We thank Gregg J. Pasquale, attorney for the plaintiff, for sending us a report of this case. The plaintiff, age sixty, went to her primary care physician’s office in April 2002 and was seen by a physician covering for her regular primary care physician. She was noted to have a mass in her right breast. Defendant Doctor 1 documented the presence of a mass in the upper outer quadrant of the right breast and she was referred for a mammogram and breast ultrasound. The mammogram was performed the following day. The report indicated there were fibroglandular densities visible within the breasts with no specific evidence of malignancy. Due to the presence of a palpable abnormality, a right breast ultrasound was performed and the prior mammogram films were obtained for comparison. The ultrasound performed that day indicated that this study failed to demonstrate a mass or cyst.

Clinical follow-up of the palpable thickening within the right breast was recommended. An addendum to the mammogram report indicated that the prior mammogram, from December 1992 had been reviewed, with the overall density of the breasts having diminished since the 1992 study with no significant change noted. The reports were sent to Doctor 1.

The record contains no indication that Doctor 1 recommended any further follow up for the breast mass. Doctor 1 testified that she informed the plaintiff of all of the test results and impressed upon the plaintiff that it was important for her to get yearly mammograms. Doctor 1 also maintained that she specifically instructed the plaintiff to have yearly physical examinations by her regular primary care physicians.

The plaintiff did not return to her physician for about four years, in February 2006, at which time she was seen by the Nurse Practitioner defendant. The Nurse Practitioner noted that the plaintiff’s right nipple was inverted and she had a palpable breast density at 2:00 o’clock. The Nurse Practitioner noted that this breast density had been worked up four years earlier with nothing noted. The plaintiff reported that this mass had become larger over time. The Nurse Practitioner described the mass as diffuse, with no margins and was slightly tender. She recommended a diagnostic mammogram with follow-up in four weeks. A diagnostic mammogram was performed that day. The report indicated that there were findings which were suspicious for malignancy. A right breast ultrasound was also performed for further evaluation the following day, and failed to demonstrate any abnormality. The report indicated that clinical correlation was advised.

The plaintiff was seen again by the Nurse Practitioner in March 2006. The records indicated that the diagnostic mammogram and ultrasound showed no changes from the previous monitoring. There was no indication in the records that the Nurse Practitioner performed an actual physical examination of the breast during this visit. There is also no indication that the Nurse Practitioner discussed the abnormal mammogram report or the presence of the persistent breast mass and nipple inversion with the supervising physician. There is also no indication that the Nurse Practitioner referred the plaintiff to a surgeon for further evaluation at that time.

Following this visit, the finding of a “benign breast mass” was entered into the plaintiffs past medical history despite the fact that no biopsy of the breast mass had ever been performed to assess whether this was a “benign” mass. Over the next few months, the plaintiff was seen by the Nurse Practitioner and her supervising physician, defendant Doctor 2, on several occasions for evaluation of blood pressure and cholesterol over the next eleven months. There is no indication of any further evaluation of the right breast mass.

In November 2006 the plaintiff developed a severe and persistent headache. She was seen by another physician who diagnosed a sinus infection. Several rounds of antibiotics did not relieve the symptoms and she developed a new symptom of a drooping left eye.

The plaintiff was seen again by this doctor in January 2007, at which time cervical lymphadenopathy on the right side and the drooping left eye lid were noted. A brain MRI was performed later in January 2007, which revealed several areas of abnormality in the brain. A breast MRI was also ordered by the doctor and performed in early February 2007, which noted significant axillary adenopathy bilaterally. The right breast appeared contracted with nipple retraction with diffuse enhancement of the right breast parenchyma, primarily in the upper central and outer quadrants. The left breast also showed a large area of abnormal enhancement in the upper central and medial quadrant as well as a more discrete enhancing mass at 6:00 o’clock. Biopsies of the abnormalities in both breasts and axillary lymph nodes were recommended. The plaintiff was then referred to another physician at the brain tumor center for evaluation of the brain masses. The plaintiff was then referred to a surgeon for lymph node biopsies.

The plaintiff was diagnosed with stage IV metastatic breast cancer. She underwent palliative brain radiation and was administered Iremidex. The plaintiff had breast cancer in both her right and left breast and right and left axilla. The pathology report of the samples taken indicated a strong suspicion on morphologic grounds that this is one tumor process. The cancer seen in the node samples taken from the right and left axilla are described as similar in appearance and have identical immunoprofiles. Both samples were described as having a discohesive appearance, consistent with “lobular’ features. The carcinoma in the left biopsy had a slightly higher nuclear grade. The report indicated that the results could be consistent with either one primary or two primary sites.

The defendants maintained that the plaintiff was appropriately cared for in April 2002 and maintained that if she had returned in a timely basis, the breast cancer would have been diagnosed and treated earlier. The defendants also contended that by February 2006 the cancer most likely had already metastasized and that treatment at that time would not have altered the outcome.

A $500,000 settlement was reached.

With permission from Medical Malpractice Verdicts, Settlements & Experts; Lewis Laska, Editor, 901 Church St., Nashville, TN 37203-3411, 1-800-298-6288.