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The goal of this study was to determine whether factors associated with the successful defense and cost of malpractice cases involving the failure to diagnose breast cancer could be identified in medical and legal records. Secondary goals were to develop a multidisciplinary clinical algorithm utilizing National Comprehensive Cancer Network (NCCN) practice guidelines with practitioner risk management strategies. Physician deviations from these guidelines were tracked to identify high-risk areas in the diagnosis of breast cancer. A multidisciplinary clinical algorithm was introduced and practitioner risk management issues were addressed. In this study specific medical, legal, and cost factors were retrospectively abstracted and analyzed to identify associations between medical and legal factors and medicolegal outcome. ProMutual handled 156 malpractice cases involving breast cancer between January 22, 1986, and November 20, 1997. Of the total, 124 cases involving 212 defendants were closed. The closed cases were analyzed, using multivariable stepwise logistic and linear regression, to identify associations between clinical factors and case outcome. Women's health practitioners (WHPs), including obstetrician-gynecologists (OB-GYNs), family medicine, and internal medicine clinicians, were the largest group of defendants (97). Others included radiologists (43), surgeons (33), and pathologists (3). OB-GYNs accounted for 31% of these defendants, with a cost of more than $16 million. The greatest number of specialists represented in the open cases were radiologists, with 38% of the total. The defense model predicts that the probability of successful defense is lessened with inadequate record keeping, a patient that has metastasis and is alive, and a delay in diagnosis of 12 months or more. The overall indemnity model predicts a higher indemnity with the spread of disease at the time of evaluation, a patient who has metastasis and is alive, and a date of occurrence closer to the present. Indemnity is less in patients who have had a lymph node dissection, who have died, or who are alive without metastasis. The WHP model predicts an increased overall indemnity with the spread of disease at the time of evaluation and the presence of a mass without pain. Indemnity decreases with a history of pregnancy, absence of presenting symptoms, or presentation with pain with or without a mass, and the performance of a lymph node dissection.

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The objective was to determine whether factors could be identified in medical and legal records that are associated with the successful defense of obstetrical malpractice cases involving the death or neurological impairment of infants. Obstetrical claims (169) closed by PROMUTUAL between January 1, 1990, and December 31, 1994, were retrospectively abstracted and analyzed to identify associations between medical and legal factors, and the medicolegal outcome. Multivariable analysis identifies that the use of pitocin, diagnosis of asphyxia, a delay in delivery, and the use of multiple defense expert witnesses decreased the chances of a successful defense. Two statistical models explaining indemnity payment were developed. The first, based on medical outcome, showed an increased indemnity payment when a case involved major neurological deficits, diagnosis of asphyxia, newborn seizures, later year of delivery, and participation of a particular defense firm. Perinatal or childhood death and the use of pitocin were indicators of a decrease in payment. The second model was based on long-term care requirements. In this model, indicators of increased indemnity payment were: nonreassuring intrapartum fetal heart rate tracing, later year of delivery, intensity of long-term care required, and participation of a particular defense law firm. Perinatal or childhood death, the use of pitocin, and settlement date increasingly removed from the occurrence date were the determinants of decreased payments in this model. Finally, the presence of major neurological deficits, the prolongation of a case, and the involvement of multiple law firms and defense witnesses increased the expense charged to and paid by the insurance company. Using the medical, legal, and financial data relevant to 169 obstetrical cases closed by one malpractice insurance carrier between 1990 and 1994, statistical models with potential predictive values for future malpractice claims involving neurologically impaired infants were constructed. These models may help determine in advance the chance a future case has for successful defense and the likely amount of expense and indemnity dollars that will be paid out to settle and defend it.

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OBJECTIVE: To analyze specific medical, legal, and cost factors that predict the probability of successfully defending lawsuits filed because of failure to diagnose breast cancer. METHODS: Seventy-six malpractice cases handled by the Massachusetts Medical Professional Insurance Association between June 29, 1983 and December 30, 1993 were abstracted and analyzed using univariate analysis, multivariate stepwise logistic and least-square regression analysis, and the Cox proportional hazards model to identify statistically significant associations between clinical factors and medicolegal outcomes. RESULTS: Obstetrician-gynecologists were defendants in the largest number of cases (38) and incurred the highest total indemnity ($7,629,570). The probability of defending a suit successfully increased with smaller tumor size and younger patients (less than 40 years of age). The failure to perform a biopsy was associated with a decreased probability of successful defense. Variables predicting high case cost included younger patient age, an increased length of delay in diagnosis, and the failure to perform a biopsy. The presence of metastasis at diagnosis was associated with an increased interval from diagnosis to the initiation of a suit. CONCLUSION: Statistical models that use medicolegal and cost factors can predict both the probability of a successful defense and the total cost of a breast cancer malpractice case.

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The lumbar spine and femoral neck densities of 123 and 141 normal adult women (50 +/- 10 years), respectively, measured by dual photon absorptiometry, were correlated with the number of hours of walking per day associated with their regular daily activities. This measure of exercise, obtained by detailed questionnaire and interview, was analyzed because it is regular, seasonally stable, and quantifiable. Both lumbar spine and femoral neck densities were significantly correlated with walking, with 0.8% and 1.9% increases in average bone density per hour of daily walking, respectively. This increase in density is substantial, considering that the age-related rate of bone loss in the same population is 0.7% and 0.5% per year of lumbar spine and femoral neck, respectively. This means that, on the average, a woman walking one additional hour per day has a femoral neck bone density comparable to that of a women 4 years younger who does not pursue this additional activity. This physical activity-associated enhancement of bone density may be critical at old age when osteoporosis is clinically manifested.

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Dual photon absorptiometry (DPA) is an extensively used technique for measuring the density of the lumbar spine. The presence of vertebral and extra-vertebral pathologies can lead to increased scatter of data and artifactual bias when constructing diagnostic reference value curves. The bone density of patients with such abnormalities cannot be compared with those of normals because it will appear artificially high. Furthermore, little effort has been made to identify and evaluate spinal abnormalities using the pictograms produced in this method. We have analyzed 60 DPA scans for morphologic changes, using x-rays for comparison, and have found practically complete concurrence between these two radiologic methods on features, though only the former is capable of accurately quantifying bone density. Examples of DPA presentation of anatomical morphology are shown to aid the user in interpreting DPA findings.

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Presented is a case report of a stage IIIC primary ovarian mixed mesodermal tumor with gross residual disease following aggressive cytoreductive surgery. Following twelve courses of Cisplatin, Adriamycin and Dacarbazine, second-look laparotomy confirmed a pathologic complete response. The patient is now free of disease at 17+ months.

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Lumbar spine and femoral neck bone densities of women, aged 35-65, were measured by dual photon bone densitometry. After exclusion of women with spinal and other abnormalities, this study included 233 subjects: 60 menstruant, 91 who underwent natural menopause (56 more than 2 years post-menopause), 45 bilaterally oophorectomized, and 37 hysterectomized without bilateral oophorectomy. No significant differences were found between the age-normalized average bone densities of the menstruant, early postmenopausal, and late postmenopausal women; nor was there a difference between the rates of their bone loss. The bone densities of the hysterectomized women were significantly lower than those of the normals. The bone densities of the oophorectomized women were significantly lower than those of the hysterectomized patients. The rates of bone loss, however, were comparable in all groups studied. The use of estrogen without progestin was associated with significantly higher lumbar spine densities in the oophorectomized women, but showed no significant effect in any of the other groups.

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The relationships between parity, breast-feeding, and the use of birth control pills and the bone densities of the lumbar spine and the femoral neck, measured by dual-photon densitometry, were studied in normal women. Femoral neck density was found to decrease by 1.1% per live-birth, whereas lumbar spine density showed no significant association with parity. Breast-feeding was found to increase lumbar spine density by 1.5% per breast-fed child, whereas femoral neck density was not significantly correlated. No significant relationships between the use of birth control pills and the bone densities were found.

PIP: Researchers measured the bone densities of the lumbar spine and the femoral neck using dual-photon densitometry in 352 normal women (range: 21 to 79 years old) in order to study the relationship between the bone densities and parity, breast feeding, and the use of oral contraceptives (OCs). Since the most common manifestations of osteoporosis, a bone disease most often afflicting elderly women, include spinal compression factors and fractures of the femoral neck, the scientists wanted to learn if parity, breast feeding, and the use of OCs increase the risk of acquiring this chronic bone disease. Femoral neck density decreased 1.1% per live birth (p = .039), whereas there was no significant difference between parity and lumbar spine density (p [alpha] = .16; p [beta] = 0). Lumbar spine density increased by 1.5% per breast-fed infant (p = .008), while no significant correlation existed between femoral neck density and breast feeding. Furthermore, researchers observed no significant relationships between OC use and both bone densities. In conclusion, since pregnancy and lactation involve complex hormonal and nonhormonal changes, the researchers find it difficult to pinpoint the mechanisms of these effects.

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A monoclonal antibody (5E8) has been used to identify and structurally characterize a previously unreported macromolecule present on the surface of human lung tumors. This antibody was derived from a hybrid clone that was produced using spleen cells of mice immunized with a surgically excised squamous cell carcinoma. Using immunofluorescence, the 5E8 antibody was observed to stain many different human lung tumor cell lines and surgically excised human lung tumors including squamous cell carcinomas, adenocarcinomas, alveolar carcinomas, and a portion of the large cell tumors tested. With few exceptions, notably the basal layer of the skin, little or no detectable staining of 5E8 to normal human tissues (lung, brain, kidney, heart, stomach, breast, erythrocytes, or lymphocytes) was observed. The 5E8 antibody was used to immunoprecipitate detergent lysates of biosynthetically labeled or surface radioiodinated lung tumors. Analysis of the immunoprecipitates by sodium dodecyl sulfate gel electrophoresis revealed a major band and a faster migrating second minor band. The molecular weights of these two proteins were estimated to be 160,000 and 120,000, respectively. The addition of a reducing agent to the gels did not alter the migration pattern of the immunoprecipitated macromolecules. The removal of a terminal carbohydrate, sialic acid, did not restrict the binding of 5E8 to the tumor-associated antigen. However, labeling studies using galactose oxidase and tritiated borohydride revealed the presence of galactose on the immunoprecipitated protein. This major Mr 160,000 glycoprotein that was identified on two different human lung tumor cell lines was also found on a human large cell tumor tissue obtained by surgical biopsy. The 5E8 antibody and the Mr 160,000 glycoprotein that it recognizes represent two very useful components with which to test several new antibody-mediated drug delivery systems in the treatment of human lung tumors. The tumor-associated glycoprotein also represents a potential analyte for a diagnostic or prognostic immunoassay for lung cancer.

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A patient with countless metastatic bilateral lung lesions from sarcoma of an extremity was treated surgically. The patient is alive in good physical condition nearly 2 years following the surgery. Although there are residual pulmonary metastases, they appear to be stational. Surgical intervention of countless metastatic lung lesions may be indicated in selected cases.

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Hybridomas secreting monoclonal antibodies specific for human lung cancer were produced by fusing immunized mouse spleen cells with mouse myeloma line X63-Ag8.653. Prior to fusion, BALB/c mice were immunized with two different histological types of human lung cancer (Squamous cell carcinoma and adenocarcinoma) obtained from surgery. An immunocytoadherence test was used to select hybridomas secreting antibodies that bound the patient's lung tumor, but did not bind to a B-lymphoblastoid cell line derived from the same patient. Five stable antibody-producing hybrids have been established and cloned. The antibodies produced by these clones have been characterized according to their light and heavy chain isotypes and for their specificity. In addition to binding to the tumor used for immunization, the antibodies bound to other lung tumors of the same histological type (i.e., squamous cell or adenocarcinoma). This reactivity was observed with both established lung tumor cell lines and with fresh tumors obtained from biopsy of patients in our clinic. Some significant reactivity was also observed with large cell carcinoma but the antibodies did not react with small cell carcinomas of the lung, bronchiolo-alveolar cell carcinoma, cancer of the esophagus and stomach, melanomas, several types of leukemias, normal human lung tissue, fibroblasts, or erythrocytes of type A, B, or O. Two of the five antibodies, 5C7 and 5E8 cross-reacted with one breast cancer obtained from surgery, and 5C7 also cross-reacted with one melanoma biopsy specimen. These results suggest that we have generated monoclonal antibodies that recognize a set of antigenic determinants that are commonly expressed on a portion of human lung tumors that are not detectable on a variety of other human tumors or normal human tissue.

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