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Hello and welcome to Case Crunch Rapid Case

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Review for the Core Exam hosted by Medality.

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In this rapid-fire format, faculty will

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show key images and you'll respond with your

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best choice via the live polling feature.

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to as many as we can before time is up.

0:33

Without further ado, please enjoy this case review.

0:37

Great.

0:37

So welcome, everyone.

0:38

Thanks for tuning in.

0:39

Today we're gonna be covering some high-yield

0:41

breast cases that we really see in clinic.

0:43

Actually, three of these cases I saw this morning.

0:46

Um, so the first three cases are gonna be

0:48

real-life cases that, um, off the press.

0:53

Start without further ado.

0:54

Lemme just see how this is working.

0:59

So, case number one: 72-year-old female

1:01

presenting for annual screening.

1:03

Um, I'm gonna go quick for the purpose of

1:05

time just because there's a lot to cover.

1:08

So, this is a woman whose mammogram—this is her MLO view.

1:11

So, this is 2016, but if you look from 2012, there's a very

1:16

subtle difference, but it's a very important difference.

1:19

Um, so I'm gonna let you look at this for a. But I really

1:23

wanna draw your attention to this asymmetry up here.

1:28

And I call it an asymmetry 'cause

1:29

they only see it on one view.

1:30

I'm gonna show you the, uh, the CC view right now.

1:34

Um, but really there's really no correlate

1:37

for the, uh, finding on the CC view.

1:40

Um, we could see that she's had surgery before.

1:43

That's resolved a little bit, but we don't see

1:44

that asymmetry that we saw in the upper breast.

1:47

So, um.

1:49

What would your BI-RADS be, um, in this case for?

1:53

I would call this an evolving asymmetry.

1:55

So we would of course, wanna give that a

1:56

BI-RADS 0 and needs additional imaging.

1:59

And now my question I want you to

2:01

think about is, let's say that the...

2:03

What are we gonna ask for?

2:05

Right now, we only see it on one view.

2:06

We only see it on the ML view on the MLO view.

2:09

So a few things that we can ask for.

2:10

So we know we can ask for a true lateral view because if

2:13

it's in the, if it's in the lateral breast, it will fall.

2:15

'Cause remember, muffins rise and lead falls.

2:19

So, um, we can definitely get spot compression.

2:21

Or in this case we did ML tomosynthesis,

2:23

which is what we do a lot at our institution.

2:27

So you can see that the asymmetry still persists.

2:31

What the tomosynthesis is telling us

2:33

is that we know it's in the upper breast.

2:35

Okay, because it's above the nipple, but it's

2:37

telling us that it's in the upper outer quadrant.

2:39

So the tomosynthesis is really helpful for triangulation.

2:43

It could help you identify which quadrant it is.

2:45

And of course, we see that this is a real finding.

2:47

At this point you're gonna say your BI-RADS,

2:50

whether or not we find it on the ultrasound.

2:53

Really needs to be a BI-RADS four.

2:56

Okay.

2:56

Because if you, it's a, a new asymmetry.

2:59

So if we don't find it on ultrasound, then we have to biopsy

3:01

this, we have to biopsy this under a stereotactic biopsy.

3:04

I've seen this recently.

3:06

I've seen this kind of missed a lot with a new

3:08

asymmetry, giving it a three, but by the definition and

3:12

asymmetry can only be a three if it's on a baseline.

3:14

So if it's a new asymmetry, that's called an

3:16

evolving asymmetry, that's more suspicious.

3:19

So, of course we now know it's

3:20

in the upper outer quadrant.

3:21

We're gonna go send the patient to ultrasound.

3:24

Um, and thankfully, actually the

3:26

first picture, they showed me nothing.

3:28

But then I went back in and scanned.

3:29

We found this very small mass here at 10

3:32

o'clock, 10 centimeters from the nipple.

3:33

We biopsied it on ultrasound.

3:35

It was a small invasive ductal carcinoma.

3:38

Um, so just wanna reiterate.

3:40

So obviously that BI-RADS four.

3:42

If we didn't see it on ultrasound,

3:43

we would biopsy under stereo.

3:46

So just to go over some basic definitions, an

3:49

asymmetry is an area of tissue seen on one view.

3:52

Focal asymmetry would be on two views.

3:54

And a global asymmetry is when it involves more

3:57

than one quadrant, and you see it on two views,

4:00

uh, as opposed to a mass which has convex borders.

4:02

And you're gonna see that on two views.

4:04

So, in this case, I would call it an evolving asymmetry.

4:06

We only saw it in one view.

4:08

Um, and developing asymmetries are important.

4:11

So, like I said, that they're

4:12

either new or increasing in size.

4:14

You need to make sure you compare it to old priors.

4:16

In this case, it was a slow change.

4:19

Um, so focal asymmetry, like I said, two views.

4:23

So, the risk of cancer in a

4:25

developing asymmetry is 12 to 27%.

4:28

So, way over that, you know, 2% that we're

4:31

willing to accept for probably benign.

4:33

So, it should not deserve a RAD 3.

4:35

Like I said, that's only really reserved for the baseline.

4:38

Um, so biopsy is necessary.

4:39

If you don't see an ultrasound, you're

4:41

gonna want to do a stereotactic biopsy.

4:43

So, again, this is a 3D image.

4:45

I'm not gonna go over this, but this will tell us

4:48

that, you know, it's in the upper outer quadrant.

4:50

Um, and we've been using this more and more rather

4:52

than just toy, than spot compression because

4:55

oftentimes a focal asymmetry might look like it's

4:57

gonna go away on a spot compression, but really

4:59

it's a true finding in the ML tomo shows you that.

5:03

Okay, so, next case.

5:04

So, this was actually a case from earlier today, um,

5:08

that this woman has extremely dense breast parenchyma.

5:12

Um, one of the other radiologists looked at

5:14

this first and she didn't really see anything,

5:17

but then the tech told me that she had a

5:18

survey ultrasound and she found something.

5:20

So, I had to look at it again.

5:21

So.

5:22

You, um, we do a lot of survey ultrasound in the setting

5:26

of dense breast, which we'll talk about more and more.

5:29

We're getting it, and this, so on ultrasound.

5:35

This little hypoechoic mass at seven

5:37

o'clock, seven centimeters in the nipple.

5:39

It was a real finding.

5:40

I went in there myself.

5:41

If you kind of go back to the mammogram knowing

5:43

where it was, it's in the lower inner quadrant.

5:46

Again, I think it's a little, it's very hard to

5:49

see, especially in these patients with extremely

5:50

dense breast spring, but it is a real finding, um,

5:53

in retrospect, and obviously that's a BI-RADS 4.

5:56

She's gonna get the biopsy.

5:57

This is from this morning.

6:00

So, a little plug on dense breast tissue.

6:02

As we know, dense breast tissue, which is

6:04

extremely heterogeneously or extremely dense.

6:06

It makes it harder to see small

6:08

cancers on mammography alone.

6:10

And additionally, it's an independent

6:12

risk factor for developing breast cancer.

6:14

So having dense breast tissue increases

6:17

your risk of developing breast cancer.

6:20

So, um, that is something important to consider.

6:23

I got my video working, so hi.

6:26

Um, and so we would either.

6:29

So for people that are proactive, I always tell them.

6:32

Add ultrasound or MRI. If you have a 20% lifetime

6:35

risk of breast cancer, you're gonna want MRI.

6:37

If you have dense breast tissue and you want the

6:39

earliest cancer finding capabilities possible.

6:42

So adding supplemental imaging allows us to find

6:45

smaller node-negative cancers at an earlier stage.

6:49

So that may potentially help people avoid chemotherapy.

6:52

Like if we missed it this year, we might see it

6:54

next year, we might see it the year after that.

6:56

Um, but it's obviously only gonna get bigger with time.

7:01

Of any supplemental imaging test is that we might

7:03

find something that warrants a biopsy that is not

7:05

cancer, but we can't tell that by looking at it.

7:07

So like a false positive.

7:09

So something to consider.

7:10

But I will tell you that more and more as we educate

7:13

more and more women about this, then more of them

7:15

are choosing to get supplemental screening, and it, it

7:18

doesn't lead to so many BI-RADS threes or BI-RADS

7:21

fours that I've experienced that are kind of false.

7:24

I think we're getting more confident with them.

7:25

At our institution.

7:26

We do handheld, um, whole breast ultrasound.

7:30

So moving on.

7:31

So this was unfortunately a case from this morning.

7:34

It was a 28-year-old female who was

7:36

presenting with bloody nipple discharge.

7:39

Her right breast was getting bigger for a

7:40

month, and um, she, her doctor felt a lump.

7:43

So, you know, of course we're under a

7:45

30, we're gonna start with an ultrasound.

7:47

We get this ultrasound, which shows an irregular hypoechoic

7:50

mass with some vascularity, obviously very suspicious.

7:54

It's a little even hard to gauge

7:56

what it, how the true size of it.

7:58

Um, we do, you know, we see some faint calcifications.

8:03

Actually, you could see these little white dots.

8:04

Those are the calcifications.

8:07

Um, so we're starting to get worried,

8:08

so obviously we're gonna biopsy it.

8:10

But something that we need to do before

8:12

we even do the biopsy is what, right?

8:15

She's 28.

8:16

She has something that looks like a cancer.

8:18

You're gonna wanna really get a mammogram at this point.

8:20

Okay.

8:21

So yes, she needs a biopsy, but she also needs a mammogram,

8:24

'cause we wanna know what we're really looking at.

8:25

So again, you could see some

8:27

calcifications behind the nipple.

8:28

A very enlarged lymph node.

8:29

We're starting to get very worried.

8:31

Um, next steps would be obviously a mammogram.

8:34

And you could see that she has an entire breast

8:37

filled with calcifications spanning from her

8:39

breast, from her nipples to the chest wall.

8:42

Um, and, uh, she's getting worked up right now.

8:47

Um, but unfortunately we've seen a lot of young

8:50

women with breast cancer that, you know, below

8:53

the screening age, they're gonna feel it, which

8:54

is why it's really always important to take,

8:57

you know, patients' uh, complaints seriously.

9:00

Um, you know, it's very easy to rule out

9:03

if it's something suspicious by imaging.

9:05

Um, okay, the next case.

9:10

So we've got a bilateral mammogram,

9:14

kind of has a funny appearance.

9:16

Um, bilateral.

9:17

I'd say that there's global asymmetries bilaterally.

9:20

It's kind of like a hazy appearance, not

9:22

something we're typically used to seeing.

9:25

Um, I'm gonna tell you, this is an antimony for something.

9:29

So just think what, think for a second.

9:31

What comes, what comes to mind?

9:33

Um, I'm gonna give you a hint.

9:35

This is the ultrasound.

9:37

Okay, so you'll notice that classic snowstorm appearance

9:40

that will tell you that she's had silicone injections.

9:43

These are free silicone injections.

9:45

This is what they look like on a mammogram.

9:47

The snowstorm appearance is really what gives it away.

9:50

On ultrasound, it makes it impossible to find

9:53

cancers on ultrasound because you're just

9:55

gonna get a complete snowstorm appearance of the.

9:59

This is a, this is a similar case.

10:01

You could see that this woman has very

10:04

old, they're, they're pre-pectoral.

10:06

So here's the pack.

10:07

You can see that they're in front of the pack.

10:09

So we call that pre-pectoral or retro-glandular implants.

10:13

They are silicone.

10:14

I could tell that because you can't see

10:15

through them and you can't see that nozzle.

10:17

That's classic of a, um,

10:21

of a saline implant.

10:23

And again, it looks like there's some contour more.

10:26

Usually, you can't tell on a mammogram and

10:28

ultrasound that something is ruptured.

10:29

It might give some hints, but this

10:31

is a classic case of a rupture.

10:33

You can see that it's going

10:34

beyond the contour of the implant.

10:36

Um, and you know, it's more dense surrounding

10:38

that it looks like it kind of exploded.

10:40

That's what it looks like on the ultrasound.

10:42

She's got that snowshoe appearance.

10:44

It's classic of a, um, extracapsular

10:47

silicone implant rupture.

10:49

If you see a silicone, if you see an

10:51

extracapsular rupture, you know, they have an

10:53

intracapsular rupture, they go hand in hand.

10:56

Um, but you can have an intracapsular

10:58

rupture without an extracapsular rupture.

11:01

Okay.

11:01

But, um, of course, like if you couldn't

11:03

tell us something, if a silicone implant

11:05

was ruptured, then you would want to do an MRI,

11:07

uh, using silicone implant protocol.

11:12

So next case, kind of an adjuvant case.

11:16

Um, so again, these are retropectoral.

11:20

So now we see that it goes, it's behind the pec.

11:23

They're silicone because I can't see through them.

11:26

And there's like, it almost looks like

11:27

there's a little bit more tissue around that.

11:29

But let's just say you didn't know

11:31

and you're going to get an ultrasound.

11:33

Um, so actually you could see actually that her

11:37

implant is actually kind of pressed down,

11:41

like it looks like it's partially collapsed,

11:43

and she has some soft tissue masses kind

11:45

of surrounding the peri-implant capsule.

11:48

So let's say this is a capsule, there's

11:50

fluid inside that looks more than simple.

11:53

Um, there's some mass effects on the

11:54

implant, so we're starting to get worried.

11:57

So there is a common, unfortunately

11:59

there's an increasing awareness of, um.

12:04

Obviously, we want to biopsy this at this point, and

12:07

we're a little bit worried about the implant itself.

12:09

So right now we know this is what the MRI looked like.

12:12

So she has this complex fluid

12:13

collection around the implant.

12:16

Um, she had some enhancing masses as well.

12:19

Um, I'm gonna show you what the, the MIP looked like.

12:21

You can see that she's got these enhancing masses.

12:24

Um, and you know, overall this whole picture is really

12:27

concerning for something that is specific to implants.

12:31

Um, so she ended up having a mastectomy.

12:34

It was breast implant-associated anaplastic

12:37

large cell lymphoma, so BIA-ALCL.

12:40

You'll see that kind of in the news.

12:42

Um, and this was all anaplastic large cell lymphoma.

12:47

Um, we, and we now know that.

12:49

Um, so let's talk about BIA-ALCL or breast implant-

12:53

associated anaplastic large cell lymphoma.

12:56

Usually occurs in patients that have textured

12:58

breast implants, both silicone and saline.

13:01

In 2019, they were all, they, no one should really have

13:04

these anymore because they were recalled back in 2019.

13:08

Um, it's not a breast cancer.

13:09

It's really a cancer of the immune system, though

13:11

they're treated kind of similarly in some ways.

13:14

Uh, patients usually present with

13:16

breast enlargement, pain, asymmetry.

13:18

Their breast gets larger.

13:20

Skin rash and on ultrasound, what you're really

13:23

gonna see, and this is what is concerning, is that you're

13:26

gonna see a large fluid collection around the implant

13:30

that comes at least a year after getting the implant.

13:33

So a few years out, you shouldn't be seeing a

13:35

complex fluid collection that you

13:38

might see in the immediate postoperative period.

13:40

But this is a concerning finding.

13:41

We had one the other day that looked just like this.

13:44

Um, and part as part of the, it usually comes

13:47

out like eight to 10 years after their implants

13:49

have been in, um, they have to get them removed.

13:52

And now there's a new association with squamous

13:54

cell carcinoma with both smooth and implants.

13:57

So.

13:58

We're going to be seeing more of this, I think,

14:00

in the coming years, unfortunately.

14:02

Um, and it's definitely something to consider

14:04

for anyone who's considering getting an implant.

14:07

Um, okay, so this was a 65-year-old female with a history

14:11

of left breast cancer after mastectomy, and

14:14

she's presenting with a lump on the chest wall.

14:16

Okay, so after mastectomy, we really, we

14:20

don't image people usually after their mastectomy.

14:23

It's gonna be more of a clinical exam

14:25

finding, because any recurrence would be

14:27

kind of near that skin tissue interface.

14:30

So it'd be pretty superficial.

14:32

So why?

14:32

It's why we don't typically image patients'

14:34

mastectomy and...

14:36

Even if they had reconstruction.

14:38

Um, but physical exam is even more important.

14:41

So we're gonna start with an ultrasound in this case.

14:43

So this was her back in 2022 of last year.

14:47

So she came in August, she had this lump.

14:50

Um, the radiologist was like pretty convinced

14:53

that they saw a skin tract and they said it was

14:57

a sebaceous cyst and come back in six months.

15:01

Okay.

15:03

Is the wrong biopsy.

15:04

I mean, retrospect is 20/20, but still any,

15:08

any mass that you know does this is in the

15:11

skin, but it's extending beyond the skin.

15:13

Okay?

15:13

So that's important, number one.

15:15

And number two, anyone with a history of breast cancer

15:18

and a new lump, you gotta be a little bit concerned.

15:20

So she comes back six months later and

15:22

you could see that it's much bigger.

15:24

Just to give you a side by side, let me show

15:26

you so that now it's up to like 1.2 centimeters.

15:29

Previously it was five millimeters.

15:31

I understand why someone might think that is a

15:33

sebaceous cyst if they didn't have this history.

15:36

But in the setting of all this, it's really, um, you

15:39

know, concerning for recurrence, which is what it was.

15:42

Um, you know, this is like a solid and cystic mass now.

15:45

Um, this was the biopsy.

15:47

It said recurrence residual / residual invasive

15:50

ductal carcinoma, grade two involving the skin.

15:53

So, you know, I think going back, I think that the,

15:56

the fact that it extends beyond the skin surface makes

15:58

it not a sebaceous cyst or not classic sebaceous cyst.

15:02

Not that it isn't, but you would wanna, you know, sample

15:05

that, especially if they have a history of cancer.

16:09

So I'm gonna keep going.

16:10

I see some things popping up in the chat, but

16:12

I promise you we're going to get to all of it.

16:14

Um, but please feel free to submit some

16:16

questions in the Q&A box that I'm gonna

16:18

try to get to at the end of the lecture.

16:21

Okay, so moving forward, um, oops, sorry.

16:24

My chat box.

16:25

Okay, moving on.

16:28

So, um, let's talk a little bit

16:30

about breast cancer recurrence.

16:32

So anyone is at risk for developing

16:33

breast cancer recurrence.

16:35

Um, more commonly if you're young, when you develop

16:38

breast cancer, that's usually because they have a

16:39

more aggressive breast cancers like inflammatory

16:42

and triple-negative cancers, which are also

16:44

a, uh, risk factor for developing recurrence.

16:47

When someone has that, those types of pathologies,

16:50

it usually occurs in the first five years.

16:52

Um, so we had one yesterday, so

16:55

it is something that we see a lot.

16:57

Um, unfortunately, you know, often if they didn't

17:00

have radiation or something that they didn't do.

17:03

Standard of care.

17:04

That's usually where we see it.

17:06

Um, but it can happen even if despite like perfect care.

17:10

Um, so something that could be considered

17:12

something, you gotta take these complaints

17:14

seriously if someone has a breast cancer history.

17:17

All right, so this is more of a case in show and tell.

17:20

Okay.

17:20

So this woman came in for her screening mammogram.

17:23

She had a history of like some excisional

17:26

biopsies, um, like when she was 18.

17:30

Somebody else, no.

17:32

Sure.

17:32

Yeah.

17:33

I mean, I dunno.

17:33

No, it's highlighted.

17:35

Okay.

17:35

Yeah, sure do that.

17:36

Sorry.

17:37

Uh, um, okay.

17:38

So she was extremely dense and actually somebody

17:41

was smart enough to call her back for, they saw

17:44

actually this area of architectural distortion in

17:47

the left upper outer quadrant, um, posteriorly.

17:50

That's concerning.

17:50

And also the circumscribed mass, not so concerning.

17:53

But we have bilateral findings in this patient

17:55

with extremely dense breast parenchyma.

17:57

So something we do a lot here,

17:58

obviously we're gonna give her a zero.

17:59

You're gonna bring her back.

18:01

You could do the standard diagnostic

18:03

workup with spots and ML tomos.

18:06

But something that we have at Cooper that

18:07

I really love is contrast mammography.

18:10

So we called her back for contrast

18:12

mammogram because we can, okay.

18:14

And I'm a big contrast mammography girl.

18:16

I love it.

18:16

I think there's a lot of role for it.

18:18

And this is what the mammogram, this is

18:20

what the contrast mammogram looked like.

18:22

Okay.

18:22

So not only does she have.

18:25

You know, this patchy linear enhancement, right?

18:27

Where she had this architectural distortion,

18:28

she's got this large right breast

18:30

cancer that I think is totally obscured.

18:33

If we go back a slide just to show you what it

18:35

looks like, I mean, even on your best day, I think

18:38

it'd be really hard to call this prospectively.

18:40

It's like here.

18:42

Uh, that's the problem with extremely dense breast tissue.

18:45

Um, and this contrast really shows the, the importance

18:49

of breast density and how obscured things can really be.

18:52

She also has these low-level, I'm

18:54

gonna show you what the read, so, um.

18:58

So just to go over her findings on the contrast mammo.

19:02

So we see a speculated mass, uh, like a 4.7 centimeter

19:06

speculated mass in the right upper central breast.

19:09

She has additional low-density circumscribed

19:11

masses with low-level enhancement that look a

19:13

little bit different if you're gonna push me on it.

19:15

But then she also has two areas of non-mass enhancement.

19:18

One in the left upper outer breast where we saw that

19:21

was a lot of non-mass enhancement, 7.3 centimeters.

19:24

We saw that distortion.

19:25

And then she also has some linear, non-mass enhancement

19:27

medially where we didn't see any mammography correlate.

19:30

So, of course, we're gonna go on to ultrasound.

19:33

And on ultrasound, we find some good

19:34

correlates for the findings on the right.

19:36

I'm gonna do the right side first.

19:38

So we see this irregular speculated mass

19:40

at 12 o'clock, six centimeters from nipple

19:42

that measures about 2.9 centimeters.

19:44

She had a few do, uh, circumscribed

19:47

masses that eventually were biopsied.

19:49

We biopsied this one, it was a fibroadenoma,

19:51

um, which she reported that she had.

19:53

So these all ended up being fibroadenomas.

19:55

So remember, this is a 40, I think,

19:57

42-year-old invasive ductal carcinoma on the right.

20:00

On the left, she had this, you know, non-enhancement, a

20:04

little bit of a mass, but certainly not as big as we see.

20:06

On the contrast, mammogram, an abnormal lymph node.

20:09

This pathology ended up being invasive

20:11

lobular cancer, so two separate types of

20:14

subtypes of breast cancer on both sides.

20:16

And this young woman without a history of breast cancer.

20:19

What I've done here is I've taken the

20:21

contrast mammogram and kind of flipped it

20:23

and oriented it so it looks like an MRI.

20:25

And just to show you how it

20:26

looks compared to an actual MRI.

20:28

So you could see that the contrast mammogram on

20:30

top has a lot less background enhancement and kind

20:34

of shows similar things that the MRI does.

20:36

To me, it's almost a little bit clearer 'cause it, you

20:38

know, it is hard to figure out what's going on here.

20:41

But the one thing, one limitation that contrast

20:43

mammography can do is it doesn't get far back.

20:45

So you don't see the axilla, but you would

20:47

look at it under ultrasound, so you could

20:49

see that she's got some positive lymph.

20:51

Um, and that was just a really nice case

20:54

of, uh, how we use contrast mammography.

20:57

We typically, I have a whole, I actually gave a prior

20:59

lecture here of how we use contrast mammography.

21:02

If you're interested, I highly recommend looking at that.

21:05

Um, but it is something we can do that day.

21:07

I'm actually doing it right now on a 40-year-old

21:09

that looks like she has breast cancer as well.

21:11

It just really helps you figure out the

21:13

forest from the trees and someone with dense

21:14

breast tissue and like multiple findings.

21:17

Okay, so moving on.

21:18

29-year-old female presenting with

21:19

a palpable mass in the left breast.

21:21

This is an earlier case, so.

21:26

So on ultrasound, you see at one o'clock, three

21:28

centimeters from the nipple, you see an irregular,

21:31

uh, vertical breast mass, um, that's suspicious.

21:34

And you also see a lymph node.

21:36

Um, of course we're gonna recommend biopsy.

21:39

Of course, we're gonna recommend mammogram.

21:41

But in our institution, I think we recommended

21:43

a contrast mammogram 'cause we kind of

21:44

assume she'd be dense and let's, why not?

21:46

Let's get the best test.

21:48

So.

21:49

Just to show you what her palpable looks like.

21:53

Um,

21:56

okay, great.

21:56

Um, we're done.

21:58

I'll, I'll look at it in a minute.

21:59

Okay.

21:59

Alright.

21:59

Sorry.

22:00

Um, alright.

22:01

So you could see that, that she has

22:03

the palpable marker right there.

22:05

There's nothing really on the mammogram.

22:07

Again, nothing really on the mammogram that we saw.

22:10

And then we do the contrast mammogram

22:12

and that's when everything gets real.

22:14

So, you know, right where she had the palpable lump,

22:17

she has this, um, enhancing mass that you could see

22:20

that it's multifocal and it's also contralateral.

22:23

She has enhancing masses on both sides.

22:26

Uh, 29-year-old female.

22:28

Again, looking back at the mammogram and maybe

22:30

on your best day, you might be able to call this.

22:33

Um, but I really don't see anything

22:35

right where the cancer is.

22:37

I am sorry, I, I shouldn't be overlapping like that,

22:39

but again, bilateral invasive ductal carcinoma in a

22:42

29-year-old. Again, I've reoriented, so it looks

22:45

like an MRI and you could see it's pretty exact to

22:48

the MRI and, but with the contrast mammogram, we

22:51

have the advantage that we could do it that day and

22:54

do it before any biopsy, before any intervention,

22:57

which will maybe falsely increase the size of

23:01

um, breast cancer after a biopsy. It might look bigger

23:03

'cause of the post-biopsy changes and everything.

23:06

So it is a great test that we can do before we even touch

23:09

the breast so we can really get an accurate sense of size

23:11

and if there's anything else we need to be worried about.

23:15

Okay, so moving on, 84-year-old, there's

23:19

anyone with a palpable lump in the left breast.

23:21

So obviously, this is a diagnostic.

23:23

She's coming in with a symptom, um,

23:26

and she has a large circumscribed mass.

23:31

In her left breast, right where she's feeling the

23:33

palpable, um, I don't know if you get the sense, but

23:36

she's got some skin thickening and it's really hard to

23:39

tell on this, but this is something I like to do a lot.

23:41

So I like to turn on the information

23:43

and look at the thickness of the breast.

23:45

So you could see that her right breast

23:47

is compressed to 3.6 centimeters.

23:49

Her left breast is compressed to 10.8, so it's

23:52

about three times bigger than her right breast.

23:54

So if you were to actually, like, go look at the

23:56

patient and look at their breast, then you would.

23:58

See that it's much bigger, and this is pretty

24:01

concerning for an inflammatory breast cancer.

24:04

She's got that diffuse skin thickening

24:06

and her breast is completely enlarged.

24:08

Alright, so on ultrasound, it has

24:11

an interesting appearance, right?

24:12

So it's a complex cystic mass.

24:15

Erin, one second.

24:17

Um, no, no, no.

24:18

I need you.

24:19

Sorry.

24:19

Can you tell her?

24:22

Okay.

24:23

So, um, so.

24:25

This woman has a complex cystic mass.

24:27

I'm saying complex cystic as opposed to complicated

24:30

cyst. Complex means it's cystic and solid.

24:33

It's suspicious; complicated is not.

24:35

So obviously, we're worried about this.

24:37

This is a complex cystic mass.

24:39

Um, and this ended up being an inflammatory breast cancer.

24:43

Um, again, this is kind of a companion case.

24:48

29-year-old left breast for.

24:51

Again, she's coming in.

24:52

We start with an ultrasound 'cause she's under age 30.

24:55

She has what I would call a complex cystic mass.

24:58

I've seen this given a BI-RADS 3 before.

25:00

Um, which is wrong because if you really see, I think

25:04

the things that tell you that's wrong would be like these

25:06

nodular areas and, um, areas that don't look not thin.

25:12

Septations.

25:13

So it looks ugly.

25:14

This, you need to call BI-RADS 4 as well.

25:16

She had a lymph node.

25:18

Um.

25:19

So again, this was her mammogram.

25:21

You know, when she's 29.

25:22

We started with the ultrasound.

25:23

You could see that they had this

25:24

mass where she feels a lump.

25:26

Um, and that's what it looks like.

25:29

It's a little bit irregular on the mammogram.

25:31

So of course, we're gonna give this

25:32

a BI-RADS, at least 4, maybe 5.

25:35

And this came back as invasive ductal cancer as well.

25:38

So I just wanted to take a minute to go over

25:41

cystic masses, which my residents even do this.

25:43

They kind of use the words complicated and complex

25:46

interchangeably, but they have very different meanings.

25:49

Um, so a complicated cyst means that it has

25:51

low-level internal echoes or some debris.

25:54

It may shift when you move the patient.

25:56

Um, it does not contain thick walls, thick

25:59

septations, or any other solid components.

26:02

Um, malignancy rate is less than 2%, so you,

26:05

it's reasonable to give it a two or three

26:07

depending on what it looks like, and if they

26:09

have any other things in the breast as opposed.

26:12

Um, I would say that if it's symptomatic or newer

26:15

enlarging, you might want to offer needle aspirations.

26:18

She, she knows that she needs a biopsy.

26:21

Yeah.

26:21

Ultrasound.

26:21

Thank you.

26:22

Okay.

26:23

Um, so obviously if it's new or symptomatic

26:25

or enlarging, I usually offer the

26:26

patient aspiration, even if it's relief.

26:30

As opposed to a complex cyst.

26:32

Okay, so a complex cyst has thick walls,

26:35

thick septations, intra-cystic masses, any

26:38

solid components, those are worrisome signs.

26:40

The risk of that being malignancy is over 20 to 30%.

26:45

So you definitely need to do tissue sampling in that case.

26:47

In both of those were invasive ductal cancers.

26:50

Um, the most common type of

26:51

cancer that these get are just.

26:55

Usually, they're in, um, invasive ductal,

26:57

which is the most common overall.

27:00

Often, they're like triple negatives, and they're

27:02

centrally necrotic, and it's because they're

27:03

growing so fast that they just necrose themselves.

27:07

So, um, complex cystic masses are concerning

27:10

'cause it'll also be an abscess, but either

27:12

way, I think you do need tissue in those cases.

27:15

Okay.

27:16

So, um, moving on, this is actually a great article

27:18

if you want, if you need more information about this

27:20

complex cystic breast masses diagnostic approach.

27:24

And Radiographics.

27:26

Okay, so next case history withheld.

27:30

Okay, so what we noticed about,

27:34

um, Erin, you spoke to her.

27:36

I did.

27:36

Okay, thank you.

27:37

So what you noticed about this case,

27:38

they had very large pectoralis muscles.

27:40

I'm telling you this because this is a man, okay?

27:43

So if you didn't know that they have this

27:45

climbed shaped retro or density in the right.

27:48

That is pretty classic of gynecomastia, but

27:52

on the left they have more of a mass, right?

27:54

It has concave borders.

27:56

We can see that it's causing some skin

27:59

thickening and going to the nipple.

28:01

Um, this is concerning also on the MLO.

28:03

You can see that they have some pathologic

28:05

lymphadenopathy that would be concerning as well.

28:08

On the left, we got an ultrasound.

28:10

You can see some nodularity.

28:12

And then there's this large left breast

28:13

mass that obviously is suspicious, 6.2

28:15

centimeters, an abnormal lymph node.

28:18

Um, this ended up being a metastatic male breast cancer.

28:23

Um, you know, males are diagnosed at later stage because

28:26

most men are not getting screening mammograms, even

28:29

though, I don't know if you saw it, but the ACR now

28:32

supports screening mammography in men who are at high

28:35

risk, so either have a genetic mutation or have a, um,

28:40

first-degree relative, uh, with breast cancer, then they

28:43

should consider a screening mammogram starting at age 50.

28:48

Uh, this is what it looks like

28:49

when it's aggressive and spread.

28:51

So you can see it has a malignant

28:52

pleural effusion and floral thickening.

28:55

Um, there's that gynecomastia and

28:57

definitely different from the.

28:59

This is another case.

29:00

It's not uncommon for men to have both gynecomastia

29:03

and breast cancer, which makes it a little confusing.

29:06

But clearly, you know, this is gynecomastia

29:08

that flame-shaped retro density, and

29:10

this is more of a mass of calcifications.

29:13

This was another case of male breast cancer.

29:15

You could see that he has calcifications.

29:18

Um, so fun fact about breast cancer.

29:21

Male, male breast cancer.

29:22

Beyoncé's dad had breast cancer.

29:23

He's actually BRCA2 positive.

29:25

I don't know if she's been

29:26

tested, but I'd be dying to know.

29:28

Um.

29:29

Male breast cancer counts for about

29:31

1% of breast cancer as it used to be.

29:33

One in a thousand.

29:33

It's one in like eight fifty.

29:35

Um, men get invasive ductal

29:37

they don't have lobules.

29:39

They usually have a worse prognosis.

29:41

Um, it is a significant amount of men.

29:43

Over 2,700 men are diagnosed with breast cancer each

29:47

year, and about 530 men die each year from the disease.

29:50

They're more likely to have genetic mutation.

29:52

So it is indicated to have genetic

29:55

screening for the men in their offspring.

29:57

Um, like I said, uh, you're gonna start

29:59

screening mammography in BRCA or 10

30:01

years before their first-degree relative.

30:03

So age 50 or 10 years before first-degree relative.

30:06

Um, I'm not sure if most places are doing

30:08

that, but we're gonna start it here.

30:10

Um, so again, just to go over the findings.

30:13

So gynecomastia is usually bilateral.

30:16

It's usually worse on one side,

30:18

flame-shaped retrodensities.

30:20

Mammo is diagnostic.

30:22

Ultrasound can be very confusing.

30:23

So then we start with, um, a mammogram over age 25.

30:29

Below that, we're gonna start with an ultrasound.

30:32

Um, in many cases, if I don't, if it's pretty

30:35

classic of gynecomastia on the mammogram, I won't

30:37

even do the ultrasound because it can actually,

30:39

you know, muddy the waters and look confusing.

30:42

Um, as opposed to breast cancer.

30:44

Like we said, breast cancer is usually unilateral.

30:46

You're gonna see a true mass of borders.

30:49

Ultrasound not necessary

30:50

if a mammogram is diagnostic.

30:51

And I think that's an important distinction.

30:53

I feel like a lot of men are often sent with

30:55

ultrasound script and not a mammogram, and it's

30:57

always a battle with the referring physicians.

31:00

Um, something to.

31:02

So, you know, the common causes of gynecomastia,

31:05

I usually could just say, you know,

31:06

have a conversation with your doctor.

31:07

Some medications can really cause this, and

31:09

if you stop the medication, it's improved.

31:11

So, idiopathic most commonly, drugs, you know,

31:14

marijuana, prostate cancer meds is a big one.

31:16

Estrogen, anything that causes estrogen excess.

31:19

So if you, um, have a testicular adrenal

31:21

tumor or liver disease, or if a man is

31:25

taking exogenous hormones for transition.

31:28

So we see that more and more now.

31:30

Um.

31:30

Also, nope.

31:31

Also, male breast cancer, um, can cause gynecomastia

31:35

just because of the hormones associated with it.

31:38

Alright, so this is a little bit of a round robin in

31:40

case I know on the board sometimes I'll just show you one

31:43

picture and say, what is this and what are we looking at?

31:45

So just, I'm gonna leave it up for a second.

31:47

And what am I showing you?

31:48

So is this from a needle loc, a stereotactic biopsy?

31:52

Ultrasound-guided biopsy, and none of the above.

31:55

Well, so if we're taking the boards, you could pretty much

31:58

knock out ultrasound because it's obviously a mammogram.

32:01

And, um, the box and the calcification

32:04

should really tell you something.

32:05

So think about that for a minute.

32:07

I'm gonna show you another thing.

32:08

Um.

32:09

So if you couldn't figure out that one, this is

32:11

another type of procedure like that often gets

32:14

infused just by looking at, so this one you're gonna

32:15

see an alphanumeric grid, and this is a needle loc.

32:18

So we're gonna tell them where to put the,

32:20

the, the, the grid and/or where you want, what

32:23

crosshairs you're gonna put the needle in.

32:26

You know, we often do a needle loc 'cause someone

32:28

has a cancer and it needs to come out for lumpectomy.

32:31

Um, and this of course is a stereotactic

32:33

biopsy, so you'll notice that there's that

32:35

square that the calcifications have to be in.

32:38

Um, so that's pretty telltale.

32:40

So something that I wanted to show you, 'cause I

32:42

didn't know this until I was an attending and I

32:44

asked for it, but, so this is a tangential view.

32:48

You could see that there's the skin

32:50

calcs and there's a little BB on it.

32:52

What I never really understood was

32:53

actually how we get tangential views.

32:56

And what they do is they actually put them

32:58

in the needle localization grid, like they're

33:00

getting a ma um, a needle loc, and instead they're

33:02

putting the BB on the, the calcification.

32:05

So in this case, we'd put a BB right on F

33:08

four, right where the calcifications are.

33:10

You can see we put a BB right here

33:12

and then we shoot orthogonal to that.

33:14

And that's how we.

33:15

Get tangential views.

33:17

So if you've never been in the room

33:18

with a tech, I, I recommend you do.

33:20

This is what it looks like.

33:21

So it almost looks like a needle localization procedure.

33:24

Um, so again, let's talk a little bit about needle locs.

33:27

Um, it's something we do a lot as a breast radiologist.

33:31

So needle locs are done for surgical biopsies

33:34

or for breast cancers that need to be excised.

33:36

Um, you are always gonna want to choose the shortest skin.

33:39

Okay?

33:40

So in this case, shortest skin.

33:43

From lateral.

33:44

Okay.

33:44

So if you come from above, it's a seven.

33:46

From here it measures 4.5 centimeters.

33:49

So in this case, we're gonna come from lateral.

33:51

And what I always lose people with, so if they're,

33:54

if you're coming from lateral, then the patient

33:57

needs to be positioned in the LM projection.

34:00

Okay?

34:00

So it's opposite of what you think.

34:02

So if you see it on the CC,

34:03

you're gonna come from the opposite.

34:04

And same if you're coming from

34:05

above, they're gonna be positioned CC.

34:07

And I think that's something that

34:08

you need to sit with and think about.

34:10

So in this case, we're gonna come from lateral.

34:12

We're gonna use, you need it to be long enough.

34:14

So, so needles come, typical needle localization.

34:18

Needles come in 3, 5, 7 and a half, and 10.

34:21

Um, so in this case, you want it to be long enough.

34:24

So if you use a three, it would be too short,

34:25

but you're gonna put in a five, you're gonna

34:26

go, they'll be positioned in the LM projection.

34:30

Okay, so LM, because I always

34:32

remember it, that the, um, that the.

34:35

The way you're coming from starts first.

34:38

So that's where the opening is.

34:39

So if I'm coming from lateral ML, I'm sorry L

34:42

I'm from medial ML, um, and if you're coming

34:45

from above or below, you're gonna put in this.

34:49

Um, and this is what it would look like.

34:52

So I'm gonna go quickly through these.

34:53

We would do it from lateral with a five.

34:55

We would tell her to do LM. So this is what it looks like.

34:57

So the patient positioned LM in the alpha numeric grid.

35:01

That's how we know it's a needle loc.

35:02

Um, we’re gonna put our needle in right here.

35:06

Um, right here.

35:08

So about like one and a half and B and a half.

35:11

You're gonna go all the way in with your five.

35:13

Okay.

35:13

This is not perfect, but we'll take it.

35:16

I think this is one from when I was a fellow.

35:18

We really wanna be right on it.

35:19

But in this case, um, you know, we put

35:22

it all the way in and we don't know how.

35:24

All we know is that it's in the same plane as the

35:27

cancer, but we don't know how deep it is until we

35:29

actually take her out and put her in orthogonal.

35:32

So in this case, you could see we probably should get

35:34

an XCCL so we could see more tissue, but you could see

35:37

that the mass, the needle goes right beyond the mass.

35:39

So then you're gonna hook it.

35:41

You may or may not leave in the,

35:42

the needle, we leave them in here.

35:44

But at Penn we took them out.

35:45

Um, and the, the patient's gonna go to the

35:47

OR with the needle and wire in their breast.

35:50

They remove it.

35:50

You check the specimen to make sure a few things that

35:53

you're looking for, the entire wire, the mass and

35:57

the clip, and that it's not near any of the margins.

35:01

Like, so if you saw it extending to a margin,

35:03

you might wanna tell the surgeon, Hey.

35:05

It looks like it's close to the margin by the hook wire.

35:08

It takes some more tissue there.

35:09

Our surgeons kind of give us like a clip they give us,

35:12

put like one for anterior, two for medial, so we kind

35:15

of know, have some orientation when we're looking at it.

35:17

So that's helpful.

35:19

So, like I said, um, this is done for, uh, it's usually

35:22

done on the day of surgery for, for cancers that we

35:25

can't, that surgeon cannot see or feel, um, can be done

35:28

under any image modality, mammogram, ultrasound, or MRI.

35:32

It's usually performed the morning of surgery

35:34

and, um, the patient goes right to the OR

35:36

with a needle and wire in their breast.

35:39

There is newer technology available, which I highly

35:41

recommend that everyone, you know, starts converting to.

35:44

'Cause it definitely is easier for

35:45

patients and for scheduling for surgeons.

35:48

So, uh, radio frequency tag, we use that here.

35:51

Magnetic tags like a mag seed, radioactive C localization.

35:55

All of them have their pros and cons, but all

35:57

of them you could do a few days to weeks before.

37:02

The breast cancer surgery.

37:04

Uh, and then they don't have to have

37:05

a needle localization the day of.

37:07

So I'm gonna show you a tag procedure.

37:09

So in this case, this was the cancer.

37:12

We put a tag, I think it was this one.

37:13

That's the cancer.

37:14

We put a tag right here.

37:16

Again, this is doing the, it’s exactly performs exactly

37:18

like a needle localization, except that when we are

37:21

done, we’re gonna deploy it and leave it right there.

37:23

So now the.

37:27

Radiofrequency, I don’t remember what the

37:29

counter is, but they could use it in the

37:30

OR to find the tag using radiofrequency.

37:34

Uh, it gives them some depth information.

37:36

Does take some time to get used to our, our

37:38

surgeons are kind of still working through that.

37:41

Um, but it is great for patients and for surgeons alike.

37:44

Uh, and it really opens up scheduling possibilities.

37:48

Um, something to consider when you with

37:50

the radiofrequency and you kind of wanna

37:52

make sure that they are done with any.

37:55

Like MI because these do cause a lot of

37:57

artifacts, which is why we don’t put it at the

37:59

time of biopsy in the category five lesion.

38:01

’Cause it will cause major artifacts on subsequent MRIs.

38:04

So something to consider.

38:06

And also radiofrequency, I’m sorry, the,

38:08

um, the nuclear tags require like a whole

38:12

uh, nuclear medicine safety program in place.

38:14

So it does have more barriers to jump through.

38:16

So this is.

38:19

So again, you know, tag, localization,

38:22

radiofrequency magnetic or nuclear, they

38:24

can be performed a month up before surgery.

38:27

Um, both sides confirm the signal, so we confirm

38:30

the signal when, when they’re done, and then

38:32

the surgeon will confirm the signal in the OR.

38:35

Um, if you place it, it should come out every so often.

38:38

You know, a patient changes their mind and they’re

38:40

like, you know what, I’m not gonna get this.

38:41

Surgery, I’m just gonna watch it.

38:43

And it’s not so much of a problem unless it’s a

38:46

nuclear medicine tag, those have to be removed.

38:49

So that is another thing to consider.

38:52

Moving on, we’re doing great with time.

38:54

So this is kind of a mini case.

38:56

I’m gonna give you a minute to look

38:59

at the, um, at the finding, but so.

39:04

For those who haven’t found it yet.

39:05

We see a pec here.

39:07

We are missing a pectoralis muscle here.

39:09

You know, it’s good technique because you kind of

39:11

see those posterior folds and they look pretty even.

39:14

So this is a classic case.

39:16

Another, this is another case with the same, uh, finding.

39:21

And this is what the chest x-ray looks like.

39:23

It's, if you haven't figured it out yet, um, you

39:25

could see that there's like a breast shadow over here.

39:27

It, and it's a little bit denser.

39:29

It is a little bit more clear here.

39:31

This is a case of Poland syndrome.

39:33

So when a patient is born with missing or

39:36

underdeveloped pectoralis muscle on one side of the body.

39:40

They have abnormalities that can affect their

39:42

arms, chest, shoulders, even their hands.

39:44

They may have webbing of the fingers of the hand on

39:46

the same side; it can vary depending on the severity.

39:50

It tends to be on the right side and it's more

39:52

common in boys and girls. Did not know that case nine.

39:57

We're moving right along.

39:58

So it looks like this is a diagnostic study.

40:01

Uh, patients coming in with a palpable, um,

40:04

I would say they're heterogeneously dense.

40:06

You can see.

40:07

Kind of an obscured mass, right where they're

40:09

feeling the lump in the right retroareolar region laterally.

40:12

So we're gonna ultrasound this, and this is a, again,

40:16

probably, um, a complex cystic mass or solid mass.

40:21

The cystic portion.

40:23

Obviously, this is, you know, concerning, um, this was a

40:27

case of angiosarcoma, and I just want to show you 'cause the

40:31

MRI was very impressive, but that's what it looked like.

40:35

And this is what it looked like after neoadjuvant

40:37

chemotherapy, so it really responded well to chemotherapy.

40:40

Um, this was her final pathology though, even

40:43

though it didn't, even though it looks like

40:45

on the MRI that it's completely resolved,

40:47

there was still residual angiosarcoma.

40:50

Um, and it just shows you that, you

40:53

know, MRIs cannot really evaluate.

40:56

Whether there's been complete pathologic

40:58

response, that's something that's done at surgery.

41:00

You know, sometimes things might not enhance for different

41:03

reasons, like we killed off the blood flow to them.

41:05

So it might not enhance, but it still may be viable.

41:08

So that's what was happening in this case.

41:11

So I'm gonna just keep going because we're doing good.

41:14

So, um, I'll leave about 10

41:16

minutes at the end for questions.

41:17

So maybe one or two more cases.

41:19

Um, so you could see it's a normal mammogram.

41:22

You could see a lot of dilated vessels, but

41:24

then, you know, three years later she comes in

41:27

and you could see that just bilateral trabecular

41:29

thickening, the breasts are overflowing with fluid.

41:33

Um, I would call this, you know.

41:35

Bilateral trabecular and skin thickening.

41:38

It's a very differential, it's very different differential.

41:42

If it's unilateral versus bilateral.

41:44

You could see that she's developed a

41:45

lot of atherosclerosis in the meantime.

41:48

So this is kind of telling you that she

41:49

might have underlying renal disease.

41:51

And this is all related to fluid overload.

41:54

So you could see the ultrasound, you'll see the.

41:57

You'll see a giant effusion.

41:58

If you wanna be an impressive radiologist,

42:00

you say get a test X-ray off the mammogram.

42:02

And we did that.

42:03

And you know, we saw that there was CHF,

42:05

we saw that there was ascites everywhere.

42:08

Um, so this is fluid overload and in

42:10

this case it was due to renal failure.

42:13

Like I said, the differential diagnosis is very

42:15

different, whether it's unilateral, bilateral.

42:18

For unilateral, you're thinking

42:19

inflammatory breast cancer.

42:21

Prior radiation treatment

42:22

obviously need that, that history.

42:25

Mastitis.

42:25

It can be hard to tell mastitis from inflammatory

42:28

breast cancer, but with mastitis it gets better.

42:30

Inflammatory breast cancer does

42:31

not get better with antibiotics.

42:32

That's a big discerning factor.

42:34

Um, lymphatic obstruction, uh, CHF, usually bilateral like

42:39

we said, and SEC obstruction, again, usually bilateral.

42:42

Um, so for bilateral, a very specific, you know,

42:45

usually congestive heart failure or some kind of

42:47

fluid overload or lymphatic obstruction, very unlikely

42:51

to have inflammatory breast cancer, but I have seen

42:53

cases of inflammatory breast cancer that kind of cross

42:55

over from one breast to the next through the midline.

42:59

We.

43:02

Thank you so much.

43:02

I hope you learned a lot.

43:04

I'm, I'm plugging in all my social media here.

43:07

And then I also run a podcast called The Girlfriend's

43:10

Guide to Breast Cancer, Breast Health and Beyond,

43:12

where I talk, it really is designed to help

43:14

people navigating a breast cancer diagnosis.

43:16

I talk to lots of doctors and,

43:18

um, yeah, follow me everywhere.

43:20

Thank you.

43:24

Dr. Roth, um, there's a bunch

43:26

of questions in the Q&A box.

43:27

Okay.

43:27

Do you wanna pop that open, or do

43:29

you want us to read them to? Sure.

43:30

Or do you prefer, um, I'll do it.

43:33

So when you use vacuum-assisted biopsy, when do you use

43:35

vacuum-assisted biopsy versus the conventional biopsy con?

43:38

I actually have a great answer to this.

43:40

So I typically use the, the spring-loaded.

43:43

Um.

43:45

I usually do a spring-loaded for everything

43:48

because it's a lot cheaper, like we don't get

43:50

reimbursed the way we used to with vacuum.

43:52

However, if I have a very small lesion that

43:56

I'm only gonna get one really good pass on.

43:58

Like, let's say it's a three-millimeter mass and I know

44:01

the second I, I take a sample, I'm gonna lose my target

44:03

and get bleeding and, you know, lidocaine obscuring it.

44:07

Then I go in with a vacuum.

44:08

So a vacuum you can go in one time, kind of turn it

44:11

around so that you know you're in the right spot.

44:13

Also, if I'm trying to get calcifications,

44:16

I'll use the vacuum.

44:17

So let's say I'm doing an ultrasound

44:19

guided biopsy, you of a mass that has calc.

44:21

Sometimes I'll go in with a vacuum and image

44:23

that tissue under, um, you know, get a specimen

44:26

radiograph to make sure that I also got the

44:27

calcifications that we saw on, um, the mammograms.

44:33

How do you use contrast mammogram?

44:34

Okay, that's a great question.

44:36

It's a complicated answer.

44:37

We, right now, we're pretty much using in the diagnostic

44:40

setting, if we are, um, working up somebody with dense

44:44

breast tissue and kind of findings in both breasts, I

44:47

think it's a great, more and more people are getting

44:49

it for, you know, they, they have dense breast tissue

44:51

and kind of that intermediate risk for breast cancer.

44:54

So more and more surgeons are, are

44:56

offering that, you know, instead of.

44:59

You know, which they don't

44:59

really qualify for an ultrasound.

45:02

They want something better than that.

45:03

Contrast mammogram.

45:04

I like using it there.

45:06

I hope to see it, like I said, in a, in their intermediate

45:09

risk of breast cancer population with dense breast tissue.

45:12

Um, but.

45:14

We're gonna see lots of that contrast mammography.

45:16

Right now, the thing that I find the biggest

45:18

struggle is being overcome, which is we can't

45:21

biopsy a contrast mammogram finding currently.

45:24

So in, in those cases, we have to

45:26

recommend an MRI and an MRI biopsy.

45:28

You can't go straight to an MRI biopsy off

45:30

a contrast mammogram, even though it makes

45:31

sense, insurance won't pay for it like that.

45:34

So, but there are newer technologies that

45:36

allow you to biopsy contrast mammogram findings.

45:38

So with that, like the world is our oyster, I

45:40

think we're gonna do lots of things with that.

45:42

Um, oh, how do you do a contrast mammogram?

45:44

I have a great, there's some really great

45:46

articles, but it's almost like you give

45:48

an injection, wait two minutes, and then it

45:50

uses dual energy and subtraction imaging.

45:53

That's all I'll say about that.

45:54

Um, but it's a great, great test.

45:57

Um, in cases of dense breast tissue,

46:00

can we skip regular mammography?

46:03

Or contrast mammogram ultra.

46:05

We don't miss a MA is 3D Ma

46:11

in.

46:14

People get contrast mammograms.

46:16

The only issue is like, it, it requires

46:18

an IV and an injection of contrast, which

46:21

is not without its, you know, limitations.

46:23

Um, but you know, we give

46:25

contrast all the time for, uh, CT.

46:28

And so I think we're gonna get there eventually,

46:30

unless like breast CT really proves itself

46:32

to be a great imaging modality.

46:34

Um, but yeah, I am pro contrast mammogram.

46:38

It's not FDA approved as a screening test

46:40

yet, so I think we have to get there.

46:42

The last time I checked.

46:44

Case number thickening has a side.

46:45

I'll have to go back to that.

46:47

Um, do you need to classify gynecomastia,

46:51

uh, into nodular or dendritic?

46:53

I don't, I, you know, you're just saying, I think that's

46:56

more of like a pathology and textbook type of thing.

46:59

I just say that there's gynecomastia and leave it at that.

47:02

Um, if a young patient in her twenties has micro

47:06

calcifications on her mammogram, what should we do next?

47:09

Well, why is she having a mammogram?

47:10

Number one, because we usually

47:12

start with mammography at age 30.

47:14

Ultrasound.

47:15

I mean, MRI as early as age 25, so I need

47:18

to know more about the calcifications.

47:20

Are they pleomorphic, or are

47:21

they classic of a fibroadenoma?

47:23

I need to know why we were doing

47:24

the mammogram in the first place.

47:25

Is she high risk?

47:26

Those are all things I would take into consideration

47:28

before deciding if I should buy into them.

47:30

So, need more information: asymmetry

47:33

versus non-mass enhancement.

47:34

So, non-mass enhancement is like more

47:37

of something you see as their contrast.

47:38

So, in asymmetry, you see on a mammogram, on one view,

47:40

it's a one-view finding of dense tissue on one view.

47:43

Finding, uh, linear, a non-mass enhancement

47:46

is something that you'll see on ultrasound.

47:48

I mean, on MRI or contrast mammogram, you need

47:51

that contrast to have non-mass enhancement.

47:53

It could be a number of things,

47:54

but, um, you know, it is concerning.

47:57

Um.

47:58

So, hopefully that helps.

48:00

I think that we're gonna stop here in

48:03

that setting, and then there's some chat.

48:05

Thank you so much.

48:06

Okay.

48:06

I think that was the big ones.

48:09

Um, any other questions, please feel free, feel free

48:13

to, you know, email me, message me at the booby docs.

48:16

I'm very responsive to messages there.

48:19

Uh, yeah, I always say follow me for the best information.

48:22

Thank you so much for this case review and for

48:24

everyone in the audience for participating.

48:26

Be sure to join us for upcoming webinars.

48:29

You can register for those at medality.com

48:31

and follow us on social media for updates

48:33

on future lectures and case reviews.

48:35

Thanks again for learning with us and we'll see you soon.