Dr. Couban - Independent Medical Opinion

I received a letter from Mr. Rob Burnett on December 4, 2012 writing on behalf of a Panel of the Veterans Review and Appeal Board seeking independent medical advice in a disability pension claim.

I reviewed the letter from Mr. Rob Burnett including the eight specific questions (vide infra). I also reviewed 157 pages of medical record initially provided to me. Based on my initial review, I requested some specific additional information. I was subsequently provided with copies of the Appellant’s entire medical record which amounted to several hundred pages of information and I reviewed this as well.

I am a hematologist who is currently practicing in Halifax where I am Head of the Division of Hematology in the Department of Medicine at Dalhousie University and Capital District Health Authority. I am currently President of the Canadian Hematology Society. My area of clinical expertise within hematology is the diagnosis and treatment of patients with malignant hematologic disorders, including lymphoma and Hodgkin disease.

From my review of the medical record, I understand the following:

• The Appellant had a medical assessment for consideration of joining the Canadian Armed Forces on November 18, 1965 at which time it was noted that he had had a tonsillectomy at age 5, a clavicular fracture at age 7 and an appendectomy at age 13. He was noted to have sugar in his urine. The medical officer’s opinion was that he was fit for enrolment.
• He subsequently had a number of medical visits which are well documented but do not address issues in this disability pension claim.
• In my view, the key events relevant to this disability pension claim and appeal occurred during a hospitalization from November 10, 1974 to January 8, 1975. The Appellant was 26 years old at this admission. The medical record states that he had fever, diarrhea and weight loss of 30lb in the preceding 6 months (Page 46). Importantly, during an admission earlier in the same year, fever (38 C) was documented (Oct 11, 1974) and during the November 10, 1974-January 8, 1975 admission, it was noted that he had a “low grade fever”. The consultant hematologist, Dr Chertkow, also makes note both of the weight loss and of the recurrent fever in his note of November 27, 1975 (Page 136). In addition, the patient had had abdominal pain and diarrhea which were repeatedly noted and which I believe are not in dispute.
• The consultant hematologist, Dr Chertkow, provides a thorough review and opinion on November 27, 1974 (Page 136-138). Dr Chertkow states that “on the basis of the history and present findings, I think that a lymphoma is extremely unlikely”. Notably, however, the consultant recommends that a lymphangiogram should be done and notes that a diagnostic laparotomy will need to be considered if other studies do not clarify a diagnosis.
• A note from Dr Agnos dated November 21, 1974 entitled “Radiologist’s Note” states: “I have reviewed this man’s I.V.P and plain films of the abdomen. I am suspicious that there is a retroperitoneal mass on the left side of the spine and possibly on the right side. The psoas shadows are not as sharp as they should be and there is a sharp margin lateral to the left psoas muscle which may be a mass….”
• Dr Chertkow makes mention of this report in his consultation and states “I would certainly agree that this patient should have a lymphangiogram in view of the reports by Dr Agnos regarding the possibility of a retroperitoneal mass. This could turn out to be some other type of retroperitoneal tumour although I think that a lymphoma is rather unlikely” (Page 137).
• I have not been able to locate the actual lymphangiogram report. I understand from Mr Burnett that it is not likely to be located and, in fact, I do not know whether a written report of the lymphagiogram was ever completed. However, there are several references to the results of the lymphangiogram in the medical record. On December 5, 1974, Dr Ziegler states: “Report from Lymphangiogram shows abnormal lymph nodes both above and below diaphragm” (Page 138). A subsequent note from Dr Choban in December, 1974 entitled “Transfer Note” states “….he was referred to Victoria Hospital for lymphangiogram. This was done on Nov 28, 1974 and was reported as abnormal with a finding of enlarged lymph nodes on both sides of the diaphragm and the appearance was reported as consistant with lymphoma and Hodgkin’s disease”.
  
  It is important, therefore, that I note that my assessment of the lymphangiogram is limited because I have not reviewed the actual report myself. However, from my review of the available information, I conclude that there was no question that it was felt to be a significantly abnormal study which described the presence of significant abnormalities in the lymph nodes above and below the diaphragm and, moreover, specific consideration of lymphoma and Hodgkin’s disease was stated.
• On December 6, 1974, a surgical consultant (Dr J.K. Prasad for Dr. D.W.B. Johnston) noted “there is a small, palpable gland in his right supraclavicular region which should be biopsied under local anaesthesia” (Page 138). I note that the hematology consultation on November 27, 1974 did not note this finding but did note: “He does not have any significant lymphadenopathy. There is a tiny, pea-sized, palpable node in the left posterior cervical triangle, and pea-sized epitrochlear nodes are palpable, particularly on the left side, where the node is tender. Tiny nodes are palpable in the left axilln (sic). I would not consider any of these palpable lymph nodes to be clinically significant” (Page 137). On December 11, 1974, Dr Shah in a note entitled “Acceptance Note” writes: “He has a few discrete lymph nodes both in the axilla(sic) and groins” (Page 139).
• From my assessment of the entire medical record and from these specific items, I conclude that the patient did not have a single dominant or convincingly abnormal lymph node which was appropriate to biopsy. In my judgment, this man had a profound illness characterized by fevers, weight loss, abdominal pain and diarrhea and it was not felt that biopsy of a small lymph node was likely to be helpful. Based on the information that I have reviewed, I would unreservedly agree and I find no information to suggest that biopsy of one of these small lymph nodes (be it the lymph node in the right supraclavicular region of other variously mentioned lymph nodes) would have provided materially relevant diagnostic information.
• On December 17, 1974, the patient underwent a staging laparotomy. This included an inspection of the abdomen, splenectomy, wedge and needle biopsy of the liver and lymph node biopsy. Subsequently, the patient also underwent a biopsy of the iliac crest. I have not found and did not review the Operative Report. However, on December 31, 1974, an entry entitled “Transfer Note” states: “There were found to be palpable iliac nodes. They were 1 - 1.5cm in diameter. They were not matted. There was no significant evidence of lymphadenopathy around the aorta. There were visible lymph nodes in the mesentery as well. One lymph node from the iliac region, one from the mesentery were taken for histology” (Page 141).
  
  My best medical judgement is that this laparotomy was undertaken appropriately and correctly. At the time of the surgery, the patient’s healthcare team were faced with a young man who had a significant illness manifesting as fever, a 30lb weight loss, abdominal pain and diarrhea. Appropriate assessments, consultations and investigations had not yielded a credible diagnosis. Three radiologic studies (abdominal flat plate, I.V.P and lymphangiogram) had suggested serious intra-abdominal pathology. At laparotomy, abnormalities of the iliac lymph nodes were noted.
  
  For all of these reasons, I believe that the laparotomy as conducted, with the multiple biopsies and splenectomy, was both clinically indicated and appropriate.
   

Mr. Rob Burnett in his letter to me on December 4, 2012 draws my attention to the following items:

1. In his report of 27 November 1974, the hematologist said, ”I think that a lymphoma is rather unlikely” (Page 137 of the record).
   
   There is no question that the hematologist felt that lymphoma was unlikely based on his clinical assessment and with good reason. However, he notes that the findings “do not necessarily rule of this possibility” (Page 137). Equally importantly, he agreed that “this patient should have a Lymphangiogram” (Page 137).
   
   The lymphangiogram study was recommended by several consultants. Once completed, not only was it not normal but it suggested very worrisome findings, including the possibility of a retroperitoneal mass and lymphadenopathy above and below the diaphragm. Based on this, it was prudent, appropriate and correct to proceed with investigation of these abnormalities. The appropriate investigation of the abnormal lymphangiogram in this setting was the laparotomy. Given the known clinical symptoms of the patient, the abnormal radiologic studies prior to the laparotomy, the abnormal findings at laparotomy (clinically abnormal lymph nodes), I think it was reasonable and correct to proceed with the biopsies including the lymph node biopsies, needle and wedge biopsies of the liver and the splenectomy.
2. At one point, a lymph node biopsy was contemplated, however it was cancelled (Page 139). I believe that I have addressed this issue in Item h, above. The issue of lymph node biopsy in an unwell patient in whom a diagnosis has not yet been established is a very important and common clinical dilemma. The decision hinges on whether the clinicians think that the lymph node is abnormal and whether biopsy of the lymph node is likely to yield a diagnosis.
   
   In this case, my impression is that the patient was thin and had a number of small lymph nodes which were palpable in various areas of his body. On one occasion, based on the assessment of one clinician, consideration was given to undertaking a biopsy of one such lymph node in the right supraclavicular region. However, this decision was subsequently changed.
   
   I think this is a very common situation in my experience and I found no evidence to suggest that this was an incorrect or improper decision. Put more explicitly, if the right supraclavicular lymph node had been biopsied and if it had been found to be normal, this would not have dissuaded me from further investigations in this individual who had fever, weight loss, abdominal pain, diarrhea, and three abnormal radiologic studies suggesting pathology in his abdomen and thorax.
3. A note from wards rounds on 11 December 1974 stated “this patient is sent over from medicine for laparotomy and possibly splenectomy for Hokgkin’s disease. The diagnosis, however, is still open to question” (Page 139).
   
   This young man was significantly unwell. He had had documented fevers, substantial weight loss, abdominal pain, diarrhea and three abnormal radiologic studies. No credible diagnosis had been established prior to the laparotomy. The laparotomy was undertaken in order to establish a diagnosis. This man fit all the criteria for a fever of unknown origin. In the assessment of a patient who is clinically unwell and who has a fever of unknown origin, and who has three abnormal radiologic studies suggesting life-threatening pathology within the abdomen, it was both appropriate and clinically essential to proceed to laparotomy and to undertake the biopsies and splenectomy as performed. These procedures were undertaken in order to establish a diagnosis.
   
   A case history sheet apparently dated 17 December 1974 stated “the clinical impression was against a lymphoma but the abnormal lymphangiogram carried out at Victoria Hospital was very suggestive of lymphoma in the abdomen, so this man had an exploratory lapatomy carried out by the surgical service – Dr Johnston; however at laparotomy there was no evidence of any Hodgkin’s disease. All the organs were found to be normal. However, a lymphangiogram protocol was carried out at Victoria Hospital, i.e. a splenectomy, which biopsy of the liver, needle biopsy of the liver, lymph node excision from the mesentery and retroperitoneal area, and iliac crest biopsy (Page 47).
   
   There appears to be a word missing from the above statement so the actual question or issue is not entirely apparent to me.
   
   There is no question that the clinical impression was that this patient’s illness was not likely on the basis of lymphoma. However, there is also no question that this young man was unwell and in a deteriorating state of health with no established diagnosis and several studies including a comprehensive investigation of his gastrointestinal system which had been normal or unremarkable. It was in this setting that the surgical procedure was undertaken, not because the patient was known to have a diagnosis of Hodgkin’s disease but precisely because the diagnosis was not known. The abdominal lymph nodes and liver were biopsied and the spleen was removed not because it was known that the patient had Hodgkin’s disease but because he was clinically unwell and deteriorating and no diagnosis had been established.
4. Was it appropriate (did it meet the relevant standard of care at the time) to conduct an exploratory laparotomy without having first done the contemplated lymph node biopsy?
   
   In my best medical judgement, it was unequivocally appropriate and entirely within the relevant standard of care at the time to conduct an exploratory laparotomy without having first done the contemplated lymph node biopsy. I believe that I have addressed the issues pertinent to this point in Item h, and Point 2 above.
5. Even if carrying out the laparotomy met the relevant stand of care, was it appropriate to remove the spleen at that time?
   
   I believe that it was appropriate and met the standard of care to have undertaken the laparotomy. In my best judgement, it was also appropriate to remove the spleen. The decision to remove a patient’s spleen is never an easy one and should always be taken after careful thought and consideration. A splenectomy can, however, yield important and indeed life-saving diagnostic information, particularly with respect to the diagnosis of malignancy.
   
   In several of the clinical assessments of this patient, there was a consideration that the spleen may have been abnormally enlarged. He had also noted abdominal pain including left upper quadrant pain and the radiologic studies had suggested an abnormality in this area. For all these reasons, but particularly because there was no established diagnosis, the spleen was removed in order to try and establish a diagnosis. It is important to convey that splenic biopsy is not a routine medical procedure and therefore if the spleen needs to be studied histologically, it is almost always necessary to remove it.
6. What are the physiological consequences of splenectomy? For instance, is the patient thereafter more susceptible to infections, colds, flu, pneumonia, etc?
   
   The main pathophysiological consequence of splenectomy is, indeed, an increased susceptibility to infection, particularly with certain types of bacteria. The patient is therefore at increased risk of certain bacterial respiratory infections, including colds and pneumonia but also at increased risk of certain blood infections, including most notably pneumococcal sepsis. To the best of my knowledge, a splenectomy does not render the patient more susceptible to flu.
7. Is there any other medical information that you believe would be of assistance to the Board in adjudicating the case?
   
   No.
   
   Please do not hesitate to contact me if my review is unclear or if I have misunderstood the questions and issues that have been highlighted.