My evidence in asbestos-related disease covers the diagnostic pathway and the surgical management of malignant pleural disease. I set out plainly below what I do and do not perform surgically, because in this area the boundary of an expert’s practice is itself a live issue.
My position on surgery for mesothelioma
Stated plainly, before you instruct
I perform video-assisted thoracoscopic surgery for the diagnosis of pleural disease and for the management of pleural effusion — pleural biopsy, talc pleurodesis, indwelling pleural catheter insertion and drainage of loculated collections.
I do not perform radical surgery for mesothelioma. Extended pleurectomy decortication and extrapleural pneumonectomy remain controversial in the United Kingdom, and the evidence base for radical surgery in this disease is contested.
Being clear about this makes me more useful, not less. If your case turns on whether radical surgery should have been offered, you need an expert who performs it, and I will tell you so rather than accept the instruction.
Where I can assist
Four areas of the pathway
- Whether pleural thickening or effusion was adequately investigated
- Whether and when thoracoscopic biopsy should have been performed
- The adequacy of the tissue obtained and whether repeat biopsy was indicated
- Delay between presentation, imaging, biopsy and diagnosis
- Whether the diagnostic route chosen was appropriate — pleural aspiration and cytology versus image-guided biopsy versus surgical biopsy
- Chest drain and indwelling catheter insertion injury
- Tract seeding
- Complications of talc pleurodesis
- Failed pleurodesis and whether a further procedure was indicated
- Empyema and infection following pleural intervention
- Whether the effusion was managed appropriately, and the reasonableness of the option chosen
- Effect of delay in effusion management on symptoms and on quality of remaining life
- Whether surgical intervention was indicated in benign pleural disease
What these claims usually turn on
Three recurring factors
Diagnostic delay in a disease with a short prognosis
The measure of loss in mesothelioma delay claims is frequently the loss of a period of better-quality life, or the loss of a treatment option available at the earlier point. Establishing what would have been offered, and when, is the core of the report.
Whether the delay was avoidable
Mesothelioma is genuinely difficult to diagnose early, and initial negative cytology is common and not in itself a breach. Distinguishing an unavoidable diagnostic delay from an avoidable one requires familiarity with the pathway as it actually works.
Fitness and timing
As with lung cancer, an intervention that was theoretically available at an earlier point is only relevant if the patient was fit for it and would have accepted it.
Scope of instruction
What I will need and where the boundary sits
What I will need
Records- Full GP and hospital records
- All imaging as images
- Pleural fluid cytology and all histology including immunohistochemistry
- MDT records
- The occupational and exposure history where taken
- Lung function tests
Where the boundary sits
Outside my expertiseExposure history and attribution are for an occupational physician or engineer.
Systemic oncological treatment and survival evidence are for an oncologist.
Respiratory function and benign pleural disease are usually better addressed by a respiratory physician.
Radical mesothelioma surgery requires a surgeon who performs it.
Discuss a case
Fifteen minutes on the telephone, free of charge. I will tell you whether the issues fall within my expertise before anything is committed to paper.
Discuss a case