Attorney: KELLY HAMER, Esq.
Firm: SIBONI, HAMER & BUCHANAN, Ocala FL
Illustrator: Jennifer Case, MS
Background
A 27 year old woman presented in October 1997 with complaints of a lump at 6 o'clock in her right breast. The defendant was able to palpate several small cysts and other signs of fibrocystic changes, but felt no dominant mass and told her to return in 6 weeks. She returned and defendant could palpate nothing at that time. She returned in 3 months, and exam showed the same result.
At her annual exam in May, 1998, a mass was palpated at 9 o'clock in the right breast. She had a negative mammogram, but the ultrasound was positive for a solid mass. Excisional biopsy showed infiltrating ductal carcinoma. She had no positive nodes, underwent mastectomy with reconstruction, and is still cancer-free.
Allegations
The plaintiff alleged failure to diagnose breast cancer, and that mammography or biopsy should have been done in October, 1997.
Defense
Mammography is virtually useless in a young woman because of the density of the breast tissue, and biopsies required the presence of a dominant mass. In any event, the actual malignant tumor was not in the same location as the cysts palpated in 1997.
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Exhibit I: Click to enlarge
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Exhibit I: The locations of the original cystic structures and the malignant mass were quite different and since tumors don't "migrate" from one portion of the breast to another, it was important to show that these were two different and separate processes. The left-hand diagram was used to allow the surgeon to show the location of the small cystic masses palpated in 1997, and the right-hand diagram the location of the malignant tumor found the following year. In court, the defendant actually marked these on the exhibit's overlay, using the exhibit as an interactive device; the lesions are shown here for clarity.
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Exhibit II: Click to enlarge
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Exhibit II: The issue of the mammogram was important, and the defense was helped by the fact that the lesion was not detected on mammogram in May, 1997, so most likely would have been invisible the previous year.
Pre-menopausal breasts are very dense with glandular tissue, and have relatively little fat. Denser tissue will cause the mammogram to read as being light in color, obscuring the presence of any solid masses which are of similar density. The first image on the left shows a malignant lesion in the setting of fibrocystic breast changes; fibrocystic "disease" is present in up to 80% of all pre-menopausal women and is a sign of active breast tissue but is not a risk factor for breast cancer.
All breasts, pre- or post-menopausal, have fibrous septa that separate the breast tissue in a somewhat radial fashion. Cysts can freely move within their segments, sliding between the glandular tissue and fat. Cancers, on the other hand, are generally attached to the septa or bodywall by their tentacles and will not move at all.
Mammography is particularly useful in post-menopausal women. After menopause, the hormones that keep the glandular tissue of the breast active are no longer present in sufficient quantities, and the breast tissue is gradually replaced by fat. Since fat is not dense, it is read on mammography as being very dark and denser objects, such as tumors, are readily seen on mammography.
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Exhibit IIIA: Click to enlarge
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Exhibit III: The plaintiff's contention that needle aspiration or incisional biopsy should have been used in 1997 was countered by explaining the procedures themselves. Exhibit IIIA showing that in needle aspiration, the dominant mass is localized by the physician's fingers, which allows precise placement of the biopsy needle.
If there is no dominant mass, there is nothing to localize and the needle has a very high chance of completely missing the lesions, making the biopsy attempt more potentially harmful than helpful
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Exhibit IIIB: Click to enlarge
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Exhibit IIIB shows that excisional biopsy is easily performed with a dominant mass, which can be both palpated and seen under direct vision. Again, if there are only small nodularities present, the surgeon would have to guess where to remove tissue, again making the biopsy more potentially harmful than helpful.
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