Case Study: A Cut-Through Hysterectomy

The Error, Stated Plainly

Most cancer malpractice cases are about a diagnosis that came too late. This one was different. The biopsy was correct. The pathology report identifying an invasive cancer of the cervix was sitting in the chart before the patient was ever taken to an operating room.

The negligence came after the diagnosis.

The patient, a postmenopausal woman in Pennsylvania, underwent a simple hysterectomy. That is the operation used for disease that has not yet become invasive. Her cancer was invasive. A simple hysterectomy cuts at the level of the cervix, and her cancer was in the cervix. The surgeon cut through the tumor and left cancer behind.

No stage was ever assigned to her cancer. No gynecologic oncologist was ever consulted. And when the pathology came back showing tumor at the surgical margin, she was told at a post-operative visit that the surgery had gone well.

She found out otherwise from a radiation oncologist.

Everything Needed to Get It Right Was Already in the Chart

The workup leading up to the operation was, for the most part, appropriate. The patient came to a gynecology practice with abnormal vaginal bleeding after menopause. On examination her cervix was bloody and abnormally bled when touched. Pelvic ultrasound showed a mass in the cervix. A Pap smear returned atypical glandular cells, which in a postmenopausal woman is a recognized warning sign of a glandular malignancy rather than a finding to watch.

The gynecologist then did the right next thing: colposcopy with cervical biopsies and an endocervical curettage. The colposcopy showed an extensive lesion on the cervix suspicious for cancer. The biopsy returned adenocarcinoma of the cervix. The endocervical sampling was positive as well.

At that point the patient had a documented, biopsy-proven invasive cervical cancer, clinically confined to the cervix and visible on examination. Under the staging system in use at the time of this care, that is a stage IB cancer.  Stage IB cervical cancer had a defined set of standard treatments, none of which was the operation she received.

Two Rules of Cancer Surgery That Decided This Case

Staging determines treatment. Cervical cancer is not treated according to how the tumor looks to the surgeon’s eye. At the time of this patient’s care it was staged clinically, based on examination findings, biopsy results, and defined clinical criteria. The assigned stage of the cancer dictated which treatments were appropriate and which were not. A physician who never assigns a stage cannot properly choose a treatment, because the entire treatment algorithm depends on the stage of cancer.

Invasive cervical cancer is not treated with a simple hysterectomy. For pre-invasive disease, a simple hysterectomy or a more conservative excisional procedure can be appropriate. Once the disease is frankly invasive, the surgical standard changes. The correct operation is a radical hysterectomy with pelvic lymph node dissection, which removes the uterus together with the surrounding parametrial tissue and a cuff of upper vagina, and samples the lymph nodes. The reason is geometric: cancer surgery is designed to remove the tumor with a margin of normal tissue around it and to learn whether disease has reached the lymph nodes. A simple hysterectomy provides neither.

There was also a referral obligation. A general obstetrician-gynecologist who diagnoses a new invasive cervical cancer is expected to refer the patient to a gynecologic oncologist before treatment is chosen. A gynecologic oncologist is a specialist trained in staging and treating gynecologic malignancy. That referral is not a courtesy. It is how patients are routed into the correct pathway. The alternative to radical surgery, then and now, was definitive radiation with concurrent chemotherapy, understood to offer comparable cure rates in early-stage disease. Either was a legitimate choice. A simple hysterectomy was not.

The Operative Note and the Pathology Report Described Two Different Operations

The operative note for the simple hysterectomy recorded that a wide resection of the vaginal cuff had been performed. The pathology report told a different story:

• No vaginal cuff was identified in the specimen.
• No lymph nodes were identified in the specimen.
• The outer surgical margin of the cervix was involved with tumor.

That last finding is the heart of the case. A positive surgical margin means the surgeon cut through the cancer and left cancer behind. In gynecologic oncology this has a name — a cut-through hysterectomy — and it is understood as a serious adverse event, not an unlucky outcome. The tumor is transected. Disease remains in the patient. And the operation that was supposed to cure her has been spent, because the uterus and cervix can only be removed once.

Why “She Would Have Needed Radiation Anyway” Is Not an Answer

The predictable defense in a case like this is that the patient went on to receive chemotherapy and radiation, which is itself a standard treatment for cervical cancer, so the wrong operation changed nothing.  But salvage treatment after a cut-through hysterectomy is not the same treatment the patient would have received up front.

The radiation geometry is destroyed. Definitive radiation for cervical cancer combines external beam treatment with brachytherapy, a form of radiation delivered from inside the body, close to the tumor. With the cervix and uterus intact, brachytherapy is delivered through an applicator system seated in the uterine cavity and against the cervix, shaping a high dose to the cervix, the parametrial tissue beside it, and the pelvic sidewall. After a hysterectomy, the anatomy has changed. Only a vaginal applicator remains, and it cannot reproduce the same dose distribution to the tissues at risk. The most effective form of the treatment has been made unavailable by the surgery.

The tumor becomes a harder target. Cutting through a tumor disrupts its blood supply. Radiation and chemotherapy both depend on tissue oxygenation and perfusion to work. Residual tumor sitting in a surgically disturbed, devascularized field is harder to treat than the same tumor in an undisturbed cervix.

The staging information is gone permanently. Because no lymph nodes were sampled and no parametrial assessment was made, this patient’s true stage could never be established. No one could say whether her disease had been confined to the cervix or had already extended beyond it. That is not a technicality. It means her treatment team was permanently deprived of the information that ordinarily guides therapy, and her own prognosis could never be stated with the precision it should have been.

The consequences did not stop at the cancer. The patient went on to a demanding course of concurrent chemotherapy and radiation, followed by a prolonged course of treatment-related complications.

Where Our Firm Came In

Nothing in this patient’s record was hidden. The biopsy result, the operative note, and the pathology report were all in the same chart. She had been told her surgery went well, and the only complete account of her care existed in thousands of pages written in a language she could not read. What the case required was someone willing to read those documents against one another, notice that the operative note and the pathology report described two different operations, and understand why that discrepancy mattered.

How the Case Was Proved

The documents contradicted themselves. The strongest evidence was already on paper. The operative note claimed a wide vaginal cuff resection; the pathology found no cuff. The pre-operative biopsy said invasive adenocarcinoma; the operation performed was one appropriate only for non-invasive disease. The post-operative pathology reported a positive margin; the patient was told the surgery was successful. Each of those pairings can be shown to a jury without an expert. The expert’s job was to explain why each one mattered.

The case was reviewed by the subspecialty that actually treats the disease. A gynecologic oncologist — not a general obstetrician-gynecologist — reviewed the care and addressed every link in the chain: that the clinical and pathological findings established an invasive cancer; that the standard of care required either radical hysterectomy with lymphadenectomy or definitive chemoradiation; that subspecialty referral was required; that the simple hysterectomy performed fell below the standard of care; and that the resulting cut-through with residual tumor meaningfully compromised the patient’s chance of cure.

The treating physician’s own sworn testimony supplied the rest. A treatment decision can only be as sound as the knowledge behind it, and the deposition testimony established that the treating gynecologist believed a colposcopic visual impression could determine whether a cervical lesion was invasive, which it cannot; that he treated a positive endocervical biopsy showing adenocarcinoma as a likely contaminant, which is not a defensible reading of that result in a patient with an atypical glandular Pap and a visible cervical lesion; that he had never applied the staging system to the clinical information he herself had gathered; and that his visual impression at times took precedence over the pathologist’s microscopic diagnosis. That testimony converted the case from a dispute about surgical judgment into a demonstrated deficit in the knowledge required to exercise that judgment at all.

The Main Defense, and How it Was Met

The “same outcome anyway” argument. A defense radiation oncologist argued that features of the tumor itself — its size, the depth of invasion into the cervical wall, and a possible finding of tumor within lymphatic or vascular spaces — would have prompted post-operative radiation no matter which operation was performed. This was met on two grounds. On the medicine: adjuvant radiation after a properly performed radical hysterectomy is recommended based on a combination of intermediate-risk features, not on depth of invasion alone, and the pathology here did not establish the combination the defense assumed. On the comparison: the defense survival estimate was extrapolated from a clinical trial that enrolled a different population — patients with more advanced disease who had been rigorously staged and who had not undergone a cut-through hysterectomy. Applying those figures to a patient who was never staged and whose radiation geometry had been compromised was an invalid comparison.

In an oncology case the defense will nearly always argue that the tumor, not the doctor, determined the outcome. Here the negligence removed a treatment option, degraded the quality of the treatment that remained, and destroyed the clinical information about the cancer needed to choose correctly.

Resolution

The matter resolved before trial, without an admission of liability by any defendant, on terms that are not disclosed here.

Four Things Patients Should Take From This Case

A cancer diagnosis should be followed by a stage. If you have been told you have cancer and no one has told you the stage, ask. Staging is not paperwork. It determines which treatments are appropriate.

A general specialist is not always the right specialist. A newly diagnosed invasive cancer ordinarily warrants subspecialist evaluation before treatment begins, not after.

Ask for the pathology report, not the summary. The gap in this case was the gap between what the patient was told and what her own pathology report said. Patients are entitled to copies of their records, including operative notes and pathology reports.

“The surgery went well” describes the operation, not the disease. A technically uncomplicated procedure can still be the wrong procedure.

How Lupetin & Unatin Handles Cases Like This One

We represent patients and families throughout Pennsylvania in medical malpractice claims, including surgical negligence, incorrect or delayed cancer treatment, failure to refer to an appropriate specialist, and failure to obtain informed consent.

Cases of this kind are won on the record and on the medicine: obtaining the complete chart rather than a summary, reading the documents against one another, retaining experts in the subspecialty that actually treats the disease at issue, and using depositions to establish what the treating physicians knew and when they knew it.

We offer a free initial consultation and handle medical malpractice matters on a contingency fee basis, meaning our attorney’s fee is a percentage of any recovery and no fee is owed if there is no recovery. Clients may still be responsible for case costs and expenses. The specific terms, including how costs are handled, are set out in a written fee agreement provided before any representation begins.

Pennsylvania places strict time limits on when a medical malpractice claim may be filed. If you believe you or someone in your family received treatment that was not appropriate for the condition diagnosed, the time to ask questions is now rather than later.