Renal Cell Carcinoma — DVA claim example

Diagnostic Assessment — Renal Cell Carcinoma

Example 1 of 1 · fictitious patient (Veteran CR)

Diagnostic Assessment

Renal Cell Carcinoma

BOP Code: 42 of 2021 (Malignant Neoplasm of the Kidney)
RH Code: 41 of 2021 (Malignant Neoplasm of the Kidney)

ADF History

Veteran CR, date of birth 07 February 1962, Australian Army, Vehicle Mechanic (later Recovery Mechanic and Workshop Supervisor), enlisted 15 January 1980, medically discharged 30 June 2006. Operational service: Somalia, 12 January 1993 to 21 May 1993 (warlike); Rwanda, 25 July 1994 to 15 February 1995 (non-warlike); East Timor, 20 September 1999 to 28 January 2000 (warlike).

Occupational History

As a vehicle and recovery mechanic the veteran overhauled brakes, clutches and engines in enclosed workshops and in the open in field workshops, cleaned and degreased parts in solvent tanks, welded and oxy-cut steel and plated components, and recovered damaged vehicles. Field and deployed workshops often operated in damaged buildings and compounds, in heat, dust and diesel exhaust.

Mechanics of that era had recognised exposure to asbestos from brake and clutch linings and gaskets, chlorinated degreasing solvents such as trichloroethylene, welding fumes including cadmium from plated parts, and crush injuries during vehicle recovery. Workshop crew rooms, vehicles and messes were filled with tobacco smoke.

History

Veteran CR, a vehicle and recovery mechanic in the Australian Army, developed renal cell carcinoma of the renal medullary subtype in his left native kidney, first shown on 04 May 2022, after decades of smoking, asbestos, trichloroethylene, cadmium and welding exposure, abdominal radiation, and the chronic kidney disease, dialysis and kidney transplant that followed a crush injury on warlike service in East Timor in January 2000. Delays in investigation and surgery allowed the tumour to grow and invade the renal vein before nephrectomy in December 2022.

Timeline

• 15 Jan 1980 — The enlistment medical examination recorded normal blood pressure, a BMI of 23, normal urinalysis and smoking of about 20 cigarettes a day since 1979. Haemoglobin electrophoresis performed for a mild microcytosis showed sickle cell trait (HbAS). He began vehicle mechanic training, including brake and clutch overhaul and parts degreasing. "sickle cell trait, smoker 20/day"
• 21 Mar 1997 — He was treated for a stage I seminoma of the right testis with orchidectomy followed by adjuvant para-aortic radiotherapy, 25 Gy in 20 fractions. The radiation oncology record shows the medial part of the left kidney and renal hilum within the treatment field, with a mean left kidney dose of 2.8 Gy. He returned to workshop duties. "para-aortic radiotherapy 25 Gy"
• 14 Jan 2000 — During warlike service in East Timor he was crushed between a recovery vehicle and a disabled truck. He sustained pelvic fractures, crush injuries to both legs requiring left above-knee amputation, and rhabdomyolysis with acute kidney injury requiring haemodialysis for three weeks. He underwent 16 CT scans of the abdomen and pelvis over the following two years. Renal function did not fully recover, with an eGFR of 48 mL/min/1.73 m2 in December 2000. "crush injury, rhabdomyolysis, AKI"
• 10 Jun 2003 — He was employed in a sedentary workshop administration role and could not walk more than 50 metres with his prosthesis because of stump pain and pelvic pain. Blood pressure was 162/98 mmHg on treatment for hypertension diagnosed in 1998, BMI was 33.4, and type 2 diabetes was diagnosed with an HbA1c of 7.4 per cent. CT showed left renal calculi. Chronic kidney disease stage 3b was recorded with an eGFR of 38 mL/min/1.73 m2. "CKD 3b, diabetes, left calculi"
• 18 Mar 2008 — Two years after his medical discharge his kidney function reached end stage and he commenced haemodialysis three times a week. A renal dietitian placed him on a potassium-restricted diet limiting fruit and vegetables to well under 200 grams a day, which continued until transplantation. He stopped smoking on 01 July 2012. "haemodialysis, potassium-restricted diet"
• 26 Aug 2013 — He received a deceased-donor kidney transplant and commenced tacrolimus, mycophenolate and prednisolone. His native kidneys were left in place and followed with annual ultrasound. The last ultrasound before onset, on 10 March 2021, showed small atrophic native kidneys with simple cysts and no solid lesion. "kidney transplant, native kidneys retained"
• 04 May 2022 — Surveillance ultrasound showed a new 2.4 cm solid hypoechoic lesion in the medulla of the left native kidney. CT was requested urgently, but because of surgical waiting lists and delays in transplant and urology coordination it was not performed until 21 September 2022, when the lesion measured 3.9 cm. "new 2.4 cm left renal lesion"
• 12 Dec 2022 — He underwent left native radical nephrectomy. By then the tumour measured 4.6 cm and invaded the left renal vein. Histopathology showed renal medullary carcinoma, a subtype of renal cell carcinoma arising from the renal tubular epithelium, with loss of SMARCB1 (INI1) on immunohistochemistry, pathological stage pT3a N0. A medical oncologist commenced surveillance and adjuvant treatment planning. "renal medullary carcinoma, pT3a"

Symptoms

At onset the veteran had no symptoms, and the tumour was found on surveillance ultrasound of his native kidneys. Over the following months he developed intermittent left loin ache, fatigue and unintended weight loss of 5 kg, and he had one episode of visible haematuria in November 2022.

He now reports fatigue, left flank wound pain, anxiety about recurrence and the need for regular CT surveillance, on top of the limitations of his amputation, his kidney transplant and its immunosuppression.

Imaging

• 10 Jun 2003 — CT abdomen: "Multiple calculi in the left kidney, the largest 7 mm, with mild cortical thinning of both kidneys."
• 10 Mar 2021 — Ultrasound native kidneys: "Small atrophic native kidneys with simple cortical cysts. No solid lesion."
• 04 May 2022 — Ultrasound native kidneys: "New 2.4 cm solid hypoechoic lesion in the medulla of the left native kidney."
• 21 Sep 2022 — CT abdomen and pelvis with contrast: "3.9 cm infiltrative enhancing mass centred on the medulla of the left native kidney, with stranding of the renal sinus fat and suspected extension into the left renal vein. No distant metastases."

Onset Date

The most likely date of onset of this condition is 04 May 2022.

At that date the veteran was a discharged veteran with a functioning kidney transplant, on long-term immunosuppression, with a left above-knee amputation from his East Timor crush injury. Routine surveillance ultrasound of his retained native kidneys showed a new solid lesion in the left kidney.

This date is appropriate because the previous surveillance ultrasound on 10 March 2021 showed no solid lesion, and the tumour was first shown on 04 May 2022. It is the first documented evidence of the malignancy and was later confirmed as renal cell carcinoma on histopathology.

For the smoking factor, he smoked about 25 cigarettes a day from 1979 to 01 Jul 2012, about 41 pack-years, commencing 43 years before onset and ceasing less than 10 years before it. For the hypertension factors, hypertension was diagnosed in 1998, 24 years before onset. For the overweight factors, the 20 years before onset run from 04 May 2002 to 04 May 2022, and his BMI was 25 or more throughout that period. For the diabetes factor, type 2 diabetes was diagnosed on 10 Jun 2003, almost 19 years before onset. For the renal stone factor, left renal calculi were shown on 10 Jun 2003, more than five years before onset. For the radiation factors, the para-aortic radiotherapy was completed in 1997, 25 years before onset, and the CT scans after the 2000 crush injury were completed by 2002. For the asbestos, cadmium, trichloroethylene and welding factors, exposure began in 1980, more than 40 years before onset. For the fruit and vegetable factor, the potassium-restricted diet ran from 18 Mar 2008 to 26 Aug 2013, more than five consecutive years within the 20 years before onset. For the physical activity factors, the 30 years before onset run from 04 May 1992 to 04 May 2022, and he could not undertake activity above three METs from 14 Jan 2000 onwards, more than 22 years. For the NSAID factor, he took diclofenac or naproxen on most days from 1985 to 2000, 15 years, before onset. Chronic kidney disease, sickle cell trait and the kidney transplant of 26 Aug 2013 were all present before onset.

For the clinical worsening, the period after onset runs from 04 May 2022 to nephrectomy on 12 Dec 2022, during which the tumour grew from 2.4 cm to 4.6 cm and invaded the renal vein while CT and surgery were delayed.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Renal Cell Carcinoma (ICD-10 C64), renal medullary carcinoma subtype, of the left native kidney, pathological stage pT3a N0, under the Statements of Principles concerning malignant neoplasm of the kidney, Balance of Probabilities No. 42 of 2021 and Reasonable Hypothesis No. 41 of 2021.

Renal cell carcinoma is a cancer arising from the lining cells of the kidney tubules. It often causes no symptoms until it is advanced, and many are found on imaging done for other reasons; later it can cause blood in the urine, loin pain, a mass, weight loss and spread to the lungs, bones and brain. Renal medullary carcinoma is an aggressive subtype arising in the renal medulla, closely linked to sickle cell trait and marked by loss of the SMARCB1 protein. The established causes of kidney cancer include smoking, obesity, hypertension, chronic kidney disease and dialysis, kidney transplantation with immunosuppression, ionising radiation, and occupational exposure to trichloroethylene, cadmium, asbestos and welding fume.

The tumour was first shown on 04 May 2022, grew and invaded the renal vein while investigation and surgery were delayed, and was removed and confirmed on histopathology on 12 December 2022.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

04 May 2022.

When did the veteran first present to a health / medical provider for this condition?

04 May 2022.

When was the condition confirmed / formally diagnosed?

12 December 2022.

When did the veteran first present to you (or your practice) for this condition?

03 September 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was confirmed by histopathology of the left native radical nephrectomy specimen on 12 December 2022, which showed renal medullary carcinoma, a primary malignant neoplasm arising from the renal tubular epithelium, with loss of SMARCB1 (INI1) expression, invasion of the left renal vein and no nodal involvement (pT3a N0). This meets the Statement of Principles definition of malignant neoplasm of the kidney, which expressly includes renal medullary carcinoma, and excludes the listed non-epithelial tumours and cancer of the renal pelvis.

The imaging sequence confirms the onset and progression: no solid lesion on ultrasound on 10 March 2021, a new 2.4 cm medullary lesion on 04 May 2022, and a 3.9 cm infiltrative mass with renal sinus and venous extension on CT on 21 September 2022.

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

Legislation: the clinical onset of this condition was on 04 May 2022, after 1 July 2004 and after the veteran's discharge. His service ran from 1980 to 2006 and spans both sides of 1 July 2004. Service from 1 July 2004 is covered by the Military Rehabilitation and Compensation Act 2004 (MRCA), and operational service before that date by the Veterans' Entitlements Act 1986 (VEA); the Statements of Principles apply to both. Peacetime service before 1 July 2004 is covered by the DRCA, under which the Statements of Principles do not bind, but every factor is still analysed below. The Reasonable Hypothesis instrument applies to his warlike service in Somalia in 1993 and East Timor in 1999 to 2000 and his non-warlike service in Rwanda in 1994 to 1995. The Balance of Probabilities instrument applies to peacetime service.

Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.

Balance of Probabilities — Statement of Principles concerning Malignant Neoplasm of the Kidney, No. 42 of 2021

Causative factors

Factor 9(1): having hypertension for a period of at least five years before the clinical onset of malignant neoplasm of the kidney; — MET

- Hypertension was diagnosed by a medical officer in 1998 and treated continuously thereafter, with a blood pressure of 162/98 mmHg on treatment recorded on 10 June 2003. It was present for 24 years before onset on 04 May 2022. It was compounded from 2000 by the chronic kidney disease that followed his service crush injury.

Factor 9(2): being overweight or obese for at least five years within the 20 years before the clinical onset of malignant neoplasm of the kidney; — MET

- The veteran's BMI was 25 or more at every health assessment from 1995 and was 33.4 on 10 June 2003. Throughout the 20 years before onset, from 04 May 2002 to 04 May 2022, he was overweight or obese, his weight rising after the amputation and pelvic injuries of January 2000 left him unable to exercise.

Factor 9(3): having smoked tobacco products: (a) in an amount of at least 20 pack-years before the clinical onset of malignant neoplasm of the kidney; and (b) commencing at least ten years before the clinical onset of malignant neoplasm of the kidney; and if smoking has ceased before the clinical onset of malignant neoplasm of the kidney, then that onset occurred within 30 years of cessation; — MET

- He smoked about 25 cigarettes a day from 1979 until 01 July 2012, about 41 pack-years, of which about 33 pack-years were smoked during service from 1980 to 2006, when cigarettes were cheap and smoking was part of workshop routine. Smoking began 43 years before onset, and onset on 04 May 2022 was less than 10 years after he stopped.

Factor 9(4): inhaling, ingesting or having cutaneous contact with trichloroethylene: (a) for a cumulative period of at least 2,000 hours, within a consecutive period of ten years, before the clinical onset of malignant neoplasm of the kidney; and (b) where the first exposure occurred at least five years before the clinical onset of malignant neoplasm of the kidney; — MET

- From 1980 to 1990 the veteran cleaned engine and brake parts in a trichloroethylene vapour degreaser and cold-cleaning tank in an enclosed unit workshop, for about two hours on most working days, with bare hands or cotton gloves. His occupational history records about 4 000 hours of exposure within those ten years. The first exposure occurred 42 years before onset.

Factor 9(5): having received a cumulative equivalent dose of at least 0.5 sievert of ionising radiation to the kidney at least ten years before the clinical onset of malignant neoplasm of the kidney; — MET

- Adjuvant para-aortic radiotherapy for seminoma in 1997, given by Defence-funded specialists during service, delivered a mean dose of 2.8 Gy to the left kidney, a cumulative equivalent dose of 2.8 sieverts. Sixteen CT scans of the abdomen and pelvis after the January 2000 crush injury added about 0.2 sievert. The dose was received 20 to 25 years before onset.

Factor 9(6): having chronic kidney disease before the clinical onset of malignant neoplasm of the kidney; — MET

- Chronic kidney disease followed the rhabdomyolysis and acute kidney injury of the crush injury of 14 January 2000, with an eGFR of 48 mL/min/1.73 m2 in December 2000 and 38 mL/min/1.73 m2 on 10 June 2003, progressing to end-stage kidney disease and haemodialysis from 18 March 2008. It was present for 22 years before onset.

Factor 9(7): for renal medullary carcinoma only, having sickle cell disorder before the clinical onset of renal medullary carcinoma; — MET

- The tumour was confirmed as renal medullary carcinoma on 12 December 2022. Haemoglobin electrophoresis at enlistment on 15 January 1980 showed sickle cell trait (HbAS), a sickle cell disorder present from birth and throughout service. Renal medullary carcinoma arises almost exclusively in people with sickle cell trait or disease, and repeated dehydration in heat on service increases sickling in the renal medulla.

Factor 9(8): an inability to consume an average of at least 200 grams per day of any combination of fruits and vegetables, for a period of at least five consecutive years within the 20 years before the clinical onset of malignant neoplasm of the kidney; — MET

- From 18 March 2008 to 26 August 2013, five years and five months, the veteran was on a potassium-restricted haemodialysis diet prescribed by a renal dietitian that limited fruits and vegetables to well under 200 grams a day. This period lies within the 20 years before onset, and the dietary restriction resulted from the service-related chronic kidney disease.

Factor 9(9): an inability to undertake any physical activity greater than three METs for at least 20 years within the 30 years before the clinical onset of malignant neoplasm of the kidney; — MET

- From the crush injury of 14 January 2000, which caused a left above-knee amputation and pelvic fractures, the veteran could not walk more than 50 metres with his prosthesis, as recorded on 10 June 2003, and later end-stage kidney disease further limited him. He was unable to undertake activity above three METs from January 2000 to onset, more than 22 years within the 30 years before onset, from 04 May 1992 to 04 May 2022.

Factor 9(10): undergoing organ or tissue transplantation, excluding corneal transplant, before the clinical onset of malignant neoplasm of the kidney; — MET

- He received a deceased-donor kidney transplant on 26 August 2013 for end-stage kidney disease caused by the service crush injury, and has taken tacrolimus, mycophenolate and prednisolone since. The transplant preceded onset by more than eight years, and the retained native kidney was the site of the cancer.

Worsening factors

Factor 9(11): inability to obtain appropriate clinical management for malignant neoplasm of the kidney. — MET

- After the solid lesion was found on 04 May 2022, urgent CT was not performed until 21 September 2022 and nephrectomy not until 12 December 2022, because of surgical waiting lists and delays in coordinating his transplant and urology teams. In that time the tumour grew from 2.4 cm to 4.6 cm and invaded the renal vein, raising the stage to pT3a. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Malignant Neoplasm of the Kidney, No. 41 of 2021

Causative factors

Factor 9(1): having hypertension for a period of at least two years before the clinical onset of malignant neoplasm of the kidney; — MET

- Hypertension diagnosed in 1998 became harder to control after the chronic kidney disease caused by the crush injury on warlike service in East Timor on 14 January 2000, and was present for 24 years before onset.

Factor 9(2): being overweight or obese for at least three years within the 20 years before the clinical onset of malignant neoplasm of the kidney; — MET

- The veteran was obese, with a BMI above 30, throughout the 20 years before onset, the weight gain following the amputation and immobility caused by the crush injury on warlike service in East Timor.

Factor 9(3): having smoked tobacco products: (a) in an amount of at least ten pack-years before the clinical onset of malignant neoplasm of the kidney; and (b) commencing at least five years before the clinical onset of malignant neoplasm of the kidney; and if smoking has ceased before the clinical onset of malignant neoplasm of the kidney, then that onset occurred within 30 years of cessation; — MET

- He smoked about 41 pack-years in total, increasing to 40 cigarettes a day on operations in Somalia, Rwanda and East Timor, about two pack-years on operational service alone. Smoking began 43 years before onset and ceased on 01 July 2012, less than 10 years before onset.

Factor 9(4): having been exposed to second-hand smoke: (a) for at least 10,000 hours before the clinical onset of malignant neoplasm of the kidney; and (b) commencing at least five years before the clinical onset of malignant neoplasm of the kidney; and if exposure to second-hand smoke has ceased before the clinical onset of malignant neoplasm of the kidney, then that onset occurred within 30 years of cessation; — MET

- From 1980 to 2006 he worked and lived in enclosed workshop crew rooms, vehicle cabs, armoured vehicles, tents and messes where others smoked, about 12 000 hours, including continuous exposure in shared tents and vehicles on operational service in Somalia, Rwanda and East Timor. The exposure began 42 years before onset and ceased in 2006, 16 years before onset.

Factor 9(5): inhaling respirable asbestos fibres in an enclosed space, at the time material containing asbestos was being applied, removed, cut, drilled, dislodged or disturbed: (a) for a cumulative period of at least 1,000 hours before the clinical onset of malignant neoplasm of the kidney; and (b) where the first inhalation of asbestos fibres commenced at least five years before the clinical onset of malignant neoplasm of the kidney; — MET

- From 1980 to the early 1990s he removed and replaced asbestos brake shoes, clutch plates and gaskets and blew out brake drums with compressed air in enclosed workshops, about 2 500 hours, and in Somalia in 1993 he repaired vehicles in an enclosed damaged warehouse with broken asbestos cement sheeting. The first inhalation was 42 years before onset.

Factor 9(6): inhaling respirable asbestos fibres in an open environment, at the time material containing asbestos was being applied, removed, cut, drilled, dislodged or disturbed: (a) for a cumulative period of at least 3,000 hours before the clinical onset of malignant neoplasm of the kidney; and (b) where the first inhalation of asbestos fibres commenced at least five years before the clinical onset of malignant neoplasm of the kidney; — MET

- In field workshops in the open on exercises and on operational service in Somalia and Rwanda he replaced asbestos brake and clutch linings and recovered vehicles from collapsed asbestos-roofed buildings, about 3 200 hours from 1980 to 1995. The first inhalation was 42 years before onset.

Factor 9(7): inhaling cadmium fumes: (a) for a cumulative period of at least 3,000 hours before the clinical onset of malignant neoplasm of the kidney; and (b) where the first inhalation of fumes occurred at least five years before the clinical onset of malignant neoplasm of the kidney; — MET

- He welded and oxy-cut cadmium-plated fasteners, brackets and hydraulic fittings on military vehicles from 1980 to 2000, about 3 400 hours, including battle damage repair on operational service in Somalia and East Timor, without fume extraction. The first inhalation occurred 42 years before onset.

Factor 9(8): inhaling, ingesting or having cutaneous contact with trichloroethylene: (a) for a cumulative period of at least 1,000 hours, within a consecutive period of ten years, before the clinical onset of malignant neoplasm of the kidney; and (b) where the first exposure occurred at least five years before the clinical onset of malignant neoplasm of the kidney; — MET

- He used trichloroethylene to degrease parts for about 4 000 hours between 1980 and 1990, and again in field workshops on operational service in Somalia in 1993. The first exposure occurred 42 years before onset.

Factor 9(9): being exposed to arsenic as specified before the clinical onset of malignant neoplasm of the kidney, where the first exposure to arsenic occurred at least ten years before the clinical onset of malignant neoplasm of the kidney; — MET

- On warlike service in Somalia from January to May 1993 his unit drew drinking water from a local bore later found to contain arsenic at about 150 micrograms per litre, and he drank 4 to 6 litres a day from it for about four months, as recorded in the unit preventive medicine report. He also cut and welded arsenic-treated timber vehicle decking. The first exposure occurred 29 years before onset.

Factor 9(10): having received a cumulative equivalent dose of at least 0.1 sievert of ionising radiation to the kidney at least five years before the clinical onset of malignant neoplasm of the kidney; — MET

- Sixteen CT scans of the abdomen and pelvis for the crush injury sustained on warlike service in East Timor delivered about 0.2 sievert to the kidneys by 2002, 20 years before onset, in addition to the 2.8 sieverts from para-aortic radiotherapy in 1997.

Factor 9(11): having chronic kidney disease before the clinical onset of malignant neoplasm of the kidney; — MET

- Chronic kidney disease resulted from rhabdomyolysis and acute kidney injury after the crush injury on warlike service in East Timor on 14 January 2000, and progressed to end-stage kidney disease, all before onset.

Factor 9(12): having renal stone disease involving the affected kidney at least five years before the clinical onset of malignant neoplasm of the kidney; — MET

- Calculi in the left kidney, the kidney later affected by the carcinoma, were shown on CT on 10 June 2003, 19 years before onset. He first passed a left ureteric stone after chronic dehydration in the heat on warlike service in Somalia in 1993.

Factor 9(13): having diabetes mellitus for at least five years before the clinical onset of malignant neoplasm of the kidney; — MET

- Type 2 diabetes was diagnosed on 10 June 2003, almost 19 years before onset, after the obesity and immobility caused by the East Timor crush injury, and later worsened with transplant immunosuppression.

Factor 9(14): for renal medullary carcinoma only, having sickle cell disorder before the clinical onset of renal medullary carcinoma; — MET

- The tumour was renal medullary carcinoma, and the veteran had sickle cell trait (HbAS) from birth. Severe dehydration and heat on warlike service in Somalia in 1993 and East Timor in 1999 to 2000 caused repeated medullary sickling, documented as episodes of painless haematuria in 1993.

Factor 9(15): an inability to consume an average of at least 200 grams per day of any combination of fruits and vegetables, for a period of at least five consecutive years within the 20 years before the clinical onset of malignant neoplasm of the kidney; — MET

- His prescribed potassium-restricted dialysis diet limited fruit and vegetables to well under 200 grams a day from 18 March 2008 to 26 August 2013, more than five consecutive years within the 20 years before onset, because of the kidney failure that followed his injury on warlike service.

Factor 9(16): an inability to undertake any physical activity greater than three METs for at least ten years within the 30 years before the clinical onset of malignant neoplasm of the kidney; — MET

- Since the left above-knee amputation and pelvic fractures sustained on warlike service in East Timor on 14 January 2000, he has been unable to undertake activity above three METs, more than 22 years within the 30 years before onset.

Factor 9(17): undergoing organ or tissue transplantation, excluding corneal transplant, before the clinical onset of malignant neoplasm of the kidney; — MET

- He received a kidney transplant on 26 August 2013 for kidney failure caused by the crush injury on warlike service in East Timor, more than eight years before onset.

Factor 9(18): taking a non-topical non-steroidal anti-inflammatory drug, excluding aspirin, on at least 15 days per month for at least ten years before the clinical onset of malignant neoplasm of the kidney; — MET

- He took diclofenac 75 mg twice daily or naproxen 500 mg twice daily on most days from 1985 to 2000, about 15 years, for lumbar and knee pain from workshop and recovery work, and continuously on operational service in Somalia and Rwanda, where they were issued freely. NSAIDs were stopped when his kidney function fell in 2000.

Factor 9(19): using manual welding equipment for welding metal: (a) for a cumulative period of at least 3,000 hours before the clinical onset of malignant neoplasm of the kidney; and (b) where that use began at least five years before the clinical onset of malignant neoplasm of the kidney; — MET

- He used manual arc and gas welding equipment on vehicles and recovery equipment for about 4 500 hours from 1980 to 2000, including battle damage repair on operational service in Somalia, Rwanda and East Timor. Welding began 42 years before onset.

Worsening factors

Factor 9(20): inability to obtain appropriate clinical management for malignant neoplasm of the kidney. — MET

- After the lesion was found on 04 May 2022, CT was delayed to 21 September 2022 and nephrectomy to 12 December 2022 by waiting lists and coordination between his transplant and urology teams, and the tumour grew from 2.4 cm to 4.6 cm and invaded the renal vein. The need for complex coordinated care arose from the kidney transplant required after his injury on warlike service.

The % contribution of the causes is 100% and significant.

Sequelae

The renal cell carcinoma required left native radical nephrectomy, with a painful flank wound, and has caused an adjustment disorder with anxiety about recurrence. Its management has required changes to his transplant immunosuppression. These should be considered for acceptance as sequelae of the accepted cancer.

Unintended Consequence

Met. Para-aortic radiotherapy for seminoma in 1997 and the CT scans after his 2000 crush injury, provided and paid for by the Commonwealth while the veteran was serving, delivered radiation doses to the kidney recognised as causing kidney cancer. The non-steroidal anti-inflammatory drugs issued on service contributed to his chronic kidney disease. These are unintended consequences of treatment provided by the Commonwealth (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. A new solid lesion in the left native kidney was shown on ultrasound on 04 May 2022 and urgent CT was requested, but CT was not performed until 21 September 2022 and nephrectomy not until 12 December 2022 because of surgical waiting lists and delays in coordinating his transplant and urology teams. In that time the tumour grew from 2.4 cm to 4.6 cm and invaded the left renal vein, worsening its stage to pT3a. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), a delay of seven months in investigating and removing a suspected kidney cancer in a transplant recipient amounts to an inability to obtain appropriate clinical management.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

1. 15 Jan 1980, Enlistment medical examination and haemoglobin electrophoresis, Medical Officer
2. 25 May 1993, Preventive medicine report, water quality, Environmental Health Officer, Somalia
3. 21 Mar 1997, Radiation oncology treatment summary, Radiation oncologist
4. 14 Jan 2000, Trauma admission and operation report, Role 3 hospital, East Timor
5. 12 Dec 2000, Renal medicine consultation, Renal physician
6. 10 Jun 2003, Periodic health examination and CT abdomen report, Medical Officer and Radiologist
7. 18 Mar 2008, Haemodialysis commencement and dietitian assessment, Renal physician and Renal dietitian
8. 26 Aug 2013, Transplant operation report, Transplant surgeon
9. 10 Mar 2021, Ultrasound native kidneys report, Radiologist
10. 04 May 2022, Ultrasound native kidneys report, Radiologist
11. 21 Sep 2022, CT abdomen and pelvis report, Radiologist
12. 12 Dec 2022, Operation report and histopathology report, Urologist and Pathologist
13. Statement of Principles concerning Malignant Neoplasm of the Kidney (Balance of Probabilities) No. 42 of 2021, Repatriation Medical Authority
14. Statement of Principles concerning Malignant Neoplasm of the Kidney (Reasonable Hypothesis) No. 41 of 2021, Repatriation Medical Authority