Faculty Bibliography

PURPOSE: To identify causes of purported malpractice in diagnosis and treatment of breast cancer. MATERIALS AND METHODS: The authors reviewed cases from The New York Jury Verdict Reporter listed between 1985 and 1991 to look for those in which there was alleged delay in diagnosis or treatment of breast cancer. RESULTS: Of 34 cases identified, 32 (94%) were based on presumed delay in diagnosis and only two (6%) on claims of therapeutic malpractice. Delay in diagnosis was commonly claimed in patients younger than 50 years (76%). Palpable masses were present in 94% of these cases. Either mammograms were not obtained (16 cases, 50%) or findings were interpreted as normal or as fibrocystic disease (12 cases, 38%). Specialists most frequently cited were gynecologists (16 of 39,41%). Highest awards (> or = $1 million) were more commonly given to patients younger than 50 years with proved distant or nodal metastasis (six of 34, 18%). CONCLUSION: Emphasis on early diagnosis has led to the perception that purported delay in diagnosis, however short, even in the presence of a palpable mass, changes the chances for survival

Nonpalpable nodules in patients with breast implants may represent silicone granulomas, fibrocystic mastopathy, or cancer. We describe a modified technique for needle localization which facilitates the surgical excision of these nodules while minimizing the possibility of rupture

Six patients with augmentation prostheses presented with a firm, painless, breast mass that could not be visualized by mammography. One lesion was demonstrated to be solid by ultrasound, and the remaining sonograms were nondiagnostic. The lesions were indistinguishable from carcinoma, by physical examination. All of the patients had fine needle aspiration biopsy despite close proximity to the implant. The patients all had silicone granulomas related to silicone leakage. Our experience suggests that fine needle aspiration biopsy is a useful technique to evaluate palpable breast masses that are not visualized by mammography in patients with augmentation prostheses

Stereotaxic fine-needle aspiration biopsy (SFNAB) was performed to evaluate suspicious mammographic findings (31 stellate lesions, 20 regions of grouped calcifications, two nodules, and one area of prominent trabecular markings) in 54 patients who had undergone reduction mammaplasty. SFNAB findings were correlated with findings in histologic specimens whenever possible; the cytologic samples were classified as malignant, atypical, or benign. In 22 lesions, the abnormalities on mammograms were considered highly suspicious for malignancy. In the 32 others, the degree of suspicion was lower, but these lesions had a change in appearance since acquisition of the first postoperative mammogram. SFNAB enabled diagnosis of adenocarcinoma in five women. Patients who have undergone mastectomy with reconstruction of one breast and mammaplasty in the other are at higher risk for development of contralateral breast cancer, as are all patients who have had such cancer. SFNAB is reliable for evaluation of suspicious mammographic abnormalities that develop after mammaplasty and findings that change after acquisition of the first postoperative mammogram

To investigate the clinical relevance of antimelanoma antibody responses induced by melanoma vaccine immunization, we studied prospectively 81 patients with resected AJCC stage III malignant melanoma who were immunized to a partially purified, polyvalent, melanoma antigen vaccine. Antibody responses to melanoma surface antigens were measured by immunoprecipitation SDS-PAGE analysis prior to treatment and one week after the 4th immunization. Vaccine treatment induced or augmented melanoma antibodies in 33 (41%) patients. The responses were directed to one or more antigens of approximately 210, 150, 110, 75, and/or 38-43 kD. The median disease-free survival of patients with any antibody response was 47 months vs 19 months for nonresponders and median overall survival was 62 months vs 46 months. The proportion of patients that was disease-free at 4 years increased by 57% (from 33% to 52%) and overall survival by 64% (from 50% to 80%) in responders vs nonresponders. These differences in outcome were unrelated to disease severity or overall immunological competence (evaluated by response to recall antigens and ability to be sensitized to DNCB), suggesting they resulted from vaccine treatment. Thus, the antibody response to vaccine treatment is an immune marker of vaccine activity that appears to be predictive of a later reduction in the recurrence of melanoma. This finding suggests that vaccine treatment effectively slows the progression of melanoma in some patients, and that the protective effect is mediated in part by vaccine induced antimelanoma antibodies