joint space. The radiologist commented that this finding suggested a long-standing glenohumeral arthropathy. The USS showed that the rotator cuff and biceps tendon were all intact and had normal appearance. There was fluid and synovitis within the biceps tendon sheath and in the shoulder joint. The synovium of the shoulder joint was hypervascular on Doppler scanning. Some calcified material appeared within the posterior joint recess. The radiologist commented that the appearances could be due to an inflammatory arthropathy or osteochondromatosis.

The orthopaedic surgeon reviewed the patient in clinic and requested blood tests, looking for inflammatory markers. These were normal. He proceeded to arthroscopy, and found inflammation of the joint lining and grape-like protrusions in the inferior recess. He took biopsies and washed out the joint.

Two weeks later, on reviewing the patient, the surgeon noted a slight improvement in shoulder movements but because of the presumptive diagnosis felt a referral to a rheumatologist was appropriate. The biopsy results were not available at that appointment.

Over the following two weeks, the patient gained a little more shoulder movement but reported continuing severe pain. He was seen by the rheumatologist who felt that it was likely that the patient had an inflammatory arthropathy.

The biopsy showed hyperplasia of synovial cells with foci of chondroid metaplasia. There were no atypical mitotic figures. The appearances were felt to be those of reactive synoviopathy.

The patient's movement continued to be restricted by severe pain, which became particularly apparent during physiotherapy. Concerned by the patient's failure to progress, the orthopaedic surgeon requested an MRI scan. This showed a destructive lesion in the proximal humerus, subsequently diagnosed as a high grade spindle cell sarcoma.

A claim was received. The MDU obtained a report from an independent orthopaedic expert. It was noted that the surgeon had not personally reviewed the radiographs due to problems with a newly installed radiograph viewing facility. The surgeon had relied instead on the radiology report. The MDU expert concluded that this was acceptable, but felt that if the surgeon had seen the films personally he would have noticed an area of cortical irregularity which he would have wanted to follow up with further imaging. The surgeon accepted this view. After investigation the claimant accepted that the delay did not cause any change in the treatment or prognosis of the tumour and the claim was settled for £7,500 for the longer period of pain suffered by the patient.

Dr Frances Szekely
Senior medical claims handler

This page was correct at publication on 04/12/2013. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.


Login to comment

Be the first to comment