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Lorillard

Antonio Cipollone, Individually, and As Executor of the Estate of Rose D. Cipollone, Plaintiff, Vs Liggett Group, Inc., Defendants. Transcript of Proceedings. Afternoon Session. Civil Action No. 83-2864(Sa)

Date: 18 Apr 1988
Length: 70 pages
85858202-85858271
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Author
Bleakley, P.K.
Cohn, D.J.
Darnell, A.M.
Decker, F.
Drozdowski, R.F.
Edell, M.Z.
Kearney, J.
Naar, A.S.
Northrip, R.E.
Parrish, S.
Silfen, T.E.
Sirridge, P.N.
Tucker, W.S., J.R.
Alias
85858202/85858271
Area
LEGAL DEPT FILE ROOM/TRNSCRPTS & EXHBTS
Type
DEPO, DEPOSITION/TRIAL TRANSCRIPT
Recipient (Organization)
Usdc District Nj
Recipient
Sarokin, H.L.
Date Loaded
12 Feb 1999
Named Person
Cipollone, A.
Cipollone, R.D.
Author (Organization)
Stryker Tams
Webster Sheffield
Wilentz Goldman
Arnold Porter
Brown Connery
Budd Larner
Greenbaum Rowe
Lig, Liggett
Lor, Lorillard
PM, Philip Morris
Shb, Shook,Hardy & Bacon
Litigation
Stmn/Produced
Site
N14
Named Organization
Lig, Liggett
Loews Theatres
PM, Philip Morris
UCSF Legacy ID
okz30e00

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v!1:33 t`a'+~lr~ V+~.iS.7 ir'.Y 41Yj1 f~VtZV\{ .21~. rYB~4lv,Af Z AtITON10 CI:'OLLONE, zndividuvily, and a& Executor tif the Latacte s of Rose 0. Cipc.i iotie, UANJ9R 1_'i DF Pi :3CZ~`i~lTrGS © gidi,fltiff, ..y a... t Newark, *iaw Jersey LiG:iu?T GR'JUh, INC# r a De.iaware Corpcsratiun; PFi:LIP s Apri.i 13, 1950 KORRI Sr INCORPORATE3, a AETLRN0DC2 SESSIJN Virginia Corparatiox:t and : LO3~,~:~'$ 'iFIEATREar ItILt v a tzew York Corporat.ron. s Defendants. - - - - - - - - - - - - - - - 3 3 F 0 R E _ i{OINORAIILE H. LEa SA:.'~rJFil;i .1"IITED Si'ATS3 D.iSTRIC:.' JUUG4 APP~.' A ii A NC e. S: i3Ui1i), LAi^t:i;c•:R, Pi.CTLsrJ,r ttrJ:iE;L'SA;J'•i. Z;r`lf):. E:3ia. F 3Ys :i.VRC .',. L=-M;.S.s E'3Q. 41s.,,r,'Ta, 20LD:iAt3 & `3?r"TZ::R, i3Yi ?sLAli t:. ',)11,RVc7.,:.L, PMO. i Attarneys for LRo P,iaztztttt. ARNt?LI3 ` PURTL.'•t, ESQa., 3Y t PETZR K. 36EAKLEY, %SQ., 3Ys TaOM31S 9. 9ZLF£N, ESQ. Attorneys for the ,a£endanr, Pursuant to 9ect.ion 753 Titie 2t3 trie ioilrwrng transcript is cerr,4led record aa taken 3tgnograp}ticai i,coceeaings. Ptsiirp Horz ia. UliitetJ States Code, to ae an accurata ab o v a ,awtit~ r_,DD v PFIYL.LI..`3 I'. LCWLSr a1 cJffic3,ai CourC Reportasr - Unit States Disitrics Court P.O. Box 35555, tNewark, New Jeraey 07101 ~:~`S"L ~.f :i :. .'I. :1ti'J:i~:.3."!t .~.`a'?
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A P 2 E A R ^y ... s: "i t (:"oT1C I F:IleJ) ~ ~ 3 a1iL~;NSAUM, 3i•1i.TH, %1Li7iIa, :)AViS & 3ht A Lt'W " .;AAfi, ::a~',~.. . -ttftt!- .?f:+aJrT'ER srit. :.i;l:iFt`1«Sr~I' :3Y s JOMLO J. t::Ja.`d, .3Q. , r 7 JAUS Ki.ARt.rY, FRANCiS OECKEst. ZSQ. Attorneys for Ovlcndant. Liggett. 8 ;3RC3idTi (k C4tdtjUY, CS~Qj~;. , 9 aYr :YKaNJ F. Attoracys €or Defenaant 10 J'4-'RY9ciRr TAi'ia & Dil.iL/ 2'.`J.,iJ . , 11 :;Yt FYLLLR:? S. ":".TC'.zsR, 3R., asc:r., -and- 12 afic?'~ :, :{ARDY * I3:\;:C]~7, :S,;l:i. , i ;t 14 3s r s~iy sVE~d s'rutislsH, Eas,'. ~ ~L'LIE:Z46 L'r. 1•10:l11tilPt iJ il W \i ?i 22 ?. 4 2 :i 'ioc c iZ 4rW :; .,, it.'i' .3 :: b v JA[ a 'i n . :;+C.'.ISTO:d, v:i n-
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1 2 3 4 5 4 7 I ! LO 11 L2 L3 L4 t5 L6 17 !9 19 10 21 22 23 14 25 861!} AF T L' R!3 0 3U S S S S I O N T8B CLBRRt All r3.se. (The #ollowing takes place in the presencz* of the Jury.) T88 COIIRTt Please he ssatld. DIRWT R]CANINATId1i COiiT'INUBS BY MR. SIRRID4B1 Q Dr, Soaaers, when we were discussing the processes of the Council for Tobacco Research this morning, you mentioned the annual reporta. Do you retaenber that? A Yes. Q I'd liite to show you what's been aarked defense joint exhibit 0432 to 0444. Are these the annual reports froa 1966 to 1981? Tak* your time. i1 Yt~t. Q Rnd what is the purpose of the annual reports? A So that the scientific rorld: to the txt.nt that institutions and iAdividual investigators and members of so.e societies, like the American Assoaiation for Cancer Res.arch, will be intormed of what the Qouncil has been funding in the way of experiAQntai work. Q Are they prepar*i ey the Council for Tobacco Research? JE3A,'~iNS M. HOUS'i't?Nr CSR, OFFzCIAL COURT RSF{7RTBRr NF.FtAR$i N.J.
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L 2 3 4 S 6 7 i 9 Lfl 11 L2 L3 14 is L8 t? L$ L9 t4 21 12 13 24 25 9oamerv - Oxract 8611 A Yea. Q Art they propacrd each year? A How they ar., yts, I notic.d the f irat oAas cover two yoars. p Do these aaiwatifia or annual rvports froa the Council for Tobacao ytssrarcA r.praant the y.ars that you have bs.A oa the Scientific Advisory soard? A Yrs e- MR. SIRRIDtiRs At this tiss I would lfic• to offrr in 0432 to 0444. TR3 COURTs Any obj#ctions, Hr. Sdall? MR. RDSLLs To provt thf truth of the matter asserted contained in them, your Honor? ltR. SIRRIDGEt Just to represent the work from the CTR in the scientific arena. THS COURTs Is it - N=. Rdt1i's quwation is the nature of the work or is the jury going to be sxpectatd to read th• contents? HR. SIRR1D43Ei Ro, tha type of scientific research during this iS year period. MR. 8DBT.Ls As long as it's not being offered for the, truth of the mattor asserted and the Court will so instruct the jury at the tin* of dslibaration. I hays no objection. THR COURTs p i na. JUANNE X. NOUS'i'4N, CSR, ©AFZCIAL, COURT RBPORTER, N:WARX, N.J.
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I 2 3 4 5 6 7 a 9 lo l3 l2 l3 L4 Jorrsaers - Direct $512 S.asically, like the tabie of contents, in other w4rds, to dfsiqnat* topics that have been researched and reported. KR. SIRRIDGBs Right. AAd the psopie who received gransa. TSB COURTs I'11 persiit it to be seceivfd in .vidanco with that understand3aq. Mbibita 0432 to 0444 are marked in .vidertca. } Q Right before we broksr for iunch, Dr. Somaers, you were describing an inhalational project with cigarette smoke and mice. that is important in the eYp.rriaaent? Do you remember that? Yes. And you mentioned the term "shaa and amote controis.' Could you txplain what you mean by that and why Yes. It I understood your question, what I =ention+ad 23 24 t3 was sham smoke controls and what that m.ans !.s that nic+r are placed in the same kind of cigarette smoking maehine that the mice are put in when they are exposed to fresh whole ciqsre#ti smoke. Uornvec, there is no aa"a turned on and the sic* do not inhale anything but air. The reasoning you have those controls is that mice don't partieulariy like being handled everyday and being put in this machine and all. JOANhtS M. Nt}U$TQN, OSR, OFPZ C 2 RL COURT RRPORTBR, N$WAMr N. J.
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•S Vllittf G tJ ~ Di C'!] L L 3013 1 2 3 4 5 6 7 a 9 10 LI 12 13 14 13 16 L7 t8 19 20 21 22 13 34 25 It'a thought mayix3 zt Proc3uces Wttat.'s callgd stress and su this ia a control for Qverythinq about th+e amoking exposure except the smoke. 0 What about the ehelf control yroup? A The shelf controls are mtce of the same inbred strains that live all their lives in caqQa and tt'a in an air conditioned animal rooss and they're not exposed to anything but filtered air conditioned air. Q why is that important? A Well, one always needs to know what the bdsei ine or the nuuber and typ. of tumora and not just lung tumors, any kinda of tumors, that a certain btrain of mice will develop with age, For exa;aple, leukemiae aren't infrequent in tne inbred mYce and ii you don't have a siqnifican't increaae or dQarsaae in either one of the *xperi.:uental qroups, then in es*enc., the experiment,a d.tsn't reai.ty show mach of anything. p Dr. Socwers, you testified riqht before lunch that no squaaoua cell careinomas developed in the mice dur3nq the •xper iaent. Do you remeaube r that? A Cor[ect. ,2 Did any abiali cetl carcinoma appear? A tNa. .7OAtJNE H. t3©JBTON, CSR, 4FF1CiAL COURT RRPORTER, I38WARK. N.J.
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1 3 3 4 5 d 7 l2 L3 14 15 ti L7 1S t9 20 11 22 23 24 25 SOxmeCa - Direct 8614 Q Did any &typical caccinoid appear? A No. Q Dr. Sossers, what are oncoqines? A wrell, oncogenes are parts of the call brought down from for aillions of years inside si.plt orqaris• organises 1fk• yeasts aAd wore coapl s organisss like aniaala and hu.an bsings, Where the sub ject op*nrd was about 1969. Q And what role do they play In cancer? A NR13, many people nov th,ink that they are the praximate causes of certain types of human cancer. aaic3* from various types of aoussr or othQr aniQ+ai caac.rs. This b.ad bten known previously. Q Now, have attteaipta been made to identify oncagenes 3.n certain types of cancer? A Oh, yes, Yes, ind.ed. Q Do you know w2seth*r any oncoqonag have been identified in carcinoid tumorsf? A In oee case, yes. Q Could you explain what that is? A Well, th.r• was a report last year that in a huraan carcinoid type lung tumor an oncaqtns -- they're all 3cnc}wn by three lett.rs, this one is called R-h-S, RAS -- was f ound, Q And how is it gound, how it would havQ been i:dontified? A Well, the way that you now track down oncoqenss is you JOANNE lK, HOUa^TOA1, CBR, OFFICZAI. COUR3' RSP'JItTFR. NSWIlRK, N.J.
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1 2 3 4 5 6 7 I 13 14 ts ti 17 i, o 19 20 21 12 13 24 23 3omners - Direct flsxs have to have a slice of th^ fresh tissue or if you are aapable, grow it for at least a few hours or days outside tbt body, so-called tissue culture and thsn tbtre are antibodies availabie, Those are substances produced in another species of aniaal, sometimes i!t's a rabbit - that was xrost cowu.on - scss•ti"s it's a qoat. And you use these as a reagent mirker. The antibody is labeled with something that either gives it a co2or, a brown color or once in awhil• with something radio active so you can make a radio autograph. And if the oncagene is present in that tumor or that tissue, th.n it will stain brown with the re.qent, the antibody and they art now so-cia3led eonoclonal antibadies, not just- ai*cellsneous in their actson, very specifically aiaed at just ons thing. And if there is no such reaction, then it's a ntqative result. Q Dr. Sowmera{ was that RhS onaagene found in small cs3.1 carcinoasa7 No. A statement is aade that it was not present in saall cie13 carcinomas. Q btow, oncogants have been identified in suall cfli caroiAoaa of the lung? Q Yes. Could you explain to the jury what bas been found? J'DANNS M. li4+ttSTOU, CSR, OgFICIAL COORT RBPORTSR, MARKi N.J.
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I 2 3 4 5 6 7 S 9 LO il t2 13 14 L3 ld L7 18 19 20 21 22 23 24 23 r7aamera - DireQi. H.LS If possible, as I mentioned, you grow the cells outaide the body in tissue vuiture. That's easy to doe a saail cell carciAw", There are probably 50 so-called cell lines, each from a different human patient that had that kind of lung car. The last slverai years it's been found that there is an oncagene super fasiZy. That means there are aors than one seabtc of this family and it's called XYC, pl-Y-C, and there ate three rsemblrs of that [olYC faaily. K-Y-Ct found In small cell caroinosa. Th+rre is C-MYC and "YC and L-MYC. And* fourthr another family of oncogenes called K--Y-B, also found in arcwse lines of saalil ceil carcinomas. C--HYB. Q What is a chromosose? Well, alil sulti-csllular organisms, so-called bigher lifep grow up and develop and ®aturt by way of mitocia. That's when one cell divides into two so-called daughter cells. 8efors they 3ivide, all of the chrcuaatin, that's the sustainable saterial, DNR containing material lines up in the iddle with soae like two little parachute, shrouds, pulls the chroaacxsa apart so that each daughter cell gets an equal aum;ber and those chromsosies carry all the inhsritable Mat+trial of that spscies of animal and a3.l th• potentialities for growth and development. Q Savf any chromoaoaal deficiencies been found in small cell carcinoma of the lung? JOANNE H. HO38T0N. C3R, OPaxCIAL COURT R8PC1RT8R, NEWAR1K, N.J.
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1 2 3 4 9 t 7 i 3 Lo i1 12 13 14 l5 li 17 19 19 t0 11 22 23 24 25 3urrmar$ - flirect 8617 A Yes. 4 Could you discribe that to the jury? A Ke11, using call linos, tissue culture call lintsr it's noa+ agreed - and there are several invastiyators - that th.re is a rytcif ic chromosomal aarter for smail call lung carcinoaa and it's a deletion of vhat is called a short arae of ahramwso.e nwoDer threer 3p, iittle p, de3etion. Q_ Dr. gonaOrs, does ssii c.ll carciAoaa occur in other places in the body b+side tbe lung? A Yes. Q Could you giv* the jury sorae exampies? A The sas.* kind of carcinosas, s.all call carcinaaar occurs in the esophagus, assumes in the thyaus, occurs in the sZcusach, occurs in the kidAey, occurs in tht Dladder, occurs in an ovary, occurs Ln a recturm and awe fsv oth.rs. Q 8av* the causes of those small cell carcineKSas i.n those piaces b..rt established? A Dlo. Q ©r. Somwrat are your views on cigarette aaoicing and lung cancer known to your colleagues in the pathology field? A Yos, indeed. 0 Were your views known to your colleagues when you were elected president of the Arthur Purdy Stout Society for Surgical latholoqists iA 1983? A Yes. J4AtJNg M. ADtJ31't?H, CSR. ©PPICTAL COURT :?MRT&R, Nfit+iARK, N.J.
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I 2 3 4 5 6 y 8 9 !0 lS !fr L7 La 19 10 21 22 23 24 2s Sowers - jirecE 8613 0 8ow do you know that? A We3.i, 1was called and said, will you serve as president? I said, •wel3., do you know and you al3l know how I feel about cigarette smoking and disease# saybe you don't want ae. • Q Were you elected president? A Yes. Q There's been a lot of discussion in the 0ase, doator, about neuro.ndocrine cancers of the lung. 8ov do you view that term and what do you include within it? A Yes. Oh, raaybe 30, probably 30 y*ars ago an SngliBh histoahessist named Pierce discovered what he thought wau a system of andoarine c*ila, not a glan d, but scattered a13l through the body in one or two or sma ll cell groups. Hf was biochemiaally oriented and he believe d they a3.1 showed xmine. Asino is a ohemical Eorrula a nd the end of a typo of ch.n+ical structurE, precursor aptake and decarboxylatinn, so be naraed this APUn after amine and so forth. It was a popular theory tor arehile, bat then it fell apart and the tecs has beccue: obsolesQeAt. What has replaced it is the terminology of tha peuroendoar ts. cel ls and their abnormalities and their tunors. Q Are there a group of tunors that are referred to as neuiroondoarina cancers of the lung? JOANNE N. HOUSTDNr CSRe OPPICIAI,, COURT FtBP©RTERi MMARRr gt.J.
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1 2 3 4 5 i 7 • 9 10 11 12 13 14 1s 16 17 ia Sommers - Uirect 8619 A Yea. Q What do you include within that group? A Saaetiats - well, not only lunqr butr yes: they are somatimes .vfn called nauroefldocClnonfise, the Suffix 0--m-a aeans a tumor or neoplasm. Q What would you include in tbo group of neuroendocr i" aane.rs of the iunq? A 4te1l, x voU2d include the bronachial carain0id, one• 4a12ed bronchial sdanona. I would include the infiltzstive or inYasiv., onct called bronahial adenaaa, now called atypical ot aalignant carainoid. I beg your pardnn. I would includ• because others have sssall cRil sarci.noma of the lung, MR. SIRRIDGEt Your Honor, could I ask soaeone op+en a window over here? THS COURTt Absolutely. Mr. Parrish. to BY NA. SIRRIDOaz Q I was distracted by savera2 things. You included what briefly now within that group? A Modern terminology, bronchial carcinoid, atypical or e,aliqrunt carainoid and small cill carcinoma. Q What is the cell origin for tbest tuaors? JOANNE M. HO#38TQN, CSR, CSCFZCIAF. COURT R$P{ORTBR, NRW7,RI{. N..7.
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1 2 3 4 3 6 7 ~ 9 to Li l3 U 14 1S 16 17 to 19 to 21 22 23 24 25 3ommra • Direct $620 A I think it's faic to say ttsC we don't reaIly knc3w. Host peopla, if tbey suspect a cell oriqin, clai.m it to tae the O[uletbitsky cfll#0 which is aA endocrine cell found s.parat.ly, ono call or smail group of c.l.ta in the brorschi, in the epith.lium and in the bronchial,: the small left. Q lsva a pathology view poiat, Dr. Somawsa, can it be diff iault to tsll the diffsrencs between these n.uro.ndoarfne cancers of the lung? A it depends on tb• type and amount of aatarial and the way it was obtained and preserved and cut and stained. it can bs saay* it can be difficult. Q Can it be difficult to tell tbs ditfer.nca b.tv.en atypical carcinoid, for raicampls, and amall cell carcinoma? A Wsll, I believe experience surgical patholoqists interested in lung pathology should, with not much diflicultyr b+s abl• to tsll the differsncf. Q Ar+ there digf.rrtnces of opinion aus+etimres between surgical patholoyista? A 0h, it's not infraqu*nt. Q Ia it iaportant to tsll tbt difference LletwiQii atypical aarcinoid and wnall cfll aarsinoma, in your opinion? A Yts. Q Why is that? A Weli, to quotz various other authors -- and I aqrrs, it said it's mandatory -- it said it you don't distinguish them JOANNS M. SovaTOU, CSR, DFPiCYAL CDDRT ARFORTER, NEWARZC, N. J.
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I Z 3 4 5 6 7 8 9 10 11 12 13 14 15 15 17 ia 19 20 21 22 23 14 25 So=ers - Jirsct 8621 the patient may be prevented from hAving the appcapriate treataent, the natural history of the Likelihood of spread by raatamtasis and death, a number of other features outside of the tiasuo z,~athology distinguish one from another. Q when you use the t+trm "natural history of disease,' what does that maan7 A What pathologists in a way ar• doing when they maice any diagnosis, because they are conveying it to trained physiCians or Qurgeun, we are saying this disease, unless appropriately treated, will slowly or rapidly lead to the death of this person or this disease is trivial and self-limited and will be gone in three xeeks. Those are extremss of the natural history. It's what happens to a disease uninfluenced or little influenced by any kind ot att.mpted therapy. Q Doctor, are there differences in the agx ratio of atypicall carcinoid versus amali csli crxrcinoa,a? A YaO. Q Could you explain that? A Nall, if you collect serie., then it turns out that frora my reading of th• 2iter+tture, there are more women than men who have atypical carcinoids. Q Dr. Soauaecs, based on your experience as a surgical pathologist, are atypical carcinoids usually located in a different place tnan the tung than sm.al3 celi carcinoma? JOANNE M. HOUSTAN, CaRo OFFICIAI. COJRT REPGIRTER, NWARIC, N.J.
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1 2 3 4 5 t 7 a 9 to II ta l3 L4 LS L6 tT t8 L9 to tI t3 13 24 23 Soamers - af rect 862? A Yes, they maybe and also sometimes they are not. Atypical carcinoids, if you are teaching msdical studants or rfsidsnts, you would say aa a group are nrore often so-called p.riphrr4kl, whereas the ordinary carcinold, the ons called atypical and the small cell carcinooas, ace mort often close to the centrr or so--Cilied hilus of the lang. Q pr. Samirs, you have reviewed th. medical records and the pathologic slidea in this case, haven't you? A Ytab, Q I'd like to call your attention back to July of 1981. Based on your elview of the rtoord, what happened to Mrs. Cipollone io July? A My understanding is that ana wasn't feeling well, that she went to see a doctor and that he took an X-ray of the chtst and that showed a rounded shadow, thought to be a turror on the right lung. Q Now, what happened then in terms of her medfca3l care? A Wall, she was then refdrra3 to two doctors on the staff of Lenoa Hill Sospital for diagnosis and pechaps reaoval of this. Q What procsdures ware done in August at i.+rnex gili tiospital? A We2l, if you refer to surgical pathology, then tbart was a biopsy of the bronchus through the so-ca2led broncbuscope, which is a teleaesopia device that you can see down into the JiJANtiL H. SDUST0N, CSBt, t7rFICYAL COURT RSPflRTEit, NB3eTA$K, N.J.
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yU:ttlltttr.'"i - Jire3: t c3623 1 2 3 4 5 6 7 a 9 to 11 12 13 14 1S 16 17 ,8 19 20 21 22 23 24 25 iargar brUnchi and that has a biting device you can take a piece. 4 was cancer found in the oiopay? A No, it was a negative bLopsy. Q Have you reviewed tnat alirle? A The. {? And what is your opxnion? A It appe+us unalt*red bronchial tiasue to mt. a And what ltapponed to Hrs. Cipoilone next? A 3ince they hadn't found anything and since the shadow certainly looked like some kind of tumor, she had the right chest opened and the surgeon began an op*ration to decide what it was and how to treat it. Q And were you involved in tn® treatment or the diagnoais of that tumor in August of 1981? A b?eli, I was not involved in the trfatmeent, but I was involved in the Jiagnosis, yesa. Q And did you write a report in the Lanox Qi13 €ioalaitai pathology departzrent? A Weli, ye$. x'm reags-n$ible for the report of the material remavedr including the rigat upper lobe of lung and some lywph nodes and a piece of cartilage from the rib. Q L'm going to ask you some questions about that re.port. Dr. Soataar3, if you' il allow :ae to get it. JOANtiE 14. HOUSTON, C3Rr OFFZCIAL C3i1R'i' R3PORTER, MZWAItK, N.J.
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1 2 3 4 S 6 7 B 9 tg i6 L7 t8 L9 to 11 12 13 14 rs Sommrs - Ulrect 8624 HR„ BIRRIDflB: This is marked as delendants' exhibit 3025 and the actual medicai record is plaintiffs' exbibit.S435 in evidence. I believe it's an exhibit the jury has s.*en beforf. Q Siacta re're going to be talking about tbis report. Dr, So.n.rs, could you ear* down and join ao7 Lat me first ask you, is this the report that you f iiied out at that tim*? A That' s a photoaopy or a represontation of tlae report. HR. SxRRXDGSt Your Bonorr the tuli report with the sas.r highlighting is in the jury notebookst if they want to turn to that. T8B COURTs If the jury vants, no objection, Mr. Bdt1i? HR. RV8LLS Dio. TSi3 COURT# Page six. Am I riQht, Kr. Sirridqs? MR. 3IRRIDGIS: 1'w sorry? T8a COURTs Page six? MR. $iARID48i Yes, it is. TBB CAEtRT# All r ight. Q teet as begin. Dr. Sovuesrsr by having you cam over and explain what is mtant by the term •groas a,pp.aranQa• and rvhit appears after that? A When any specimon arrives in tba laborattory, tissue sp+eciawen, even foreign bodies liict bullEts or somfthinq, it JCANNI+i dt. R4USTDN, C9R,. 48'PICIAL COURT RBPCRTRR, NWAJU;R, N.J.
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1 2 3 4 5 i 7 8 ~ LO Li L2 ~ ~ _ L3 t4 l5 L fi 17 i8 19 20 21 22 23 24 Gcwraeri - Direct 8623 reduir.s in a teaching hospital appruved by the dm+er ican College of Surgeons that it ee described and that msans look at it with the unaided eye, perhops a magnifying glass and Cell what it is . Q I notice rio me nunberra up in the upper right-h and corner. Why ar e those used at the hospital, hist ory nunu3ec, lab nwab.r? A Well, when the report is finisbed , with otber s, it will bo put in a pink envelope, all of tho se going to the same part af the hospital, so it could be properly delivered and be put i.nto r=cord, as a che ck, the hospital nuAber of the individual patient is listed . That is a cneck against all the other information so it won't gat misplaced. Then on the second line, you have the na aes of the responsible surgeon or surgeons and then the dmte of the operation, and then at end of the second line you have what is ca3,led the imtxoratory nuwbe,r. Starting with the .first worlcing day in January* it would have the speciaen nunber 1 hyphen whatever year. Th; last two digits, '%l and goes to the last day of December. Q Tell the jury what you believe ls important about the report. Basically explain why it is done and how it is done. 25 JOAt,iNE H. N40ST©N, CJR, 4FPZCrAL COURT REPURT$R+ NMOARK, tt.J.
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1 2 3 4 5 6 7 t4 E5 L6 0 La t9 E0 21 22 13 14 Is Somiaers - Direct 8626 A waii, F am a profestsionai pathologist. It is aey business. They pay ae for this. Why do they pay me? Hecause I am supposed to wrke diagnos*s which will help the doctor to help the patient. And I do it, I havs done it 411 the tiso since 1946. Q How would the material for this r.port aome into the pathology .taboratory2 A WdXl, if you will look down to the fifth line of the gross daaariptioAr you will find a line which says Frox.n S.ction Diagnosis in capitals. That indicates that from the oparating room on the 10th floor, one of the orderlies or tenants has carried the specimen up, plus the patiant's history to the lab, and has said to the nearest technician. Prozsn section. At that point there is one or two of the staff pathologists that week asaigned to frozen section, 8a aay be across the ba31. Ha aay be down the ha1l. Rs has to b* close. Also there is likely a rasident tht re, assigned to frosen section to learn how ,it'a done and sake his own independent diagnosea, and they will issadiatelY iook at the tfssue. Thty will cut it, bacaust what they ara going to do is to put a slic• or portion of it on a metal chuck, and it'a in an irtstrument which looks iikt a treeseri except JC1ANNE X. H4USTQH, CSR. 01PFICSAL COURT RSFOItTER, NBWARS, IQ.J.
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1 1 3 4 S 6 7 a 9 14 ls t6 t7 t8 t9 t0 ti 12 23 i* 25 SCJmoi 3 - Di rect 8627 that it opQnn at the top. co they open ttu top, get ou t the chuck. pull the tiasue ofE, very quickiy it treeses, pu t back Ins Now, it is put in the middle on a aase which i a next to a rery sharp knife and there is a wheel outside. When you turn the wbeel, it brings the knife up and gets a very thin group of sections of th tissus e f rozen f resh . One or aors of these arf picked up on other glass slides. With the heat of the finger the y are ungroaen and put through a series of sitalna, dyes, so that in three or four winutfa, you have the quick stain and than another three or four sinutes# you havs the slow er stain called fi and E, for heeatoxylin and aosin. The patholoqist unywhere or she dotsn't As soon as the is standitzq by. go anywhere. slictas are avall F3* doesn`t abie, ha or go ahe iook at the s.tides, usually with the resident and says, in tnis cas4 I don't see any cancer. Then there an tntercau to the operating coom and you press a button, you know, what room the operation tak*s piact in, and you say, Dr. Ste ichen, he happened to be or he was the chief of surgery at Lenox Hospitai.. The reason you say it is, smetiiaea the surgeon vi,iY say, the patient is awake. if the patient is awaice JdAN?M N. SOUST!]Ne CSR, QFPICYAL COURT QZPORTER, NffWARIC, N.J.
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I 2 3 5 6 7 a 9 14 L5 L6 L7 3,8 !9 tfl tl 12 13 24 as 5omm+rre - Direct 3628 nothing cumes trom patdo3ogy. Ordinarily he aaya, yes, Wboever is the pathologist saya, air, no cancer, but there is soaetAing wrong with the lymph nodQa. They have little granuioeaa. Those are for sake of inforraation and - tbey are sorietAiwg called sarcoid reactioq, a take tuberculosis. You don't grow any tubical bacilli out o# it aad we don't rNt1ly know what it 2eaAr. It siay be that the person is a certain group of white blood cells are not quite normally reacting but we are not sure. Narever, no caacer. Why does Dr, Steichen want to do it? Because most thoracic surgeons where they find cancer in lymp nodes, they stop the operation because they know there is practically no chance that tumor can be removsd 4y the surgeon. They ciose the patient and by begin giving chemoChsrapy or radiation or both. Q Do you know Or, Stetchen? A Yes. I have known hiea since he came to Lenox tiill. Q And can you tell who the resident was at the tiwe? A 'fes. Where the resident's nam+e is down at the end of the gross description because earlier in the aftermoon, say it's a morning operation, Br. pernandes' job to identify all the different parts that caee from this patient at that operation, to wake sure that they sll have the name and JOANNE M. #1fJU$TON, CSR, 0MCIAL 04i3RT R$FORTBRi HEWARXs :+t.J.
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I 2 3 4 5 S 7 8 9 10 LI 12 13 14 t9 10 21 a2 23 14 25 Somrasra - Oirect 8+b23 section nuaber, as we call it, and again witA what was firat rtceiYitd and go on to what he considered 2ast received, he -- and he did that, That is his signatare followed by the typist. Q What was Dr. gernandes' training at this tiae, do you r iinembe r? A Yes. Dr, Fsr4amdes had already had two years of anata.ic pathology residertcy. IF be wanted, which he did, he could have goae right on to take two years of clinical path and got his boards. RowQVer, he wanted one additional or three years of anatvmie pathology riesidency, which he had begun in July. So comparred to many residtnta he had aore •rparienae, and this shows in his - to war professional typa of gross description. 0 And how did he descr irse the rcumor in the gross description? A Well, if I may# i would like to point cw t that a frozen section had been dwze, that ts about line 12P and that the next frozen seation diagnosis is carcinaid of imng, Q Do you know who did the frozen seation diagnosis? A Yes. When I pick+ed up the coixeetion of slides and began to euaaine the Aiscroacopie slides, attached is what is called a rfquirtition slip, gives the name of the surgeon, JDANNE M. HQUSTV:Y. CSR, OFi+ICIAL C©UR3' RSPflRTER, N$WM.K, N.J.
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1 2 3 4 5 6 7 8 9 10 11 12 l3 14 i3 16 17 18 L9 20 21 22 23 24 Well, it starts out and that is th* "C" part for benef it t5 I of those looking in their noteoao3cs: that is raaybe ten or Stsaamarg - 3irect 8630 has a otarqes a plate stamp of the patient'a statxstics, vitality, male or feaalt, whatfver. Aui it has roaa for the clinician to writia soaatning* but almost inevitably there is nothing written thare at all in the way of cXinical informatiort, and it they have wrr#,Lten anytbing, more often than not, they have just written lung which we can tell. But anyway on the bottom of the requisition s1 ip zhtre is a l ine that says frozen section. If y.S, you check a oox and the pathologist that s4de the diagnosia writes out by hand what he said and puts his initials and that was prisent at that tims. Q 4 And what waa the frozen section diagnosis? Carcinoid of .iung. HI. Kow long have you known Or. Ioachim? I have to w- that is -- weli, excuse me, Imean I don't .liks to objeCt to My own question nr teatiuony but it is a tirst. I know you mentioned Jr. Ioachim. Q What does •FIZ" stand for? I know ]aim since I eame back from California in '63. BI is the initials of Harry Zoacbia. Q L+at m* ask you, horr in the tzuaor deacr ibed in the gross description? JOANNS $!. 3OUuTOt7r CSRr OFFICIAI. COiJRT R6POMR, :3$34J4RKr N.J.
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I 2 3 4 S ; 7 a 0 t0 11 12 13 14 13 16 17 is 19 20 21 22 23 24 25 9cx4mars - +Jirect 8631 eleven 1 inea down. A sprrci$en labeled *lung tissus• is submitted fresh consists of the entire right upper lob. of the tight lang weighing 90 grams. That is a good pro s.ctf.on. A prosector is a person who debridea and out the tissue out. Residents ar• taught to weigh solid tissues aAd he did. Then hs gives the dimensions and then this has been highlighted up hors* it says a*dialiY and posteriorly located per,iplserally there is a well circwnscr3bed firm white yellow subpleuxall saas which measures 1.8 a 2 x 1 cco. This atass is five millim.t.rs away fraw the pleura and does not retract or puclc+ r tha pleura. Q What can you ttl3 about the location nf the tumor in the rratfrial? A Wtl1, Dr. larnandss has stated that it is sadiai, close to the aid liAt and posterior, around the back. Q Would it help you to draw that? I can bring scsm over if it would -- A wrl l + it aight. A It is a right 3.ung, and we always draw as if the individual were facing us, so that would bs the right lung. S4 rsdiaYly and posteriorly you have to realist the lung goes around and ir has a round edge to fit inside of your rib. This wouid be laterally so it would be something like iM there. J4ATjNE M. FIDUSTQN, C3Z, OFFICIAL COURT R$PdRTER, NEWARRs N„J.
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1 2 3 4 3 6 7 8 9 10 11 12 13 14 L3 L6 17 18 19 20 21 22 23 24 2S Sowerx - Direct 8632 Now, iz we try to draw the same pro3action but latora.tly, then Let us aae, it would be post.riorly, medially and posteriorly and that is a little enlarged so that is a iittle enlarged. The biggest dimension is 2 cfntimeters and 2.3 centimsters so he measured, and the largest diaeension is four-fifths of an tnch. Q Says five illineters away from the pleura and does not retract or puck.r the pleura? A Yis. He in eaeasuriny this distance. This tumor has elock.*d off the circulation of air 3utwetn that and the pleura, Thar pleura is the ceilophans--like shining thin covering of most of both ltings, and it's circumscribed. That means what it says. It is aharrply dsi.arcated, circumscribed, and it does not pucxet or retract the p.leura. Zt this were an ordinsry carcinoma and it goesi that closf to the pleura, one would be surpcised if it didn't either pucker or retract the pltura, and the reason Sg a little nest of cells would be growing out in this direction just as they dight grow in other directions. Q Bow would you describe the location of the tuaar, central or peripheral? A Peripheral. Q Does that have any significance to you? A Yes, it aakss it less ii.lcgLy that it is a so-called JOANNE M. Ef0i15T0N, C3R, OPPICIAL COURT RFtPORTER, WWAR1C, N.3.
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I 2 3 4 5 6 7 a 9 LO 11 L2 13 14 15 1S 17 i$ L9 20 21 22 23 24 25 I Sawars - airact 9613 bronchiat adfnaals, because it is in the part of the iung where there art not very many bronohi and thous are so soall, they don't have any naenes as opposed to the central tumorg, so this would be a periphtrs3l lung tumor instead of a central bronchial tumor, and if Dr. Joachim is right it would be what is olten called a peripheral carcinoid. Q Dr. 8aaaoiars, does the color of this havQ any significance to you? A Yes. NQticw it is firw white ye3.lc3rr. The comrson carcinoma, the four typea of I mentioned are not ysllorr, they are either gray or taa or look like wet cement. Yallorr is interestsng just aa this stage and that is becauae the cells that form carcinoida were called y4ars ayo by one of the or ig inatars in the f itld, in Geraan. The Gsltbaat,lla, the yellow celis, so the yellow cella Make a tumar that, is yellow. Q Have you Kavitred the pathoiogy alide of tbe frozen sedtianT A Y'tu. 4 1 would like to show you whatt is raacked i?sfsncl4nts ` Joint Euhibit 3019, and ask you whether this is a blowup of a photograph you took of the pera3antnt froaen stction slide? A Yea. This is an enlarged color print of a photo micrograph or iCodachrozo that I matda of the parraanentiy-kapt frozen section. JOANNE X, F3OUSTaN, C3R, oMCIAL CoUR2 RLPOftTfiR, NUARX* N.J.
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I 2 3 4 s 6 7 a 9 l0 Ll 12 L3 !4 1.3 16 17 i8 19 20 21 22 23 24 23 3ommgrs w Jirect 8834 Q In your opinionr Dr. 9ommera, is this a fair and accurate representation of how the fro:en section looked under the microscope? R Yes. MR. 9YRRIDGBt At this tio., your Honou, I would like to offer into wideAc* Detendants' 8ichibit 3019. TNL COMtTt Any objection? N8. wAL?aR3: No objection. TtiB CGVRTa Al l r ight. In ev idersce. (Defendants' Joint 15aeiiibit 3019 was received in evidence.) Q !et me aak you, Dr, 3omers, to describe for the jury what this picture represents to a pathologist. A Yes. It to fresh tissue that was froxen. ©nce you treese cells up, break soaa of the cells, you don't gat the derta il. Secondly, you can't cut the slide as the section is rather thin as if they bad be.n run through in the routine oanner. Thirdiy, you want what is ruYlerd a rapid diagnosia, don't wa,at to oraste a couple of hourn. The patient is still in the operating caom, so you are taking artifacts, that is, the knife that cut the thin slices isn't perfectly sharp and it has torn the tissue in places and those are called artifacts, they are not part of the disease or of the body JpMMS M. HOUST4N, C3R, aFpICIAL COURT RMRTZ.R, NEiaTAA1K, N.J.
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1 2 3 4 S 6 7 a 9 t0 11 12 13 1• is ld i7 ls 19 10 21 tZ 23 24 tS Sommors - Dir+rct 5635 blfore the t,issue ia Eroaen Then tbe upper part, upper four-fiEtbs, very blue or purple, and it appears cellular and that aeans nuclei are alose together and that xn a way suggests iaomtdiately there is soaa kind of a tumor r,*cause soas are nore cellular than the norma3l tissues from which they arise. Thtn at the bottoa you see cmpressed uninvolved lungf these are th. air saas and aoeall artery. 4? Is thfre anything els• of signiticanc.* in this picture that you would point out to the jury? Ael3., you are going to try to m.ke a diagnosis. if you call up Dr. Steichtn and say thsre is a tumor and it is a cellular, he will think he better got another pathologist. You have to classify the tumor. Say swAothing diagnostic to help hiat, if you ar• going to help. xtt spite of the tearing artifacts, I think you soe what is a pushing margin# that ig, it it were one of the major types of luny canaer: a llgbter nest of cti*ls would be growing out into the lung. I don't see any. It seews to nte a pushing aRargin, evasive oargin, and the pink aargin is somexhat the sanre, growing ia a slowly growing tunor or .ay be benign. Invasive growth is one of the characteristics of all kinds of cancer by which pathologists identify them. .Iaxt, notice the pLnk, which aeparat+es the purple JOANU$ H. iiOU3TON, CSR, t?FPICYAI. COURT RMRTBR, NBYfhM, if,J.
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I 1 2 3 4 5 6 7 t ! Lif tl L2 t3 14 Ls L6 17 La L9 2o 71 22 23 24 25 5ommrra -r)iract SS36 ~tasrt~tg. Now, they _.- tumor aells, purple masses of the tumor cells ar• farming soesething. Not just a Rass of cells, This in called organoid pattern. We don't know wh#t it is trying to do, but it achiev*s 90" kind of organization. And it you look at som" of tbe neatsr you s!t that the cella at the edges of the tuaor and against the pink connective tissues are stained a little darker. And ke know for years that anywhere in the body and there are caraitloids elsewhere in th• lung, tbat•s on* of the features and I don't know for sura we understand it. So at once we begin to think looks like a carcinoid. Nor, if you 1.ook at everything, you shouldn't just look at this under the ,aicroscope but look at ev.rything. i look at it twice. You look back at the gross, if you have any question. Then at least I say, we1Lp it's got pushy margin, organoid structur., the island stain a little darker around their edges and looks to se like a carcinoid. There are so.e other things. I think at that point you'aa got to a make a d+Mcl,sion. Uoasn't look like squamous carcinoma, adanocarcinomas, saail ceitl undifferenttated, doesn't look like any of the rare tumors. So the oparation is still going on. Ne can't iceep JOANNE M. H©USTON• CSA, ©FF2CIAL COURT REpoRTER, NEWARX, N.J.
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I 2 3 4 5 6 7 8 9 10 11 12 ~ i3 14 Lg 16 17 lm 19 20 21 12 23 24 23 Sommers - airect 8637 the surgeon waiting around while we go and look in textbooks. t,M` ra supposed to know this stuff, Dr. Zoachim, exparianoed patholoqist, carcinaid. Q What was Dr. Ioachin's experionce with Lung pathology in 1981? A Kall, he wasn't just an av.raqe pathoioqist. In 2977, when the International Acades.y of Pathology tud what is called a long coursa that lasts all day, arronqst all of the m.nbers, about 4.000r rie was the one that was picked to yiv8 a lectur• on now aspecta, never aspects of lung canc.r, which he did. I was in the sudisnce. There wer• about 1440 pathologists a nd that was publish ed as a monograph called the lu ng in t he next year, 1978. 8e's a.on intarested an d don• research on lung cancers, inc2uding using tissue culture for many years. Q Was Dr. I oac bia'e diagno sis of carcinoid of the lung reasonable? A Yes. Civen the i imiltations of the tozhnique, the thicker sectiont of the time conatraints and of wda t he saw. I beliov• it was r.asona6le, Q Who aade the diaqnosl.s on the final pathologic slidea, spscl.mtirn? A It was ay rogponsibil.ity. Q I'd lilua to show you soaethingr just a ainette, Dr. Saumers. JORDtUS M. fIOtTSTOt#" C5RO OPFICIAi. COURT REPORTSRt NBWAMs N.3,
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1 2 3 4 S 6 7 I 9 to 11 i2 13 14 15 Lb 17 ts t9 20 21 12 23 24 23 Socusrs - Direct 8639 This is defendanta joint exhibit 3023. Lot o+e ask you, Dr. 8oamers, whether this is a blowup of a photograph you took of the pernan.nt slides, lung tumor in August of 13817 A 2t's aA enlarg*d color print of a photoaarttagraph that I took af a portion of the tuaor, so-called Rodachsose. Q 11ad is this a fair and aaaurate represeptation of the slids tros where you took the photograpb? A It reprer.nta fairly tht portion of the tumor pushiRg: up against the bronchus. AlR. BIRRIDGRi I'd like to offer exhibit 3023 in evidence. THg CC?URT& Ks. Wa3ter$? KB. GiALTEA9t No objection. TNE CO£1RTt In evidence. tSxhibit 3023 is marked in evidonce.? Q Dr, Si4ra+aors, couid you oxpiain to the jury what thLs photograph represents? A Yo3. U*rt is the lu®en or airway of this bronchus, thio sraall bronchus, bwt you can't tell that. 9econdly, here is the covering epith.3iwz. lvow, it in a little torn and either by the knife of Dr. aernand.z or in -- by the knife of the h3.stotochnologist cutting the very thin alice out of the psraftn lung. JOANMB K. 8OU3Tt1N, CJR, OPPICIAL COURT REPC)RTBR, N3WARK. N.J.
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1 2 3 4 5 S 7 a 9 10 11 12 13 14 13 16 17 1k 19 20 21 22 23 24 25 Somz*rs - Diract 3630 8oweve3r* where the epithelieta rceimins, it has the nora.ai appearance of respiratory Qpithe3ium, you ".n evea ss tht little hairs on the burface, rbich are calied cS.Iiaa They beat and sweep the maaou* up towards the back of the throat where we without knowing it, swaYlow it. So I don't stie any le*ioa or any pathologic abnormality of the bronchial Mpitharliuus. Sor• rre have a section. N.re it's cut aleaa, hers at an anglt. This is artifact, this in my opinion is artifact of the knif.# either of the prQsactor or of the histot.ch. Q Ar. Sosntrs, does this photograph havt anything to do rrith the stateIDent in your report that the tumor does not rasrqs with the bronchial +rpitheliuaT A xee, that's right. I say this haw L-ooen highlighted. it'a next to the last highlighting and says at the p'eriphe,ry« bronchial xai2 an acini are invader3, So it ref.rs to that and reters to what you askeci, that the tumor doe* not :oerge with the bronchial epitheiius. Q Tret me go back a little. What DOES the term 'low aagnifications aean7 A well, most microscopes have four different iEns.s at the bottaa. The lowest one is magn,ififd four times and nost eye pieces now are ten times. 3o low powec would be four times JOAMM .4. HQtJSTQN, CSR, OFFICIAL COtTRT R8FC3RTCR, NSWARiC, Ai.J.
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Hommers - Direct 8640 I 2 3 4 S i 7 $ 9 LQ Li 12 13 14 21 22 23 24 25 ten, 40 +Aagnification. Alow, this, of course, is mstcb larger. In order to figure out what this magnification is you have to take that by two Rodaahrwmt and zuasuc• it so many times across and that would give you thf actual magnif icaCion. Q So can you explain anything about the colors that bs ss• in this parti.aular picture? A Yes. L.enox dtll Hospital uses a stain on surgical material that is unlike that used in most hospitals in the country and it involves h.satoxylin, that's blue or purple for nuclei. it includes fioccino and that is cosey pink for cytoplasm and f oz: some parts of the tuwor ceils and blood vesiael walls and the yeiiow is aaffronine and that's the sama stuf f to color rice yellow, if you put aatfronine in rice. We have what is cal2esl tr.ichcoau, tYtree colors, blue purulrp rosey pink and yellow. And t.h* yel1osw is for collagen or fibrous connectivt tissue and you seo it forms a band beneath the spi:tbeiium between th. surfaa*, epithe2iw and the tumor. Q Is there anything else you would like to point out? A well, L don't wish to take any more tiww, except to point out, knows how the stroae either oranqf, pink or yell.ow, diviaes the tvMor into rt*sts, cords or somstimeas cai.led trabeculae and once in awhil• called tubules and JOJhNNE M. iiOtlSTONr CSRY OFFICIAL COURT REFORTER, NENARKr N.J.
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I 2 3 4 5 6 I a 9 10 11 12 13 14 is 20 21 22 23 24 25 SoaAiersi - 3irect 8641 that's an organoid pattern. fl And what is the significanca ot an organoid pattern? A N.li, the tumor is diff*reAtiated enough to be trying to build swathing and at low power you can't be sura, but it's just not a mass of calls. I think maybe tb.ri is one other thing L rould say. That is, if 23r. IOachia has mactt a oistake thon. and it's an ordinary type of careiAoo., it will have rat+ A its way out in the luaan. Carcinoaas don't respect the bronchiai lining layers the way this one shows. Q What carcinomas are you referring to vh.4 you aake that stat.wntT . A Squasous call, adanocarcinow; sfaaii cell carcino0a, largt c.ll undilfer.ntiatsd. Q Dr. Somaers, Let a* show you exhibit 3fl2x, defense joint exhibit and ask you whether this is a blowup of a photomicroqraph which you took of Mrs. Cipoxlons's turour from. the August, 1981 slides? A Ya, it is an enlargem*nt of a color photometragrapb or iodachromo that I took of the part of the 1961 tumor. Q is this a fair and accurate rapresfAtatf.oq of what you saw under tba aicroscope when you took tha picture? A And a part of the tuaor, yes. HR. SIRRYDGB: At this time I would lika to offer exhibit 3022 in widence. JOANNE N. HOUS?aN, CSR, 4FPrCIAL COURT REM)RTBR, N8WARR, N.J.
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Smaers » Qirect 9642 I 2 3 4 5 6 7 8 9 to 13 16 17 18 19 20 21 22 23 24 25 TPlR CDi7&T s Any ob3 ec t i on? M3. KALTERSt I'm a litt3.• concarntd about the size of these exhibits. Do you think that the d.fendants saYba could introduce the ph4toqrapbs? They probabay have pbotographs. I don't see how the jury caa us• thes• in the Jury roam, they'ra so iiugf. TgB COURTs WaI i - liR. SIRRYDdss I'11 ttli you how we caa r.solve that. MS, wALTRRSe I would rather not have the exhibits coming in at this size. THa CoUR'P: z'13 ovarruie t33e objection and permit it to bs recoived. iie can decide vitether thsre is some way the jury can r+eceiv* smaller varsions, but I'll ptrrait that to be received. (3022 .im Aarkod in avi3ence. } Q Dr, Somm.rs, in viewing this particular txhibi,t, couid you •xplain to the jury what you think is significant about it? A W.r11, there are a couple of thingi.- Raasab»r, the previous onas was low eagniticatfon ti4as 40r then blown up into the print. This one says madium aaqnification. The next magnification on tae av.rsge sicroscops I JOANNP+ H. H4U$T©Pt, CSR, OFFICIAL CQUR3' RL'PORT$RO N8WAR.~.Cr N.J.
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Soaators - airect 9643 1 2 3 4 S 6 7 a 9 10 11 12 13 1; is 16 17 18 will be about 1fl0, 125 tLuc• s and then the ont beyond that about 254 and the highest ona yon can got witbout using oil eraarsion is about 400. This Aediuss aaqnification appeara to be about 200. MQ+r, h.rs is the edge of the twwr. Rsrr is the stro.a, which soparates it into bundl.s. ltowe. at the soasrhat higher porer you aan ses eeittain features that Waybe rEren't clear before, One of thera iQ -- notice these ceils are crord*d up against each other in this part of the twsor and her* and then in sasm other places, hsr* and that is called palisadinq, It's supposed to r*semble a picket fence or canoes lined up in a row. The cells crowd each otber. That's a sign of soas kind of difterentlation. Then s*condly, notice that tb.*re are a bunch of hoi,es in the tumor in this part. Saao of thsm are just blood vessels and the blood hass run out so they appear easpty, . Others contain aat.rial which is stringy and looks 25 rather mucoid, Noa, this is not degeneration because the cells lino up around the edge are healthy and so tbis is foraing cysts or tubules soastirae called miccocysts and that was a part of my description. Realise, I have to look at everything. I can't just focus on one part. t have to look at everything often JOAi+iNB .4. HOUST©N,t CSR, OPFICI7lL. COURT RXPOATER, 338WARB[, N.J.
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I 2 3 4 5 G 7 a 9 1Q Li 12 13 14 15 1s 17 19 19 !o 21 12 23 24 25 r7omers - LIiroLir' 9{?4$ under both low and high aagnif icat ion. So I say, a few places have a qlandular or aiaroaystio arranq+ ment. Another fora of differentiation. w411, that' axaanipqful . I tel3l you why. I already think there ia, after view, of carainoid and now I lind that quite a few wrotnoids hav been recorded to have this aicroaystia appearance. There isn't any other kind of lung tuoor, benign or maliqnant, that I know of, that has this bit of a Swiss Ch.eso to,raati4n, which doesn't involve deqeneration, It's a aaAiftstation of $ome kind of dif f©rentiation. 9o I take it as another nwtrker Eor some type of pulmonary carainoid. Q Okay. A I should uay, the sl3.de doesn't have the sarue quality of aolors, zt's a little p,ale. After aWhile, no matter hcnr much care you took, oxygen and acida within the aiidQS is cov.red with a cover siip will begin to cause a little fadinq of atain, and also I don't know for aur• whether -- wden it was originally atai,nadr it was a fresh batch of stain or saybt it had been used for s.v.ral days. Q How long does a laboratory usually use a batch of stain? A Well, these stains are expenvive and hospitals now have to worry about expenditure in evfrything, so usually a week. Q Let ms show you one last exhibit, Dr. Sommers. JOJNNE X. t3t?USTON, CSR, Orrrczaw covRr RspORsM NMRR, N.J.
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1 2 3 4 3 6 7 8 0 10 11 12 13 Z4 LS 16 L7 Le 19 20 21 22 23 24 25 5om! ra - 3i r Q ct - 8645 1981 tumor. This ist defendants' exhibir 3021 and I'li ask you, Dr. Sownrs, whether this is a blowup of a photomicrograph that you took of the 1981 tumor? A Yes. It's an enlargement of tifte godacSrQme that I took and it says high magniflcatton, so that nsans it'a about 400 tiaes further enlar ed . g 0 And what ar • the significant things that you would iike to tell the jury about this particular photograph? Well now up to this , , p Let rae back off and say, doctor, is this photograph a fair and accurate representation of the siid e as you viewed it in the 1981 tumor? A Yes, I consider i t so. MR. SIRRIP?GE t I'd iike to offer in avidunce 3021. THE COURTs Any objection? t48. wALTBRS: No objection. THE COtIRT& 1111 ;~erait it to be receivoJ. lMxhibit 30t2]1 is }mriced in evidence,) A Now, recall th at up to this level of e7tamlnatton. the or iginal diagnosis of c arcinoid of the iunq stili holds. Dr. Ioachia made the diagnosis with a less refined technique on thick er se ctions, but now with bettar sections and better cellular detail and better fixation, fxeexing isn't reslly a way to f ix tissue, you need to use a solutiOM and in Lenoac #iii2l we us e a ye3low fluid cailed Souin's, J°JASNZ M. .KOUSTOhir C°.3Rr OPPIGIA£, COURT RZPURTCR, NVARK. N.J.
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5cxmarr$ - Qirect 8546 I 2 3 4 5 6 7 a 9 10 L1 12 13 14 l.5 16 17 is 19 20 21 22 23 t# 23 which has picric acid b+tcauae i.t'a an exce.tient prccserver of cell detail, came stain an previcw$ly. Q Let sae stop you. You used the terrms 'thici¢• and 'fixation." Sow is that used in the pathology iib©ratory? You sas, to fix tissue is to drop it into something, hn ordinary lizative is 3iqnid and in sany laboratories it's a diluti solution of gas called formaldehyde. Tar surgical pathology what aart uae thts yellow colored solution, which is largely picric acid because it provides, we think, superior preservat.ion of cell dsfiail. Nowr hera's a high power and her.'s, in my opinion, where you have to look at it more in detail and make sone distinction*. In the first pla<:e, ar• those c4lls uniform, da they look as though they caae from the same factor? ws1l, no, they're not. 3ome of the nuclei are twice as big as the other nuclei. Snme of the nuclei are round, oval, sons are perhaps neither quite round or oval. So they vary, That ia called cytologic atypia. 3acondly, what kind of calls ars they? Ar• they res].ly opithelial cells or could they been soae other form of cells? The way they foria tba masses and the way they locally palisade is a strong indicator they're spith#liuia. Algo notice that they havt cytopias:a. That'a the JOANNE M. HOU8TQlY, CSR, •JAP'ZCIAL COURT REPORTER, a2WARX, N.J.
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30mmera - 11tect 8647 1 2 3 4 5 6 7 a 9 LO tl L3 L3 L4 t3 l5 t? t8 L9 t0 11 12 13 24 part of the coil arouna the nuc3.eu3. Art.i that 4swes apink btckqrou:u3 to tiie carlluiar s,asaej. The shape of the eeils where they ere cwt appropriately aQ"a to ie not equare bat in =ay opinion, coi inr3inal, that ia c3S,2=£erent, not qusto squarod aff or not quite recC.anyular ehape. Thirdly, the nuclei are too biq for the cail. There ie no norssal coil spitheliai coil anywhere that has suab 4ig nuclsx. '1'hat'u calleci nuolear cyrdpiscam, another marker of aoma kind of maliqnarit or invesive ntop.i rna. Nwr, itt's 1oaK at tne aucziet. The nualesi are pala arh3 pala nuclei are aharactaristic oif carcrnoid and atypzr:ai carainois, but they're not a c"ractax L.,st.lc of the E(juj: ma jor types, wi th the axc$lat ion of ierge ca.Ll un3ifferaatiateJ. And ,2usti oy .looking at thaae, k>erhaps ,+ou won't knorr, theae atra no;: helt the aixe ot the lac;;+a coil ut' iarge co2,L carclno". So thtn we have u cytolo9icaliy atypi+:a.i +rpithetisL tuoor with ;rink cytoplaaw, rose colored cytopiasm and it kiarx two iarye 4uciei sAd it haa proMirarit Aucli1, Oitay. Those are ail featurea ol ths •typical or malignant cW1rci.noid. Then tbQ next thing we do, are wral:~ed to ao, ja to look foc mitoaia. We a11 yreW tO the 3iZm w* are Uy 2s I Mitosis. ~lito4i% a.tons j4n't muan canear or any uthetg Jf3111VNu M. !jUU31"J:3, CmR, 3. `rICTAL COURT A.:.PUR'PBR, Na=rZARJK, :v.J.
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sO2MOrJ - i)irgct 3633 I 2 3 4 5 6 7 a 9 10 ll L2 13 14 t5 l5 17 1a 19 20 21 22 13 24 23 dijoase u4t the euie &:>uut tihe tyPIcatL carct€tr3id xs von't s.o a singif mxtouifs. You :zee one you better thinking of something eLse. you start So AQre we see c:el ia that are in the procesa ot dividing, thsse ars aiaost daugbtir eei ls, rbiess ace the 3itt1• Chriatmas tree like appeacing ceiis, purple, ric2l app+tarance aad tbtrt ar* at least four •asiiy identifiable mitasts. So it can't :* an ordinacy carcinoid. The other alternati;re, as ve g.t cloae to tne diagAUSiis, it muat be tsjeEn atypical or ad-cali4d Mallgnazjt carcinotd. Now, I'a aPattsoiagiyt and T`w supposed to ba up to date and ii t aay this is invaaivo bronchiai adsnoiaa, peopia viil wonctsr it I have aphanayrapt) or a running "ax:i un +a;{ car.- You can't do that to other patbc+i"Eets. Xou have to ba up to c3ate. So what is the up to date tarraY It' i netaroendocrina ~:arcinamai3. 4hen r'm talking to a surqaon, these ar.a vezy rins surgeons but he doesn't read pathoLogy .Litwratu:e, hr w3y n*ver have hoard the ghrasa nauro+endexsrine carcS.Aom.a. You havs to give hia a cltar m*ssage without any doubt he aiii 4nslerstand. And the clear zwgsaqr that he wiii certainiy unclsrst,and, beQaus+t he's an exper ienc+Qet surgeon. La atypa.ca; carcinoid or raltgnant c:urcinoid. t psovtde him that !assuaj$. JrJR14tIS ?t. UOi1a`TO'N, C:3i1, OMCiAi, COURT R!,'?ORT'°.Rf 2MA€t:{, 11.:}.
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Sw"erj - Diz eLt 4640 I Q or. Sjlml:tor:i, .rnAt .loox it mean to you witen you s1gn you: 2 3 4 S 6 7 a 9 10 L3. L.2 t3 L4 L5 Lf L7 L8 L9 xo 21 12 23 14 23 "as rtn a repart7 A W*Iit it' s i3y profeusipn, ik's cay apecialty, it' aay joa, Lt'a wi life for 40 years. I'm gaing to do the begt job Y can. I'M not qoiny to sign ay name to stomath3ng L don't telieve, I don't esars. Seconctiy. I'm trying to toip the aury9on help the patl,ento so Z'm aakxny the most accurate 3iaynosla 'E cnn 30 ha c:an do what ha 9*eia to b* r xght. Nwaier thr*ep tne reputation of the iiospita3 and the iaaoratory and our pathoiogy group ans# sayseif haa ta ae based on the accuracy of the aarvice we give. ;Utd 00 it'a alL those t.hRn,4a togather. ~ at. 5«mmer$, it inJiaata3 on the ceport 8/36 and iG tnat a different data than taa avrgery? A Yes. Not ice that the date of apvLat ioct i.3 Six cta;rS befo-e thv dat+e of the rraporc. Iaii, Lhrr r+rason for tnat ia i f you ioak just above the diagno$is: and just at thE end of psragcapn EC or the whole paragraph a of Dr. Perna.ndea' qrosa dey,cription you' il, see that what was received last or +i*acxi3>ed last was a pieco of the cartilage part of the lung. You can't cut into the a1las of tho thorax unl*aa you cutt throug73 either bone or cartilage or both. So tnat naa to 00 cieca3.cif ie3. An;i that meanw iv. hau to be puC i.n J'OAUPd£ M. a{?td3'2'0;N• C`aRr Ot`:'TCLAL COURT Rf'aPtJRVERr ZiLIAR£'is ii.J.
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1 2 3 4 5 6 7 0 9 tU lI l2 « 14 l3 l6 l7 la l9 20 11 22 13 24 SOMMOt'S - DLrect 3650 auii saiutLon tor tilraa or eour days. iC you try to Put that through just in Acwin's ani then the r.schnivxan trio3 to out it the next day, she vili nick her icnite and shs wiL1 3ae vary angry iscciua* nor 3cn.iff is ber 1.iveiAhooc# ahd it has to be atnt rrff to the factory now. So three or four 3ayS iatar, in thia acid aolution that catcium is dssolvsd, now it will cut and it wili be sott •nouqh to cut. ?hat' a tbs reason I beLiRv• vhy it was sign" uix daya -- signec3 out 3ix days latar. 0 shFhat's the policy at Lenox :3iit aLwut that .i.nianiny the l4nal c'liagnasia? A Weil, tv* ru.ie ia that we will not examine or diainuao a fi.Mwe until iIi the aLiLiSa arYt a'7ailaols. ".'.'r1Qre is r1oC1e ot this piecam.ai $ta££. You gat in tazribi.o traAole. The inst speclmen zai.t;&L aither ahou aomathiAg cosplete~.y diftorent or addrtianai. Q Or. Sa:amrra, cari you give t:ie jury any ir3ea 09 hcs,a caxea you would riavt diagnosed on uay Auguat 25, 1981,. :3eaxdes tbirc? A I think I would &ave done ten or a dozen. ~aa ny Wtat we do is not allowesi, that ynu pick out which aaase yau'ra going to Jiaqnoeet. You qo in a roace and whatevet ia raady: pick it up and take it to the sicroscop* and 3tart wordsing. They would be eiacelianaoua thinga. I t5 1 knorr they incLuded bone *i>a-aimena that had to be decatcified JUAl1,N,E' .+i. HD37.~'iTON, CSR.- OFP'LCIAL CQU3`#' RM.)R'I"dFt, U214AR3'ss N,J.
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I 2 3 4 5 6 7 i 9 tQ lI l2 t3 t4 l3 t6 l7 !8 l9 to 11 12 d3 U I5 3o0AaXs » Dire~:t 8651 on differr.nt patientat. Q what did you know about Ars. Gipoiione wn.n you dia4naarrd this tawr? A i+lelY, I didn't know anything about her, except aithou9h I didn't look at it. I could have agoertafntd ber history nu.aber, rhich wouldn't bav• ar.ant aAythinq, har ward, which wouldn't have helped a.a. I already kne+r what day it raa and the na" of the surqtona. But other than that, I didn't know anything about her. Q Thabk you, 3Jr. SaaEmera. You can resume your seat norr. A All right. 0 Did you use the technique of e%Qctron aicroscopy in 1981 when yoU dtaqnaaeci tae tuAor? A mot in 'S1 on this tumor, no. ,~ why not? A El+ectroA iticroscopy is ujod in our co,mpitial for difficult caaes to resolve wtz*3ra there ia asaccana. Connectivo tiasu# or carcinoaa or maybe a avlano;aa. ror research if somebody is coliecting a yroup of cassa, you want to study tham witu electron aa.icroscopy. But ainc* it is expensive and diffiault# unless we feel it would contrl.bute to the caxe, or we ars using it as part ot the reaeaxch project, the answer ia Wa don't do kt. Q Dr. Som+ars, do you know vhat happenef to Kra. Ctpailone ln gay of ' 82? io&vmz M. HOUST[?U> CSR, OFFICIAL CC}JRT REP47RTEi2. W314ARR, h. J.
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2 2 3 4 5 6 7 a 0 l4 ll L2 13 L4 l5 ls l7 13 l9 to 11 tZ 13 14 3s 3d046rs - 0irsat 3652 I A Yas. Ay unzieratanJing :3 cnat she #43 uotter, felt better for  wrhlle, and then in 1382 xne came Dack to see 3]r. Sttichen at Grnox Hi2i, becaust there had btren problem,r with her breathinq and witti the x-ray wk the right aida Uf h.c ch4at and somt s tom8 m y . p Q Do you know +rhat proaedure was done at that tiaet A Weii, at that tia*, she had anotbar bronchaaaopy. 0 111ld how did that relate to the patholoyy dspartmoont? A well+ that broaehoscvpy waa autaitted to the iaboratocy for dia nosis g . Q Dr. Soa"rs, iet wa aborr you orhmt i,r aarkQtl defense Sxhibit 2607. The actual a*riicai r*cflrd is Qlafnttff's Exhi.bit 5436. It i.a aiso in thM aury nestart~aokv th4 ncxt a a p g . KFt. SxaRIDCEs Wou3.d it be a ii ri4ht 19 they turn to it? TtiL Cf7UR`Pz Jury Aay turn t4 page S. Q Over on the iQft-hand aida hare, flr. Sommers t ia this the Cfport that was filled out by the pathology departaant at Lenox Ri117 A The dat*, +rctua3ly here sips 3/I3/82. That would be Hay, and giv.u a nuaRbar, and the sca,ae naaee, and suxgeoftr and yroa4 apPeaC+anc* i3 stated to Lse Labeled rrhen it camt ta thx lab, biopsy in the bronchial rtqton, y*a. 0 WUO was the +iiaynoai.ng pat3zol:,q#.at on it? J'Ol1,VNE Xw fiOUSTQN, CgR, OP'FrCiAF. CODT~' StSFORTER/ ULUAaM! tt..T.
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1 2 3 4 5 6 7 a 9 to tl l2 L3 1.4 . tS l6 17 k#3 L9 to 11 12 13 14 15 3C1m~,trsd - NrQct 3I5a3 A Yes. Th+e report ij si4nad for 3c. Ralph 4. :3nyrier. 0 What do you mean signed for him? A if you sea, there is aslssh followed by the inittals H.R. That is tiirxy Rotterdara, another staff pathology obvLously or. Snyd.r was out of town or out of the iab, and t»for• ht would leiver he would say to Heide, •Would you sign my ceports for s* ?' And that is perftc=iy proper. 0 why do reports have to be aigAad? A They have no validity eitber medical or aedically, legally or any other way, and it to a requirem.nt if we ar+e going to bavt an approved laboratory Por teaching rQsidsnta. 0 wbat wasa De. snyder's +iiagndsis of tne bXoPgy? A First* description, and you read aqd it is highiighted and enlarged, you raacf tha dxaynosiac. Smal.t c:oll Caic:inu4a, oat call type, c.cur rent in broru:hua. Q Any 3ndicaati4n in the recQrd that other people were conuulted on tha JiaVaa4is? a €3n the 3sottora *t the ssae report# vhEc3 is agatn hiybliqhted and tnlarged, there is a4tatsment that this twoor wai also ssar+intd in consu.itation by Dr. Yoachia anci RQtterdam who ia+ttievt that at present: biopsy is +nttrexy aimllar to the tumflr diagnoa+r-d in 1901 and gives the surg&cal niuabsr of the prsvious lung reaection. They fs.i tnar the present morphology is consistent JOA:aN..~ ?!. SOt3S'I'OtJ. CSR. ©-7FIC,CAi. CDt1R`t' R$F4R3'ERr CiEWAM, N..i.
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1 2 3 4 3 6 7 a 9 10 L1 i,2 t3 t4 is LG l7 lS t9 10 21 22 :3 34 3owtaaru- Direct 9651 with tha trariler diagnosia of malignant carcinoiU tu30r. Below that there are two handwritten aignatures and this typed business ia yarenthes3.s isn't acruaily vi$fbla on the teports but I=fccignize an U read sCa H. Ioachim and d. Rotterdam, and then tha initia lst again are gart.ly oblitaratad, but they are U,R. That is Htida Rottsrdain. 'Yhat is her wr iti rr Q Art you tami3, 9. iar with rcue abiiity of Dr. Snyder. Dr. IopcMim and Ar. tt 4ttord*m aa s urgiuai patnoioqiata? A They ace all patholdgiats. axperiersced, competent surgical Q Did tnere cdms a ta.mo whsa you actually or strike it lot oe reptzrabe it. ' S iZ ? ld yoit ri4V.ltiel the fJ.liiq3y at ti3ilf ti:3* toor J:.. Giw33$t L $ A Yes. Or, Steschan as+te.i i40 to 'L©ok 8t the slidars aj3j give bi4 a y 0,?inicsn. Q And wtt at va3 your o;~s.nton? A ,7al.i, my opinion waa that the bronchoacopyr aaali apecxman sbovad the sawe kind of tumot as was present in tha up*cinen of thQ r iyht upper .ioba removed !n 1901 and that the diagnosis again was &typical or raaclignant carcinoid if you are 3Lmn;cinq with the reapoaaibia sur9s0n. Q Waa titere aJiefersnc• ot opirsion in the pathol.ogy 13 J*dvpartaertt at Garirox 11111 0vet' this biopay? J'a11.'?NE :3. 9OtJ.ST"f.,3' Ni t:SiY r OFFf C: I M. {'Oi3IT 3i1:POR?.'SIRfi SMMU, :3.j.
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1 2 3 4 S 6 7 8 3 1© tI t2 ,'r'ot3I''$Cs - DiYoCL ar.55 A :1anifatatiy tncae af U3 'Jie.ziroyeu it wQu1%1 te rtio dn4d tuzor 4s '6I. i3c. 3nyder tnoughti it waa a different type Qf cancer. AR. aIRRIdt;Et ;ftuici f t t)* aguoe3 tiare for the aftornoan break? TtiB Cai3Rxs Yea, ft wili taike our brsek and roa"e at ten of forsr. AIL r isa for taQ jury, piease. (RQCS au taken.) xPtB CLZRKt .A.L1 ri.se. (The to1.Iowing takes p3,ac:e in the PresOnee a[ thg Jury.) ' l3 I 'CR8 COURis Pxea,e oa sctatad. i4 15 ts t7 ta l9 20 :1 33 :3 14 7bPUXT 9XAMzraATrOU cOWrNUes 3Y AR. SMtInC:E: ~ .a youc &iuruv:}ons on? Gouci. BePoce we diaazuas tn* biopsy repQrt in taorae d+etaeil, ar. 3omuarrs, I'd iike to call your attentian to une gag* in the jury nnteoaox. 00 you have one of those noteacso#cs? And i a:.Uo woui.d iiks to ;3lrect the Jucy bacx to page aeven -- :'.u aorry. ~4,Aje Aix. ;g ,7OA:al:ia .'I. d30f.ISTJ:i, oerlCltlL C.C3:fR'}.' ;Ig:PO,fitT?:Rs tiE£dTiRlie :I.J.
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1 2 3 5 6 7 a 9 lfl li L2 30"Qra - Direct 665& TH& Ct7tlRTz All c iqbt. t~ 09. 5oMN+rrs, do you aaa tb• blue aighl#ghted uatacrial on the top part of tht paga? A Yes. Q "nissaction of the uoncht rereals a small bronchus 10ading straigbt into the mass." 3ihoat descr iption would that have been? Fornandexa ~ What's your interpretation of that description? A That since he has first descr ibed a peripherai t,unoc in the blue hiyhli.ghtsd part just aDort that# that tho 4rorrchus he refars to is vhat h• aays it is, a small bronchus. 13 0 L L4 l5 l8 L7 l3 19 10 11 12 13 14 Is Would it have a name? A t7a. That brQnchus that uizo would L-a tcto soa1Il to have a spacif i.c name. !#8tr SIRRIDGEs Could yoa flip back to page eigh#c? Q T' m going to ask you to -.ome c3otin and g oak at daf+en3e exhib.it 3DA0, Dr. Jowwrs. I rrill ask you whether this is a n.loaiup of 4 photumiccoqraph that you took of the b.lapsy in tb* 1982 slide? A Yes* it is an enlarged colot print of a color photomttragraph ar RodachroaN that I took. p is it a fair and accurate representation of the biopsy siide in your opinion? JOA.NNE M. i3?USTON, CM. 0FSY: ZAL COURT RZPaR'1'ER. MARK: U.J.
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Sommers - Oirect 36S7 1 2 3 4 5 6 7 8 9 !4 ll l2 0 l4 l5 16 17 La i9 10 tl 13 33 14 A Yea, it ia, guut of the centril 4)art of zhe =ait bLupay. Horr, !t eays her• that it was cut into 18 sections. That meean& that there were what ar4 cal.ted so3riaiut iittle Pttcea ©f tirtaua Jotted slong the same sl fcia, MR. 52RRlrities S' d 1 ike to ©ffer 3i?38 in Qvidenca. TnC COURTs Any objacstion? MS. WALTSRB t No ab j eat i.on. THU Ct1UitTs Ln ev:dence. tEshibtt 3018 is aarktJ in evidence. ? ~ Let xe ask you first. 3octtir, vy gayinq why is thsra ao rauch :3aricnesa in the materixil in tttis aection of the pictura? A There is wery tieaviiy stained c+ti in are notabay elonqatad in aany caae3 and in other caseA they are sc d4rk that we auat conclude ta.y are dearl. Q 'Row, now was tFAlra upacimea cettrrevrsd Prou 4ra. or riow was it vbtainecl? A Weii, the ;>ronchialacQpe z$ iLk• A teleacope witn -- you can go •round t1he bend and on the- end there ia a cutting device and you out off or pinch off a bit of tiaeua, ecaes out anc.i the Yndividuai - and Z think it was Dr. Stichien thSac time Jeops it into a twttle of f ixstive wbicn is 3auin's, thAt ieii.vw c©L0rad f iui:3. 9. 1 0 'Daea tryat oracedars ever cause Prt4biawti f4r the aurgica:; .JUA:tUF 3. ItJU3TOU, i5ft, OFF'ICSAL w'}U?T NT-dA."tX , :'t.J.
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I 2 3 4 5 i 7 a 9 l4 11 E2 13 li 15 15 17 l9 19 to 11 12 x3 14 25 gammars - Dir4ct Use pathoiogist? A w.13. -f- 4 in trrma of ths condition of the tissn+r? A Wel.lr it d " nda on partly what the aond#.tion of the tisaue was before the biopsy was taken. Partly dapends upon th. skill and *xperitaat of the indiriduai who took it and partly it way b* a isattoc of chaince# hcw vell preserved or poariy preserved the specimen is. This kind of thing is a5ually cailec3 a Droncboscopic biopsy cruah efftct. 0 Could you explain again how that's aauaed by the proceJure? A Weli' you aincts off the rissue has to be hs3d in aaa411 cup like dwiwcs, which has a cutting vdge an.l ax it's cut afl .it's necessarily pinchsd to pull it ioose. And if tne tissue is either suecepti,o.l* to being da;aeged by the zqaoatinq or rP t3y ahancar or acuoe otiler reason it's dqueezeu hsrder than it might ae& then you got crusA artifacC. 0 Can you a.ak+e a d1aynoais baaad soi+tly on crush artifact? A I Can't, no,. 0 Could you •xplain to the jury what you f+se3 is significant about the biopsy fros this picturt? A Yes, tt's my nei ief t4at you can't diagnoae at ciajsify aelis that are dead 4ben they're rsaoved or that urt so altered by tnar ~rbcerAure remavai that you cnn't taill what 3C?ANNE k. WUSTONi :sap +?Pr:°:IAL tiOt)R'I` RSPOXTt:R* +1E'i9Aitxr ~.j.
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x 2 3 4 5 6 7 3 9 LO ll l2 l3 14 l3 lG 0 L8 t9 20 11 12 13 14 is 9"Aars - t}tract J653 Chey rxre. 'Kou cdiA'L• teii v'-:ether they're +apithellai, fibecgirsa -- x'ra at a losa to id*ntity cells alnng there with a few •xc+rptioas. So it's my belief that you should identi.fy tiasuus and diaqnoa• thea by tho cells that are alive when they vsrs raeved and they'rar reasonably wl11 or perhaps very reli, if rre' c• lrscky praserv.d. a. So x draw your attention to thfse ce1ls here in the misidle. And tblrs weren't maay of th.m. And since I've counted cells in different orqans for a lony timt, I counted what I thought ver• the lire ca3.Is. c?n each aectfon i could find 90 aella. Now, L'm not goinq to uak. rf3ra diagnmsra, I'm ricst goiog to caami.t nayselt to 90 ce31s, there is just not enough coi ls. 50 we lask at the celis that sre alive anJ deacr ii)o them to you, They are, in my opinion, colin9*s1, I think there ia no qutstion t:1at tbey hrvt pink cytopla" because where they're appropx iatstly cut# ytiu can actua23y gr* rc44 light pink 4round the outsidt of the nuc.iei. Seconrili+r the nuclei are enlarged. For a ceii that gixe that nucleus is just too big. You have h.nrci that b.fore, that's cal3.ed nuclear aytop3assa dispsofersion or sometims N/C ratio. Notica th• nuolei, those olua purple dots in Lie aield.is of the nuciei of many of the a+e31 Prasecved cali.s. Thosa were the siam+ critEeria that I c3escri?aeJ- to you under JpA2tUB H. MOMSTC?N. CSR, OPFSCiAL c:4UR`t' R3xO:t't'ER,. MAtA, N.,3.
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1 2 3 4 5 6 7 l3 t3 t4 t5 16 17 16 l) to 21 32 23 14 15 5o=rrs - Dirscr a560 the high powec of the large lunq specia+an, tha aPsoimen oi the tuao ,e of the r i ht u er iohe g pp . Ninety celiw there would be too few eitosis that you coul d make anythin g ou t of thea. I sirsn*t happen to uear oan+t. An d, iC av, baso d on tbe few live, W.ll priaerver3 cel;.s vi th the tail nuclei and the prorxinsnt nnclsi, to me this ia tbe aaM 0011 type anct appearance of twror as seen in the rev ious s eciAWn . p p . So if it had been Ay caeav to dt,agaous, I woulj hava said abrcino®a suggestinq neurcwndoerine csarcinoma, parentheses atylrical caraino sd ar aaliyAant carainoid. D Or. ,3+ownera, what happen ed to Xrs. Cipnlidnrr after the blo s what aecs si on was aaje7 p y, . : A ;4e.11, Dr. 5tichiCn wag in a qu»ndry. ne was in a strious yuandry. And so again, he asked for conauitation witih the other staff j~athaloylsts. sihii.e it's 4uite a long tij" agoi 1do reaamDac. .z14 standing in the hall of the lab rrith 3r. ioachia and RotterdAm and mysel f and saying, what are we yoinq to do7 What is this? You have to LQll wr. Dr. 3+sydfr said smaii oea 1 aarcino". I, said vell. Hlid3 or Harryg g.t out the s3s ides and t' 1l loo ic at thea and .t' l l cal l Dr. Stichi®n and tell hfm. I did so, fl What did ar. S+tiwhiar, dsci;3t to do in the case? A Weii, ha was a vacy thoughtfu3 4an and I don't know if JQRNZ+i9 if. HOU3Tt?N, C3R. OPPECyAL, CC?URi R&1't3R'PSR, NSWARK: NsJ.
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I 2 3 4 5 6 7 a 3 to il t2 13 k4 l5 tIS l7 l6 [9 10 k1 12 23 14 23 saraaaexa -- ;.7lract -3661 the ireUicoi rscor.i is in avr,ience, Dut anyway, iia wrote ,{ulGe a note mxpiaining the proGiea+s. Xf it wag a auAil oeli oarc:inoma, he thought he s3souidn't oparate. .tf it sras an atypfusl a+crcinoid, he taqught he b~rrttsr uperate. And so i inaily he ca:na around that unr3.r the asscuuption that t;hla was an atyptcal aarcinaid, bt w+4sulri reaova the r.uinder of that right lung and be did so. a Cou,1d you atep to your aoat, just for a eacand, ar. ;3OM61QCA 3 Okay. tiR. SiRRIUut E' l,t ask the jury to turn to paga ten, tt that'3 ptarraiaaitale, your HonUr. TH9 COURI"t Yea. Dr. So,x%es.J, is page ton ln the 'rx0ok, is that tile rapQrt triat yau'ro talkiny about troz or. Ur1Chiea,i? This is the ogerating rerpor t. Ln every approved ?~u~pit.air a:~estir~c ;~urga+4~ 4aut does tne oparation ia axpecttcf e.o wrlta & reportp aithsar befcrra, duriny or he :auat aftecwards write what he fo4nd when be did the aperation and what operation tie did. Thix ias, as I guess everyone w.it'rs acupy can see, it'a almoet a fouc-,page report. aow, uid Dc. 3tiihien deci;ie to rem<avu hoc lung? Yta, and he did So. Or. 5ommers, L',a yoing to $r,ow you 4hai:'s ~2arkari as Jt~.~+dxf~: 'i. iiOU3T". C~~, 'W»CIhF. :YJtjRs RnPf3R:aR, ii~''~AR, L{ :i.J.
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I 2 3 S 6 7 0 9 LO l2 l2 L3 L4 t3 ld l? t8 l9 to 11 12 33 td t5 I sa=azs w Direct 0662 desfernsz joint axhiijit 3017. I asic you whether tbese are biowupa og LristCure3 you took of the 19$2 pneunoneato.~ry section alid.s? A Ytn. They are color print QnlarqeYaents of color photaaticrogrsphs that I took at different mwgnifications of a portion of this tunor. I'il r."ric again that if you're a practicing pathologist, you have t o look at all the tu,aar. You can't just look at part of it . Q In your opinian, Dr . Sooaers , is thia a fair and accurate representation of what the tumor looked 1 ike under the wi,croscope in Jun+r of 19 BI: gneuvon.ctoay? A Yeu, of a part of the tu mor, not the part ciosest ta thv 4ronchum, bot part tit the tu uwr. J Ia this tne ,7redwzinant pattern in the tuaor in June of 1982, in your uptnion? A Y'ea. Mn. SIttRiDGEs At this tirae I'd like to nffer exhibit 3017 in evidence. MS. WALTZ"s 3o objection. d TiiB CQUR? s In ev i once. (3Yhibit 3011 is aarkad in evidenas. ) Q 7r . 1 Sotttal*rs, why did you t4ice four pictures an4 could you explain what you mean by or what is Aeant by low, ntg h# "UghaL, nignesti2 What is gaing on in th is pxcturo? .T'D"1dB 4. fiUttS'I'at+, C3Ei. J?FrCl?iL COtTRT RSPDRTLRs rl"?!'RK. id.;7.
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i 2 3 4 5 6 7 a 9 !0 li L2 13 i• L x t6 l7 L9 tfl 11 22 E3 14 25 ~1ts1*;aors - Di.tect A Yes. Wai.i, tt's cepst? * ton, but the way aprofasslonai patbo.loyiat hand2rs a t issu e sp.cimen of any si4o on a siive and it's about the siss of a postaqt stsap en ag.iaus slida is urulec tb• low po++lrr, 40 truss. You looic at all the tumor . Then whin you find sosethinq interes ting oc you think rilJ. help you 09 you need to look at ai oser, then you go up to one or aore of the higb.r powers. And th®n, as soon as you've checktd whether thia is or #.an't atossotbinq you're thinking about, you go riVht back to loar, brrcause if you are to worlc ail your 3 e ifs at the highest power. yUu wouid g+et lost in ths breeze of the f orrtst . ;ro, what ws have here you aeQ if they Vant to dtnrgrate Patt3ologiata they cail us pattern eecdyniz:rs _.~ so natice this stroma h e.*# this pLnic situEf, the conijQctfve tissue and this iiexe sn d no t zce that this i>ar" of the z: ije has th*n been enlarqed and thtce is the saae cannncctive tissue aati you soe on the Lower power. xhen agatn, if you wi,il notice - I beli+rv* it's th ig -- no, wait a ainut• nor. Thts. You not ic• that. AnJ you take this part and yoo see it hors agairt. Ther• is that •nlarg" and here's the top part of tnat enlargad, so again we have a part of the saaa iEield. And tr3en see thls yere. Jere it 1-sa at the hiqheat JOANN6 1, it{SUSTOY, CSR, aFPTC1AL CJURT :MftTERs t494NARK. N,J.
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I 2 3 a S 6 7 a 9 tQ L3. L2 L3 L4 L5 lG l7 Ld L9 ta 21 U ! 3 3; 'J,J:ShdEClCtu "' 13i[4ti:t power eniasgeci, so what wra'v* ,ione is iurthea gnlsrqe of znaz one. Q ~art What would be the benefit of going througa this proc.as of en3a ryement? A Weilp fi,rst 1 have to "ire an srcbitectuci3 diagnosis. Tisaus, growth pattern, and thera f inally 14 there is any discussion or ig it isn't obvioua that everybody, inciudirtg a s+rcund--ysor wedical student, I have to be pregared to supisort it with detail. Q Okay. What do you bel iev• xs signi t icant about tiYede picturts or how would you deucr ibQ the 4atdr iai to the jucy? A aarae stainr HFSs not i[ arid E pink - o.tue ar purpie for nuc.%e f . Rossy pinic for cytoLs.isaa and axange or pink or somotimes if it'a mctura, ysl.io;r tor coilngan fiLorous ti,rtsue. So hsre we nave rather denae str;una, and ir sep&rates the tn+x,r :nto 5+sndlas and cords, and what are c:alled trab*cuiae. Bo in nry opinion here again i,s an organoid pattern. t,te don't know what it is trying to tsuiid. Yt ifs not just aoas3 of co.ils. Thsy are organtzw3 to aomQ extarnt. 3v higher porser, now ate they oFganixoa? Y4u are 13 1 familiar vita pa.liaadeJ, The cartoea lined up gide by dide, JfJANNS M. ffO()STC3>i, C;3~'c, UFgiCLAL, t:U[JRT F+tEP7a"t"P3R, N0Y4ARX, kx.J.
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1 2 3 4 5 6 7 a S LO tl 12 l3 t4 L5 L6 17 tS L9 20 21 t2 13 14 rs j"Me,rs - Diraat $665 shown very nicviy. Pa2isadinq, the sign is clesr;y •pitba3ium, dcaoc ibsd aa colwar-Ax ca31a, :ong narrov sq+urt d-off aoiis. Lt is a distribution of csrciaoids. 4ka y. Next hiyher poarer, notice a,iittle blue dot in what amouets of fragment s of blue 4ots. W*11, those are focal3y dead or the tera is necrotic eei.ts aAd cell frayaents, so tb®re is focal ntarOsis . Xs th+ert a lot of necrosis? ls moat of the tumor nscrotic, no. Tbe reason i®.ntion it* o ther kinds of caresnona hav e iarle area s of total ntcro sis. Q Nscrosis, talking about what? A Dying of celZs, mQst of which app+aar to ba Jaad or fraigmented tumor c.*3is. p And going ont o the highast aagnificat ion? A W41.1, aqain y ou ste the palisadiny. Nov# we l.ooic at those nuclai agai n. Tuey oce too iarge ior the cei,:s. ;4e look to 2fs if we ca n sea cytopiaism. Q YQs. A Tb• cells are an gular uhapes. To n e they are an wsr say polighol. Also, the n uQlet oc rather paele staininp, not as pale aa befor*, but rather paig, and there are again prominent nuclei in quite 4 number of the tumor cex=s an d also remvabtr that thdy sre differenfi, the nuclei sn;3 ce i3 s JOARNR :4. :3Ot7*s`ToN, CsR. OFMwI?UL. CaG1Tt'P UAORTER. INTUtA, X.,3.
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I 2 3 4 3 6 7 a 9 L0 !i !2 t3 L4 ts L6 L 7 l3 t9 to 11 22 13 14 25 oommars - airect 9666 are of ditf.reRt aities and ahapga and not ail regrslaKiy arranged. Tttnaily, we took around. we aan aet aMytosia or two iii thid f ield. So having anciep•n3entXy and as objaetively as posaibia go thraugEi f coe; low architectuce to high cytoxogys th. acaaa kind of a lornr power and bigh power appearance of this tumor was sfan when the right uppex lobe of tbe lung was removed. In my opl.nlon it's a recurrent atypicai o+r Malsgnant r.arcinnirl. 4 Lat me ask your W+ers there any areas that were .lersa aaiEfarentiated than tbis in the 1982 pneumoneatoay slidfa? Yes. 3omt, r+lleta for onat reason or another, tht .:e3.la werre apindled 4nd oioaor togathor. darker xtained or very darkly atained, so you coraldn't see tne pink cytoplaam erltber very w+eli or at all. fa Now cloeS the &ur3zcaii apatuoi.vqiat daai rith rreaa Lik,: taat when aakf.ng tho dtaynoai3F Tbs rule is you haa4 a tuaor aftar tbe beat differentiated portion, and you qaade it, if you grade it, atter the poozeat dilf+erentiated portioQ. At Tsnox Hi11 re have not gractsd aarcinomia becauaa we find it cortfuaaa the surgaon, also it c#iff*ca "tween patholagists in the aatme lai>oratory uaing the same specimsn. Theref4re, F vaoidE acay that ++ba a leax J4}AUNE 3i. UOUST4h=* CSR. ;3FPsCIAL COtIRT AMA°1'ER, 1i3WARFCo ti.3.
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Saxaera - airect 3667 I rlifferentlated part of w*aat ;a to t;,a ari ai:y;iii:a1. Lacc,:1QiJ. Tni6 is nrat 3uat 4+t. Iit is in the sit+erAture. artrcie on the *ubjeet, or in Pact. There sa nn 2 3 4 S 6 7 0 0 LO !i l2 13 L4 lS L6 L7 is 1} to 11 22 23 14 as Q L)r. Sosa"rs, did you iuok at tne sii3es of tuia tutaur Ln Juna of '82? A Y+t». 0 And what occasion wcwlsi you riave looked at the ai idera in JuAt oi ;M A You see* as a ccrnsu.ltont I came once a wrr*A and did a dAy'o a+.rvicet waatever xy successor. Dr. Loachim as d i rector want*e3 ae to do. When I vould be there iieidee Rotterdam or fieieii Wouia say, 'vo you rekaezoer that oeit of Dr. 3teichen." "9ur+e. • "AMaC hwp=xtnes3?' *Shta ;13d "IaC 1.ung out,• ";3a you Know waara thra %: iciea ar*? 4ay L iauk At tAOtx7 a "3urer." I looked at a3idas. Q Waac thec+s a ditference in the pathoioyy drsosrtmeat in June of 182 after the paau3onectomy? A Yera. Oc. Snycler maintAkned it was ax"il ce,il carcinoma. '.3r6 toachim, Rotterdam and ayxeit re,4ardesS it as an at;(Laiaai or aaltynant 4arti:}.noid. JOANNi .4. UOt.IS'i'rJt+1. t,.aq, OP'°'iCIaIVIL COUR'1' itZP01MER. :ngWARX. !'3.J.
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I 2 3 4 5 6 7 a t0 I1 !2 l3 ti t5 16 l7 l8 l9 to tl 12 13 24 ts 5nzzors • Direct 8668 Q Thank yC3ur DQCttir. You aay resume yoar seat there. Dr. 3owaeera, did Mrs. Cipollonf return to the bospiCal in August of 1983? A I an not aure of the aonth, but she did aame back the nexfi year. 0 And what was her probl.a at that tia*? A Weti, arsong various proble" of poor health, she now h43 as YremembarrI high blood pressure and a gesling of fuiinos:a or pain in the ubdomen, and studies oE this by x-ray and plthaps other metbods showed an abnormality th.ce. Q i1as there - what 3Qcis.ian wass made at the hospital as to how to treatt the probles? A otgll, no one lcnew f*r sure wnat the mass in thv ais~:io4era was, Lt was in the region of the r iqht ac3ranai giand. Thosa eert called that. secauae thty r 0e just above the xidneys, iitCie +thfngac, tnraa cornareJ shape, and of cour3e tney hawt :eorcxortM production, 0 1tow aany are there? A '!'Sere is oni oA eaah sic3e noroai,ly. An3 so the problem tias could her high blood preasure and the m3ss be explaiu*d by a tvanor that srose pcimari3y in that right adrtna.i 91and? Their* is a tumor that arises .in the middie part of JOAN1"i3 3. HOUSTON, c;SR, OFFLCiA.i, L"QURT RWOR'f8R, UNWAARK, N.J.
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i 2 3 4 5 6 7 s 9 l? lJ. 12 13 14 l5 Lfi t7 t8 t2 t€} tl 23 13 14 :J Zawar4 - 5ire~zr. 16 6 q the aclrenal qixnd or 4lancis wharr the adrenai and tne nouroerulocr ine line comQ from an.i thase tcoravnes iaiaa the biood presaurer. Ft you ressove that twnar, you curt the blood preesurs. Aiso, it is itnowu that iaaopie who have aarcinolae, and it is not just lung ot bronchial r.ircinoids, a.t ia carafnoida e2ee+,rhere gomehow have a syndreszaa. A eyndrame a connection of different diaaraees seen often enough tagetner, whtct; wera rQcagnizad to oe a entity, anJ tht) aynric era+e f.s c:*ileti au3.t f pi ine endocr ino neoplaaia. That wQans the horwone prodecinc; q1an4a will show benign or raalignant tumar, and thsrre are two typea, and two has t:ia adrenai tu;aor in it. it yas a l.onc; name and ct can ~)+e sborevited ;?hau, so i don' t givo A lonq Adma. The !~eais for oporaititky was tne poadibf i.ity U13L aha naJ a curaz:,e ca6i3Q of nar hy~;Ortan3LOn, ari6 tt,st titeY w0oid f ind a i,41eo anJ re:aora it. 4 Whxt ia the fuli teria that pheo is an abor+eviation A Pheachroaal cytcxna. 0 waa the diAgnosis of that antertained? A Yea. Q Whut was -- what happened to Araxs CY~JaL iane? of ? A 4etl, she had the right adcenal +3iand aAeas rather in t;)a iO.:ation 4Z it, nine cOntiMUtara 3.n ci:xaeter reaovads is jGAN>iS 14!. if•'3J.'37TQsd, C-03€2, 01'PICiAL COURT R&POR'i'^A'. NEWARX, N.,7.
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1 2 3 4 S 6 7 $ 9 LO 11 L2 13 L4 l5 E6 L? i8 L9 20 21 12 23 ;4 ts 3o:j"rs - OirR Ct 8670 ~ 4ldtl Chat Yyl@t1t to tj7Q pdtht3'.t3ir,}x d!!PaCtZ$At? A 3~~ts. ~ i.et me show you what is marked Na dsfeaaEe joint 8xdibir 3024, and ask you to stsp down ayai.n. Dr. Soam*rsr and I wilx aak you whether these are blowups oE photagraphs you took of photasicroqrapha you took from tkwe adrenal tumor xn 0837 A These art enlarged prlnts of pAotomicro$raphe I took of the twaor. This nine csntimeter masa waa 3aryely Aeawx:hage andi dead tisaut. And as I said csfnr.t at least I can't make a diaqnosis on tninqs like that, so that the** pictur*4 coma from around the edqsa of tAe tumor or the Zo].Qoei supply being better, the tumor :s alive, ~ Dr. Sn$imers, why would there ba JeaJ tiaau+s, hotaorrrsagg in an adrenail tumor? A Many tusaors, either !:~+aniqn or rr.a.liqnant, if tney get. -~)ig enough outgrow tnsir h1ood uuppiy 4nd the Lenter'a ut particulacly having lost tne olrrod flow, and the nutrienta in the blood, the ce11 dies and you get a rnasaive puipy or heaorrhaqic aaterial. 9 Dr. Sommers, in your opinion aro these phot0qraphs a fair and accurate representation of the live ctlls in th* adrona.L tumor in ' 83? A xars. I think so. AR. SiKRZDGL: At this time I would like to offec JOANNS H. Hi7C3g3'f3t7* C3R. OFFICIAL COURT REFOR28'R, HZAARKr N. J.
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1 2 3 4 5 6 7 a 9 La LI L3 t3 L4 iS Lfi LT t8 19 t0 11 22 t3 24 25 sokw*rsu - Direar $673. Defsndants' 4:aahiiiit 3024 c,.to evi3enae. )19s WALT$R,Sl3 go objeCtiaE'1. Tts COURTs In eviefenoe. (Chart r{eaeive3 in awic)onaa 44 Detendaents' Ba.bibit 3#)24. ) Q Would you iike to ao" over and tetl the jury vhat the high, bighec raeinr?. A 2000 400. 0 And how do those two piotuces relate to one anotnsc? A As you ree, this unusual looking asll here is tnrthec aeagnifietl her*t so that part has been enlarged. 0 Can yout esplain to the jury what you would vierr as the sx9nif ioant festurRs of the tuftdc froa tu+rse Pictures? A Wall, I asn tnt+sreatsd tor years and in prn9o type tumarg, and it doegn't look .Like any suan tusser i ever sak or read about. I don`t thinlc it is a priaary adren»L stedui.lsry tvxor that prociuZas sdrenal nor adrsnalin. What is it then? I wou.is) 3Lke to point out that in places the cells l,ine up, they 3ine up around oioos3 vesstla where the nutry.tion is better, where it ia not so good, you, aee thors ia heabrrhaq* and ce1l debriu and the pigment is broken doYnp red blooci cal'is. Whan they line up like that and shown hera, ti,oue are almost in.Fvitab2y epitaaii.a c:Oiis. Isn't J0Mi7Ei 1. il0Vi3AONe .r.SR! 3FOICtAL COiJR'P RgPt3RMr ??E6dAR.Kr N.J.
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1 2 3 5 6 7 a 4 !4 L1 12 i3 L4 LS L6 17 L& 19 20 21 22 23 24 25 jV~i~iatF S - i.e ii. ect a672 arly cannec.tive tIsAuG Gaii, except 50ra0 locailzsj parts ox the Oratn tnat wcsu3.d 3irie up i.iK* that. r think it is 4arae kind of an epitheiia.l gxowth» It's cslluiar: Many nuciei, so Z think it ia a tuaor. ta it beniqn or arii4nant3 Wel3., crs us+e the saaee criteria we used before, factvr ? i?a a.13 the c.l,ls rlook like they a"* tram the aama y 3C3* 3er@ Ate ta $ q .idnt on* ans3 jualler one, *AnJ anoth*r giant one. These ar e in nuclear siiae, shape, an;3 staining. Alsu the coira $r e of differ+tnt aizas ahapms an,i staininq. 30 Lhoy nave C'Y'top#. iiaa? Ye3. You can se e a ume of thea have ;,ui Ce ev ident r7 riM of Pink c:ytoplasu, an d t nay are trapotoad 3hapQa or t:a0sa fi+arWs ua0d in jeonet3ry, sc+ it'a :uatignsnt u;,rtheiis: U{"iia?[ • WhoA I s?2y t[1at1 lt t 3 t~1e :31Y:3a A.Tt £3tltylrlg ii0:aCi esI n4 of a cdreirlorAa . Okiy. 4hat Atout the nuclear utructu,:ea7 We1 i, again, the nuc le# are rather paie. Yo u can ses light shining tbrough tcm a, and they are prozinon t nuclei. Those +lark aotz Ln t he centers uf tita eniarg ed nuclei. So I nave meen thia hePors. hooks tne maze as the aptLi.nnrt rtmwvew xitn :zer vho::e rlght lung and iooks not JOAtJNf3 R. dc7Jc+TOR, CI.R, OFPLVi4L COURT RCPt?R^t32, w7OWARK, N.1.
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1 2 3 4 5 6 7 8 2 LD tl L2 L3 L4 LS LS U L$ L9 20 23, 22 23 24 usit zke the spucirasn taLei -jed 0° ths par ipa*f ai ruraor oZ ttio r i ht u er tari+a g pp . Are there eytosis7 Hars is one. I ba1 ieve it would be metaactatic atypic:ai or m9i.ignant cairCinof.di. Nov, this is very unu$ual. H..ci tney known thia baforaharid, I don't think they had any right to oporst+as Ydu don't o etata on metastaxis . p Zt's so unusual, bacaust if a lung cancer of any kind csatastaasaes to adrenml g.tandn, it does usuali.y to r)ota aqual iy and the other giand, na far aa anyboJy knQw, wasn't +rven vniargQd. So thrs ie a rare type of uniiaterai, onar-aa3ad adrenal gland ractastas i s. Q Dr. Sonzsrs, who :n tt,e Vataoiogy d$p*rtaantc daagnoaao the tumor in ' 83? A Thi.s particu.laz tumor, the reyort ia 4tgnad by a., 33arttin. ~ Da you rQmaiabar what Dr. Uortan'u axayno%i:: wa3? A My ;"awry waia it wais =etaaitia sr~dif£vr~antiate~3 carcincuaa d l d to a rena gien s. Q 1 batnd you a raport lrom Dr. Hottan. A Corraction. Mstastat.ic poorly differentiatod uarcinojoa to ardxenel gianda. Fxic pulmonary pri;aary. Laat sentsnce. ~~ Doas 34. H4Xton indicate that t4e tumor mi.ght be an )at ce3i tumor? 23 1 : Tf you raacl hfs Jsscr iption, he 3ays i-- just tne ir.a3t Ji7AUN."; 3. d:)WTOPJ, ^Sr2, JF'gICaAL COURT 3WORT:aRr siLWARX, :i.J.
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I 2 3 4 5 6 T 8 9 LO Ri L2 t3 L4 Is L6 17 L$ 23 24 as 30=648 w Direct 8674 sentanc*, &nd t an not triring t4 ayoid anythinq. tie says the bistolagicai keatures are arore consistent with aalignant pulmonary tumor espociaity of the oat ceii variety. Q Could Dr. Bortan have diagnosed aetastic oat cell ar scul3l celi to the adrenal glands? A Certsialy. 1lR. SIRRZDCiSt Could I have a brief word with you at aide bar? T8S COURTt Cextainiy. (Tte, fol lvqring takas place att skde bar. ) MPl. NORTURIPs First aide bar of the day. THZ C<3t3RTr I cflngratuiate you. MR. Si4RI:3GEt I icnsw I wvuld qft it. TME tOtIR'ts You asksd for it. It's even wr+s 44asit3rJ. HR. StlRRlOCEr it ha3 L~tan 4 long dsy attd it ls warta in here, and I aae at a convenient breaking point and L will not tiniaA.- mR. ZD&LLs I th3.nic you should go to five. MR. StRRIi?GE: to there any cAance we can just begin toaorrow with Dr. Soawers? TtiE eDURT; Anythsnq on tomorrowT TH3 CLZ=; :vo. THE COURTs Sure. Do you have any ob jectiou JUARPtS H. UOU3^aUN* GSR, JFz'IWIAL COURT REP?RTER, NWARX, ;i.J.
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I 2 3 4 S 6 7 I 9 to L3 L2 l3 L4 !S lb L7 ta L9 to 21 32 13 24 (5 $475 stoppi.ng ten iminuta$ •arly? MR. WELLi Horn lonq wx.ll you b+r tomorraw? bla. StRRIDQEt Lassc than an hour. And xs can start iny tiat thatt warks out for everyone Qis.. TBN C9pRT: Lat us try to shoot for quartRr of ten. Str ahat h* happ.ns. X.S. i1ALT6ABi All rtqht. HR. SZRRID6Rt 'Pry for sta€tiag tims of quartsr ai ttn? TUN CDi3RTs Y#s, (8nd of itide bar. ) THX COUR?t Memberx of the ,)ury, counaal iedorms Aa iyawaurse there is a new area to b* stact+eci, it Uight tse czonveniarnt to break foc the day, only ten ~xinutea bsfore o"c normntl breakiny timt, and I Kouit,i appraciate if you wouid be here tacrorrow wornxng no :atex than quarter ot ten and try to start again between quarter of tsn, but no later tban tern u'ri..lock. THS CLEBSt A.il rise. ?HS COtJATt s iavs a nice sweninq. Stv you towor cow morning. (Jury excuaeed. ) TNE C©t3RTi You can stap down. (Witne02c axcuZecf. ) 7QAN'242 A. :14U3TUNt C;R, t?FFFCIaIL C4URT l33Pt?RTER, NWATt:C, U..:.
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1 2 3 i s 5 7 a to 11 l2 l3 L4 LS l6 l7 1a 1o 1Q 21 12 13 14 as 3676 Tt3y Cc?JRi g romor cosr iwl:33I ste cauns&s quarteec of ton . KR. l+iA]1M OnE eeconr3. " vould iike to hand mp a sbort zeply brief on hetsa3C of Liygett iA connoetion with th di d e zeate verdict xotioa. KIt. bQril2ard SILFlftNt We have ona for Philip Horcis anci . TFiS C4JRTs How many pages. HR. SILrM Poui tafn pages? HR. NliAlts Tw*ivo. HR. $Ii.]PBNt Very arriort, but vary strong. (Court adjaurnsd uati3 April 1S, 1988 at 4s43 a.a.t JJA:'ti)3 M. 'iOtt3'i`O.3. 0.3R, WFS:,.IAL C-WRs RMA'T'9A,,..N8iAktX' u.J.
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WITNESS DIRECT CROSS REDIRECT ILECROSS HAROLD H. KASSARJIAN By Mr. Edell 8506 8539 By ![r. Bleakley 8523 SHELDON CHARLES SOMMERS By Mr. Sirridge 8546 EXiIBIT IDFN't• % EVD. 3019 3023 3022 3021 3017 3018 3024 8634 8638 8642 8645 8662 8657 8671

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