0:02

Hello and welcome to Case Crunch Rapid Case

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Review for the Core Exam hosted by Medality.

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to as many as we can before time is up.

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Without further ado, please enjoy this case review.

0:37

Thank you so much, and thank you

0:39

to everyone for logging in today.

0:41

Um.

0:42

Thank you for that introduction.

0:44

Today I'm gonna be talking—I'm gonna be

0:45

showing some breast imaging cases, um, with the

0:49

emphasis on appropriate workup and management.

0:52

Um, I hope you find it helpful.

0:54

Uh, these are my cute kids,

0:55

just to kick it off on the right foot.

0:58

Um.

0:59

So the goals of the lecture are to review the

1:01

appropriate workup of screening and diagnostic

1:04

findings, to emphasize important management issues,

1:07

and discuss special circumstances in breast imaging.

1:11

And just as a disclaimer, I hope I don't get

1:13

interrupted, but you're still at a clinic right

1:15

now, so I might get interrupted, but I hope not.

1:18

Um.

1:19

So before we get started, I'm gonna, uh,

1:22

give you guys some pre-test questions to test

1:24

your knowledge before we even get started.

1:27

Um, a patient presents with a palpable area of concern.

1:30

Diagnostic mammogram is negative.

1:33

What is the next appropriate step?

1:36

And I just want you to answer this in your head.

1:38

Um, you don't actually need to put up the polling

1:41

feature because I didn't give the answer yet,

1:43

but we're gonna come to this later in the talk.

1:46

So think about this, what you wanna do for

1:48

this palpable with a negative mammogram.

1:50

Reassure, ultrasound, MRI, or surgical consultation?

1:55

Um, patient had a biopsy, which

1:57

revealed atypical ductal hyperplasia.

1:59

What is your recommendation?

2:01

You followed up in six months with the BI-RADS 3.

2:03

53 00:02:03,794 --> 00:02:05,655 Say it's benign, follow up in one year.

2:05

Surgical excision with a needle loc or

2:07

surgical excision with stereotactic biopsy.

2:11

So, you can take a minute and answer that in your head.

2:14

We will learn the answer if you don't know it already.

2:18

Um, and what is the difference between

2:20

multifocal and multicentric breast cancer?

2:23

So, um, multifocal involves more than one quadrant. Um.

2:27

Multicentric involves one quadrant.

2:29

Uh, B-multicentric involves more than one quadrant.

2:32

Multifocal involves one quadrant.

2:34

You know, it gets a little confusing

2:35

with this multifocal multicentric.

2:37

So, we're gonna talk about, you know,

2:39

which one is which, um, going forward.

2:43

All right, so 70-year-old female presenting with a

2:45

palpable area of concern in her right upper outer breast.

2:49

This is her baseline study, and when you're

2:51

reading a case in MAMO, it's really important to—

2:55

to determine whether it's a

2:57

screening or diagnostic study.

2:59

So, you know, for starters, a screening

3:01

study is an asymptomatic patient.

3:03

So, by definition, this should be a diagnostic study.

3:06

If it's not, you have to call them back.

3:08

But palpable should be a diagnostic study.

3:11

So already we kind of are

3:12

thinking it's a diagnostic study.

3:14

So, keep that in mind when you're giving your

3:15

BI-RADS, uh, because it does make a difference.

3:19

So, um, these are—this is her CC view.

3:22

Um, she has a palpable in her right upper outer breast.

3:26

Um, and certainly, you can see an irregular spiculated

3:29

mass, um, in her right upper outer quadrant.

3:33

But, um, take a minute and just see if you see

3:36

anything else, particularly in the other breasts.

3:39

Satisfaction of search is a big problem

3:42

or diagnostic dilemma in breast imaging.

3:45

So, even once, once people find the cancer, their

3:48

natural tendency is to stop and, and stop looking.

3:51

But, um, if you look, you'll notice that there is actually

3:55

a fo—there's two focal asymmetries in the left breast.

3:58

So, um, let me—why is that not coming up?

4:02

So, she's got one here, which is in the left,

4:06

um, upper inner breast and then also one in the

4:08

left upper outer breast, which, um, you know,

4:13

you could get—I would recommend getting spot

4:15

compression for those to see if it persists.

4:18

Um, and then we would proceed

4:20

to ultrasound for both sides.

4:22

So, you know, when you're looking

4:23

at the left, left upper inner.

4:25

So I always want you to think about what quadrant

4:27

we're in, in terms of clock position, because

4:29

that becomes important when you're looking at the

4:31

ultrasound to make sure you found a correlate.

4:33

Um, so in the right breast,

4:35

this is her palpable area of concern.

4:37

You can see a large, um,

4:40

irregular hypoechoic mass corresponding

4:42

to the area, palpable concern.

4:44

I don't have calibers on here,

4:46

but it's certainly over two centimeters.

4:48

Um, and then always, you know, we—it really

4:52

is institutional dependent, but at our

4:55

institution, if you see something that's highly

4:56

suspicious for malignancy, we always look in

4:58

the axilla to see if there's any abnormal nodes.

5:01

Um, and in the left, remember we said that there was

5:04

something in the left upper outer quadrant, so, um—

5:07

I'm sorry, there was something in the left

5:09

upper inner quadrant, so this is left upper

5:11

inner, so there's an irregular mass at 10,

5:13

and then there was a second one at two eight.

5:17

So these are different quadrants at the left breast.

5:20

So, um, I want you to think, is that

5:23

multicentric or multifocal on the left?

5:27

Uh, and what BI-RADS would you give?

5:29

So you wanna give that a BI-RADS 5.

5:33

So, we're gonna take a minute to talk

5:34

about multicentric annd multifocal cancer.

5:36

So multicentric is more than one quadrant,

5:39

so on the left, when it's 10 o'clock, so it's left

5:41

upper inner, and then two o'clock, which is

5:43

left upper outer, that would be multicentric.

5:46

Uh, multifocal is when you have two areas of

5:49

disease and one quadrant or fairly close together.

5:53

Um, synchronous.

5:54

So she also had this, so she had synchronous cancer.

5:57

So, two tumors diagnosed

5:59

within six months of each other.

6:01

Um, or metachronous means two tumors diagnosed

6:05

greater than six months apart.

6:07

Um, so it's not uncommon to find something in the other

6:10

breast, um, where, you know, in the other quadrant,

6:13

that's why we get staging MRIs to see, you know,

6:15

if you didn't really find that on the screening mammogram

6:18

or on the diagnostic mammogram, you would certainly

6:20

find it as part of the staging workup with an MRI.

6:24

All right, so that was case number one.

6:27

So case number two, 54-year-old female

6:30

presenting with a painful new lump in her left

6:32

breast, negative mammogram two months prior.

6:35

Um, so you know, if it was a negative mammogram

6:38

two months prior, you could, you could consider

6:40

going straight to ultrasound at that point.

6:43

Um, for some reason we did a mammogram.

6:45

Um, you'll see this triangular marker

6:48

right where she's having the lump.

6:50

Um, you can see that she's got

6:51

this pre-pectoral saline implant.

6:54

The pec goes—the saline implant is in front

6:56

of the pec, so it means it's pre-pectoral.

6:59

We know it's saline 'cause you can see through it

7:01

and you can see the nozzle for the saline infusion.

7:05

Um, so again, she's got this area palpable

7:08

concern indicated by the triangular marker.

7:12

Um, again, nothing really two months prior.

7:16

On the implant displaced view, uh, there's

7:19

maybe a little skin retraction there.

7:21

Um, so what is the next step for the area of

7:24

palpable concern on this diagnostic mammogram?

7:29

Do we wanna reassure her, send her for a surgical

7:32

consult, do an ultrasound, or do a biopsy?

7:38

So everyone got that right?

7:39

Great.

7:40

So yes, you always wanna do an

7:41

ultrasound if something is palpable.

7:43

So that's why they have to be a diagnostic, so you can

7:46

do that ultrasound, even if the mammogram looks normal.

7:48

Definitely wanna get an ultrasound.

7:51

Um, let me move this alone.

7:54

So, right. Utrasound's correct.

7:57

And at 11 o'clock, three centimeters in

7:59

the nipple, we see an irregular hypoechoic

8:01

mass, um, an abnormal lymph node as well.

8:05

Uh, like I said, we always look in the lymph node—

8:08

in the axilla to see if there's any abnormal nodes.

8:11

So what would be your appropriate BI-RADS for this mass?

8:15

Notice I left BI-RADS five out, so there's no confusion.

8:21

Good. So everyone's gotten that right.

8:22

So you guys are doing good here.

8:25

Alright, so let's keep going.

8:26

Yeah.

8:26

So that's a BI-RADS four.

8:27

Obviously, you're gonna want to do, um, a biopsy if, um—

8:33

If you see it on ultrasound and stereo—uh, and mammogram,

8:38

it's better to do it under ultrasound because what we're

8:40

really going for is we wanna know if it's invasive cancer.

8:44

Um, if you do a stereo and target the calcifications,

8:47

you might get DCIS, but no invasion, and you may

8:50

be falsely reassured, so they won't do nodes.

8:53

They won't do a sentinel node

8:54

biopsy or anything like that.

8:55

So that's why it's important if you see

8:57

it on mammogram or ultrasound and have the

8:59

choice, you want to do it under ultrasound.

9:01

So, of course, this came back as

9:02

invasive ductal grade three.

9:05

Um, you know, it always tells us the estrogen progesterone

9:08

receptors and the HER2/neu, um, and that sentinel,

9:12

that lymph node was biopsy positive as well.

9:15

This is what it looks like on the MRI.

9:17

You could see it's sitting right

9:18

on top of her breast implant.

9:21

Um, and she's got that abnormal node.

9:25

Okay, case number three.

9:27

So, 71-year-old female presenting

9:29

for annual screening mammogram.

9:32

So, this is her mammogram in 2016.

9:37

Um, and it's kind of a subtle finding,

9:40

so I'm gonna draw your attention to it. But

9:45

it's in the right upper breast.

9:47

So, you really see it up here.

9:49

This is here from 2010.

9:51

You have something in between that

9:53

is from 2012. So you can see that,

9:57

um, well, let's see what you see.

10:01

So, the salient finding, oops,

10:03

sorry, I didn't mean to away.

10:06

So, we see it on one view and it's been kind of

10:10

growing or becoming more conspicuous over time.

10:15

So, would that be an involving asymmetry, focal

10:18

asymmetry mass, or architectural distortion?

10:23

Good.

10:24

Good.

10:24

So, I'm glad somebody got this wrong 'cause you guys were

10:27

doing too well and you didn't even need this lecture.

10:29

But yeah, so an asymmetry is something

10:31

that you're gonna see on one view.

10:33

Um, and it's not a mass.

10:35

A mass has convex borders.

10:37

So, if we go back to just look at that, um, that

10:40

lesion, you could see, we only saw it on the, we

10:43

really didn't know where it was on the, um, CCVO.

10:46

We saw it in the right upper breast.

10:48

Um, you can't really call it a mass because the

10:50

mass you have to see on two views and a, and

10:52

you can't really call it a focal asymmetry

10:54

Also, 'cause you have to see that on two views.

10:56

So really, it meets the criteria for developing asymmetry.

11:00

Um, like we said, so the appropriate BI-RADS here.

11:08

Good.

11:09

Yeah.

11:09

So developing asymmetries are suspicious.

11:11

Um, and you would want to call her back.

11:14

Um.

11:15

To kind of work that up further.

11:18

Um, you know, BI-RADS one is negative,

11:19

so it's certainly not negative.

11:21

BI-RADS two is benign.

11:23

BI-RADS three is probably benign.

11:24

You really can't give that off a screener.

11:26

There are certain circumstances where

11:28

you can, but this is not one of them.

11:30

Um, so in terms of what you

11:32

want to bring the patient back for.

11:34

All we really know is that there is an asymmetry.

11:36

We know it's in the upper breast.

11:38

Um, I like to do tomosynthesis.

11:40

I mean, you could do this by compression as well,

11:43

but really, we don't know where it is except that

11:45

it's in the upper breast and it's really small.

11:47

So if we need to kind of know what quadrant it's in,

11:50

so tomosynthesis is going to give that a set location

11:53

information. That's going to be really helpful to

11:55

determine, you know, where it is in the breast.

11:57

Can we biopsy it under ultrasound if necessary?

12:00

So.

12:02

Tomosynthesis.

12:03

So this is an ML. Um, and actually, sorry, this is an MLO

12:07

and this is actually an image from an MLO tomosynthesis,

12:11

and I don't know if you've ever paid attention to this.

12:14

Um, as you scroll through a tomo, you're going to see

12:18

something that looks like this clock and the line.

12:22

So this is a really helpful tool to help

12:24

triangulate where you are in the breast.

12:27

So in this case, um, where is the abnormality located?

12:33

So I want you to tell me which quadrant, this is

12:35

the right breast, but now what quadrant is it?

12:38

What are you going to tell the tech to look for?

12:43

Okay, good.

12:46

This.

12:47

What this is telling us is that we

12:49

know it's in the upper breast, right?

12:51

So the correct answer is actually nine to 12.

12:54

Um, so actually, I don't think, I don't

12:56

think anyone got that right, so it's

12:58

good that we're getting something wrong.

13:00

So I want you to learn something, so we

13:01

know it's in the upper breast, right?

13:03

Here's her nipple.

13:04

If we go straight back, then we

13:05

know it's in the upper breast.

13:07

So already we either know it's.

13:09

In this quadrant or this quadrant, and this line is

13:12

telling you that this is where we are in the upper breast.

13:14

So it's, you know, it's not a straight up and

13:16

down line, it's oblique because the MLO is oblique.

13:18

So what this is telling us that it's in this

13:20

quadrant, the nine o'clock to 12 o'clock, it's in the

13:23

upper breast and we know it's in the outer breast.

13:25

If it was in the lower breast.

13:28

Like, let's say it was below the nipple, then it

13:30

would actually be in the three to six o'clock range.

13:32

So this is a really helpful tool.

13:34

If you see something on one view, you know, in the past

13:37

we would get true lateral to see if it drops or if it

13:40

rises, um, to see if it's in the medial or lateral breast.

13:43

But this is a great tool that, um, so

13:45

tomosynthesis is really helpful for triangulation.

13:48

Um, so now we're gonna tell the tech

13:50

to look in the nine o'clock to 12.

13:55

So the tech goes in, you know, really she

13:57

shows me a negative picture, but I'm worried.

13:59

So I go back in and I find this very, very subtle thing

14:03

at 10 o'clock, uh, 10 centimeters from the nipple.

14:06

It's slightly irregular, but

14:08

it's really the right location.

14:11

Um, and uh, we think it corresponds to the mass.

14:16

Um, again, we always look in the lymph node.

14:18

That looks fine.

14:20

So that would be a BI-RADS four.

14:22

Um, you know, it was suspicious and

14:24

it ended up being invasive ductal.

14:26

Um, so evolving, focal or evolving asymmetries.

14:31

Are a new or increasing, uh, in,

14:37

in size or conspicuity compared to prior mammograms.

14:40

Um, so in this case it was developing, you

14:44

know, it got more conspicuous over time.

14:46

The risk of malignancy is high for developing asymmetry.

14:49

Um, certainly over the 2% that would warrant a biopsy.

14:53

So this would certainly be a BI-RADS four.

14:55

And if you didn't see it on ultrasound.

14:58

Then you would biopsy it under stereotactic biopsy.

15:02

I don't want you recommending an MRI.

15:04

Um, really you should be able to biopsy.

15:07

You see that, you see it well enough on a, on a, um,

15:10

mammogram that you go biopsy under the mammogram.

15:12

But developing asymmetries have

15:14

a very high risk of malignancy.

15:16

Certainly well over the 2% that we would,

15:18

um, you know, accept for probably benign.

15:21

So that would need to be biopsied.

15:23

Um.

15:25

A focal asymmetry on a baseline is a different situation.

15:28

So if you have a focal asymmetry on a baseline and you

15:31

do the appropriate workup, you get spot compression

15:33

views and you do an ultrasound, there's nothing there.

15:36

Then you could say it's probably benign by BI-RADS 3.

15:38

But if it's a growing or new focal asymmetry or

15:41

asymmetry, that needs to be addressed, so that is

15:44

suspicious and should be biopsied one way or another.

15:47

Um, and this is actually a great, um, article

15:50

in radiology that developing asymmetry,

15:52

revisiting a perceptual and diagnostic challenge.

15:55

So if you need some nighttime reading, I recommend this.

15:58

Um, so she goes on to have breast

16:01

conservation therapy, right?

16:02

It's one small little area.

16:05

What can we do in radiology to take out the tumor?

16:09

Um, and I'm gonna give you a minute to answer this.

16:16

So I, and I will give you a hint.

16:18

This is what it would look like if you do this procedure.

16:24

Good.

16:25

Glad some people got this wrong.

16:27

So.

16:29

Um, you know, on the board they can certainly show

16:31

you something that looks like this alphanumeric grid.

16:34

Um, when you see an alphanumeric grid,

16:36

you know it's a needle localization.

16:38

So needle localizations are done before

16:40

surgery to help localize something that we

16:42

can't see, that the surgeon can't see or feel.

16:46

Um, stereotactic biopsy.

16:47

On the other hand, I wish I put a picture

16:49

of my lecture, but it looks different.

16:52

Um.

16:53

It's going to have a little box.

16:56

You know what I, I'll, I'll add that for the next time.

16:58

But when you see an alphanumeric

17:00

grid, you know it's a needle localization.

17:01

Um, and that is what we do in, uh, mammogram,

17:05

in breast imaging to help, um, localize it.

17:09

Um, something before surgery, you could do

17:11

it under mammogram, you could do it under

17:12

ultrasound, you could do it under MRI.

17:13

If you have the capability, you could put

17:15

a tag in and then they take it out later.

17:18

Um, so be familiar with those procedures.

17:21

Because it's something we do often.

17:23

Um.

17:24

And my question to you is, um, I, I, I want people,

17:31

Actually, this is very interactive, so I want people to

17:33

Jump in, and if they have any questions about anything

17:35

I'm talking about, um, I don't know if you guys are

17:38

In practice or your residents, but, um, certainly if

17:41

There's something I talk about you're not familiar with

17:43

And you want more information, please, um, let me know.

17:47

Feel free to ask.

17:48

So we wanna, what size needle

17:50

Are we using, and what approach?

17:52

For our needle localization.

17:58

Good.

17:59

All right, so we have things all over

18:00

The board, so I'm so happy about that.

18:02

And let me take a minute to explain what is going on here.

18:05

So this is the ML. This is her

18:08

Clip, and this is the, um, CC view.

18:11

So what you're trying to do when you're

18:12

Planning for a needle LO, is you wanna

18:14

Find the shortest, um, skin surface.

18:17

So, you know, certainly it's in the upper outer breast.

18:19

So if we measure from the, from the superior

18:21

Breast, it's about seven centimeters.

18:24

If we measure from the lateral breast, it's 4.2.

18:27

So already we know we wanna come from lateral.

18:29

That's just the closest skin surface.

18:31

Now you wanna talk about what size

18:33

Needle you need for a needle LO.

18:35

Um, typically they come in 3, 5, 7 and a half, or 10.

18:39

But the, the, the real underlying theme

18:42

Is that you need something that's long

18:43

Enough to reach the, um, oh, I'm sorry.

18:46

The answer is five centimeters from lateral.

18:48

It needs to be long enough that you reach the lesion.

18:51

It's okay to go past it, but um,

18:54

You don't wanna be too short.

18:55

So a three would be too short.

18:56

A seven and a half would be really long.

18:59

You would need to pull it back.

19:00

'Cause really you're gonna want the hook, right?

19:02

Kind of at the tip.

19:03

So we're gonna come from lateral with a five.

19:06

Um, this always trips up patients, um,

19:09

Residents, but if you're coming from lateral.

19:12

You're positioning the patient, LM.

19:15

Okay, so for some reason it didn't show up well, but

19:18

Let's say that the, the, um, the clip is right here.

19:22

So you would go in.

19:25

0.5. So that would be right here.

19:28

And you basically go in straight, um, straight with

19:33

your needle at one, sorry, at 0.5 in E, and then

19:37

you're gonna take a picture to see that it looks

19:39

like it's straight and right on top of your lesion.

19:41

So in this case, it is.

19:43

So all we know is, is in the same plane as our lesion,

19:47

but we don't really know how deep it is yet until we

19:50

take the patient out of LM and then put her in CC.

19:54

Okay.

19:54

And so you can see that the needle

19:56

goes right to where we want it to.

19:58

So it's the five centimeters is just perfect.

20:01

Um, you know, if we went seven and a

20:03

half, it would be a little too deep.

20:05

So once you confirm that the needle looks good,

20:07

then you're gonna put the, um, wire through that

20:09

needle and it's gonna look something like this.

20:12

Okay, so it's at our institution.

20:14

The patient will go to surgery with both

20:16

the needle and wire into, in their breast.

20:19

They put a little Dixie cup and they wheel them over.

20:21

They usually go to same-day surgery.

20:24

Um, they go to surgery and then

20:26

they're gonna send you a post.

20:27

Um, after surgery, they'll send

20:29

you a post-surgical specimen.

20:30

So you're going, you're, when you do a specimen,

20:33

you're making sure that you have the mass

20:35

and the clip and the whole needle and wire.

20:38

Sometimes they could break in the breast.

20:40

Um.

20:41

So you wanna make sure that you

20:42

don't leave any fragments of that.

20:45

And, um, yeah, any questions about this?

20:48

This is a really important concept.

20:50

I would love you to understand.

20:52

Um, so take a minute to look at this.

20:56

Um,

20:59

okay.

21:00

If anyone has any questions, like

21:01

I said, please feel free to ask.

21:03

Okay.

21:05

All right.

21:07

So moving on, 41-year-old female

21:09

presents for a baseline mammogram.

21:12

Bilateral implants were placed 10 years

21:14

ago, so, um, these are her CC and MLO views.

21:21

It's, I will tell you, it's really hard to see it

21:23

on these views, but look at this mammogram and what,

21:27

number one, what type of implant does she have?

21:29

Does, is it saline or silicone?

21:32

And is it behind the pectoral

21:34

or in front of the pectoral muscle?

21:36

So in this case, these are retropectoral.

21:39

So you can see the pectoral muscle coming around the

21:41

implant and they're saline because you could

21:43

see through them silicone implants tend to be

21:45

denser and they are more white and you won't see

21:48

this nozzle like you do in, um, saline implants.

21:52

So they're, um, they're retropectoral implants.

21:55

But what I will tell you that doesn't

21:57

display that well is that she's got some

21:59

calcifications in her left upper outer breast.

22:03

Um, that, I don't know if that's

22:06

displaying well, but they're there.

22:07

Okay.

22:10

So you're gonna give her a BI-RADS 0 because, um, we

22:14

need to call her back for additional diagnostic views.

22:18

What view should we get to further

22:20

evaluate these calcifications?

22:24

CC and MLO mags.

22:26

CC and ML mags.

22:29

Um, SPA compression or XCCL.

22:39

Okay, good.

22:41

So the correct answer is CC and ML magnification views.

22:45

Um, really there's no indication for any MLO mag.

22:50

The reason we're getting ML mag is to see

22:53

if, um, or true lateral magnification view

22:56

is to see if the calcifications layer.

22:58

Okay, if they layer, it's benign milk of calcium.

23:01

So that's really the best way to see if something layers.

23:04

So whenever I see an MLO magnification

23:06

view, I kind of roll my eyes because there's

23:08

really no role for MLO magnification.

23:11

So if you see that on a test, you

23:12

could already, um, exclude that answer.

23:15

Um, so yes, certainly for calcifications,

23:18

we wanna get magnification.

23:19

Always wanna get CC and ML, not MLO.

23:23

Okay, so, um, these are her calcifications.

23:28

If I had to use a descriptor, I would say that they're,

23:31

uh, they are segmental, pleomorphic, calcifications.

23:35

They span a large extent.

23:37

They span about 10.5 centimeters.

23:40

Um, I don't always do an ultrasound, but in

23:43

this case, I felt like there was maybe

23:45

an underlying mass and she was so dense.

23:47

We've been doing a lot more survey ultrasounds.

23:50

So in this case, we saw an irregular hypoechoic mass in the upper outer quadrant.

23:52

coic mass in the upper ATAR quadrant.

23:54

Um, you can see these little punctate echogenic

23:57

foci, which corresponds to calcifications.

24:01

Um.

24:02

We're suspicious. We're gonna look in her lymph node.

24:05

This is a BI-RADS four or five,

24:07

depending on how confident you are.

24:09

But certainly, if these are—this is very suspicious.

24:12

Um, like I said, in this case, actually we

24:16

did it under—actually in this case, I think

24:18

we did a stereo and an ultrasound biopsy.

24:21

Remember, if you see something on mammogram

24:23

and ultrasound, you would like to biopsy

24:24

under ultrasound to give you the better chance

24:27

of getting invasive cancer, if there is any.

24:30

Is what her MRI looked like, you know?

24:32

So she's got this linear, clumped, non-mass enhancement in

24:35

the left upper outer breast, um, that corresponds to where

24:40

we saw the calcifications, and it's certainly suspicious.

24:44

Okay?

24:46

So, 29-year-old female presenting with a palpable

24:50

lump in the left breast for three weeks.

24:53

Um, what is the first step?

24:57

Oh, sorry.

24:58

What is the first step?

25:00

Um, so under age 30, you're gonna

25:04

wanna start with an ultrasound.

25:06

Um, so in this case, we see a mass

25:09

right where she is feeling the lump.

25:12

And then the next step, what's the next best step?

25:17

Do you wanna do an ultrasound biopsy,

25:20

a mammogram, and an ultrasound biopsy,

25:24

or refer to a breast surgeon?

25:33

Alright, so I'm glad most people got this wrong.

25:37

So if you see something suspicious on ultrasound in

25:40

a patient that you know, that's under 30, you—you

25:43

certainly wanna do an ultrasound biopsy, but you're

25:45

also gonna wanna do a mammogram because really this

25:48

could be the tip of the iceberg, and in this case, it was.

25:51

Um, so you're really going to assess both breasts.

25:54

I mean, you might see calcifications

25:56

that you didn't realize were there.

25:58

Um.

26:00

You couldn't appreciate on ultrasound.

26:02

So in this case, you wanna do ultrasound

26:04

and bi—a mammogram and ultrasound biopsy.

26:06

There's a little subtle skin thickening

26:08

here, and maybe a lesion in the skin.

26:11

Um, so here's what her mammogram looks like.

26:15

Okay?

26:16

So you could see that the left breast is,

26:20

um, has diffuse trabecular and skin thickening.

26:24

Um, and if you didn't appreciate that.

26:27

Just by, you know, imaging, if you looked at

26:30

the, um, if you looked at the, um, thickness of

26:35

the breast, the right breast is 6.8 centimeters,

26:39

and the left breast was 9.2 centimeters.

26:41

So really the left breast is very

26:43

enlarged, very swollen, and emus.

26:47

So already you're starting to think that this,

26:49

this is suspicious for inflammatory breast cancer.

26:52

Um.

26:53

If you went in to go see the patient,

26:55

you would see the discrepancy, the size

26:57

discrepancy, and that's often how they present.

27:00

Um, this is a beautiful case.

27:02

If anyone knows what this is, take a minute

27:04

and think of what, what is this study?

27:07

Um, but this is something we do here at Cooper.

27:09

Um, it's called a contrast mammogram.

27:11

If you've never seen it, it's a really great study,

27:14

especially, it's kind of like doing an MRI on the same

27:16

day as a mammogram, but basically you give them contrast,

27:20

you do, you give them contrast, and you do low dose.

27:23

It's a dual energy mammogram.

27:26

You get low energy and subtraction images, so

27:29

low energy look just like a regular mammogram.

27:33

And then the subtraction images will show

27:35

you if there's any abnormal enhancement.

27:36

And in her case, you could see that she's got, um, you

27:40

know, many enhancing masses throughout the left breast.

27:43

Um, and skin thickening.

27:45

And then she's also got this little

27:46

right breast mass that ends up being a

27:49

fibroadenoma, but it was certainly undressed.

27:51

But now we know that she's got multiple lesions,

27:53

so now you could appreciate the skin thickening.

27:56

You know, she had that one lesion at six

27:58

four, but then she's got things at seven four.

28:00

She's got abnormal nodes, she's got things,

28:02

she's got multicentric cancer, and every quadrant

28:06

she's got diffuse skin thickening, abnormal

28:09

axillary, and infraclavicular lymphadenopathy.

28:13

Um, this is certainly a BI-RADS 5, um,

28:17

invasive ductal with lobular features.

28:20

This is what her PET/CT looked like.

28:22

Um, so you could see like, just to give you

28:24

an idea, um, CAT scan, how asymmetric the

28:27

breasts are, but it's certainly enlarged.

28:29

You can see the diffuse skin thickening

28:31

and all those masses that are PET

28:33

positive, FCG positive in the left breast.

28:38

Um, and you can see all of her lymphadenopathy.

28:41

So once it's inflammatory by definition, you know,

28:44

they're gonna have, they might have that, um,

28:47

swollen, peau d'orange, uh, appearance of the breast.

28:51

Um, you know, it can often mimic mastitis, but

28:53

in the clinical history has to be appropriate.

28:56

Like it has to be, you know, um.

29:00

You would, if they, if it was only going on for a

29:03

short period of time, you would maybe try antibiotics.

29:05

But at this point, we were suspicious and

29:07

she went straight to, you know, we kind

29:09

of bypassed the whole mastitis argument.

29:12

All right.

29:13

Any questions there?

29:15

Please chime in if you have anything.

29:18

Um, all right.

29:20

So we're gonna keep on going.

29:23

So 79-year-old female, history of right breast

29:26

cancer, status post mastectomy one year ago,

29:29

presents with a palpable mass on her right axilla.

29:34

So,

29:39

so she, you know, she had mastectomy.

29:41

So you're gonna wanna start with

29:42

an ultrasound in these patients.

29:44

Um, and you can see this little hypoechoic mass.

29:50

It looks like it has some internal

29:51

vascularity, so certainly it's suspicious.

29:56

If you have something in a postmastectomy patient that

29:59

does not clearly, you know, it's not clearly a benign

30:01

lymph node or fat necrosis, you're gonna wanna biopsy it.

30:06

Um, we did an FNA and it was positive

30:09

for malignant cells, adenocarcinoma.

30:12

New palpable areas of concern

30:13

following mastectomy are suspicious.

30:15

They must be evaluated under ultrasound.

30:18

You might wanna even consider a mammogram if you're

30:20

thinking it might be fat necrosis and you wanna

30:22

see if there's like coarse calcification there.

30:25

Um, but they certainly do have recurrences.

30:28

There's like 10% left breast.

30:30

Depending on the surgeon, there can be as

30:31

much as like 10 to 20% left of breast tissue.

30:35

Patients with mastectomy are not routinely screened

30:38

with mammogram, so those patients are gonna

30:40

really present with a palpable area of concern.

30:43

You certainly want to biopsy it if the

30:45

imaging appearance is not clearly benign.

30:49

And like I said, recurrence after mastectomy

30:51

is usually palpable, and that's the reason

30:52

they're usually fairly superficial just

30:55

because of the way they do the reconstruction.

30:57

If they do a TRAM flap, they have a little bit of

30:59

native breast tissue on the top, and then under that

31:02

is abdominal fat, so it's gonna be at that, like,

31:05

interface between where they do the reconstruction.

31:08

So they usually are palpable and that's how you're

31:10

gonna find a cancer in a mastectomy patient.

31:15

Um, so this was again, her PET/CT.

31:18

You could see this PET-avid lesion and the

31:20

right axilla, right where she was feeling

31:22

the lump and ended up being a cancer.

31:25

So I thought I had a few more cases, but I guess not.

31:29

Um, so in

31:34

patients, present with palpable

31:36

area of concern.

31:37

Diagnostic mammogram is negative.

31:39

What is the next best appropriate step?

31:48

So, yeah, you certainly wanna do an ultrasound.

31:50

I mean, MRI.

31:52

Not really appropriate if we

31:53

haven't done an ultrasound yet.

31:55

If, you know, if you do a mammogram, an ultrasound

31:57

and it's negative, but it's still suspicious, then

32:00

you would consider maybe an MRI or surgical consult.

32:03

There is a very small risk of malignancy

32:05

with a negative mammogram and ultrasound.

32:07

It's around, it's under 4%, but that's a decent amount.

32:11

So, you know, if something is suspicious on mammogram.

32:14

If something is suspicious on clinical exam and

32:16

the mammogram and an ultrasound are negative, then

32:18

you might consider an MRI or a surgical consult,

32:21

but not, um, you would wanna go to ultrasound next.

32:25

Um, patient had a biopsy which

32:28

revealed atypical ductal hyperplasia.

32:30

What is your recommendation?

32:36

Good.

32:37

All right.

32:37

So, yeah, atypical ductal hyperplasia is a high-risk

32:40

lesion, so you are going to want to take it out.

32:42

It would be surgical con um,

32:44

surgical excision with needle localization.

32:46

Remember, needle localization is that type of procedure that

32:48

we do, that I showed you with that alphanumeric

32:50

grid where, um, we're gonna put a needle in and

32:54

a wire, and then they're gonna go to surgery.

32:56

So, atypical ductal hyperplasia should be taken out.

32:58

Um, and, uh, most, most surgeons would take that out.

33:02

That one's not as controversial as an LH or LCIS.

33:06

All right, and last question.

33:08

What is the difference between

33:09

multifocal and multicentric cancer?

33:16

Good.

33:16

So everyone got that, right?

33:17

So I'm happy about that.

33:19

Um, yeah.

33:19

Multicentric, I'm sorry.

33:21

Um, wait, did I get that right?

33:25

I don't know.

33:25

Multicentric involves more than one quadrant.

33:27

Multifocal is going to involve, good.

33:29

Everyone got that right?

33:30

Good job.

33:32

Um, involves more than one quadrant.

33:34

So, um, you know, in summary, we talked about the

33:39

appropriate workup of screening and diagnostic

33:41

findings, emphasized some important management issues

33:45

and discussed special circumstances in breast imaging.

33:48

Um, this is my child eating an ice cream sandwich.

33:54

If you have any questions, please

33:56

don't hesitate to email me.

33:58

This is my email address, Ross Robin at Cooper Health IU.

34:01

Also, shameless plug, you can follow me and

34:03

my best friend at The Booby Docs on Instagram.

34:05

We are both radiologists, breast

34:07

radiologists, and we work together.

34:09

So we talk about, um, breast health in an

34:11

approachable way, so you can always check that out.

34:15

Um, I want to open up the floor for any questions.

34:18

You know, we have a little bit, we have a

34:19

few minutes left, so if there's something I

34:21

talked about that you want more information on.

34:23

Especially like needle looks or something.

34:25

I'm happy to show you more images and even images from

34:27

a stereotactic biopsy so you could tell the difference.

34:30

So whatever, you guys would be helpful.

34:31

This is your time, you know, if you want, um, if

34:35

you just give me one minute, I want to show you if I

34:38

could pull up another portion of a lecture so I

34:41

could show you actually what a stereotactic biopsy

34:43

looks like, because I think it really is important.

34:47

To know the difference between the two

34:50

or to recognize it just by seeing it.

34:52

Brian, am I able to do this? Yeah, we are.

34:54

And I just wanted to say we do have one question.

34:57

Um, are there any okay

34:59

on triangulation.

35:01

No, but you could take a tomosynthesis course and

35:04

it's really not, I mean, it's not hard, and I'm

35:07

happy to talk about more about, um, that concept.

35:11

But it really is, if you, if you've done any tomo

35:15

tomosynthesis and you start paying attention to that

35:17

little clock in the grid, you'll notice that, um, that.

35:23

That you'll, if you pay attention to it,

35:24

you'll start to see that, um, you know, it

35:27

will tell you where you are in the breast.

35:29

So that is a really important feature of tomo that's not

35:32

as discussed that, um, I would like you to recognize.

35:36

Um, so this is what a stereotactic biopsy looks like.

35:40

Um, so unlike the needle localization,

35:44

which had that alphanumeric grid, you're

35:46

gonna see, um, this little kind of.

35:51

And that's where the calcifications are going,

35:54

where you wanna center the calcifications.

35:57

So it looks like, you know, people I think often get

35:59

confused between the two, but they look fairly different.

36:01

Um, this is a stereo, you'll know because you'll see that.

36:05

This needle device kind of here,

36:07

this, this radiolucent grid.

36:10

Um, you might be getting, um, you know, I'll,

36:13

I'll let you look at these too, but these are some

36:15

other questions based on stereotactic biopsies.

36:18

So this is a type of, if you were looking

36:20

at this, I don't have this pull feature,

36:23

but this is from a stereotactic biopsy.

36:27

Um, the degree of separation.

36:29

So this always catches, this always messes people up,

36:32

but when we take, when we do a stereotactic biopsy,

36:34

you're gonna get the calcifications, you're gonna

36:37

get them, you're gonna take a, um, mammogram picture

36:39

at zero degrees and then plus and minus 15 degrees.

36:44

Um, and so people naturally wanna say that the,

36:47

the degree of separation is 15 degrees, but it's

36:49

actually 30 degrees because it's plus and minus 30

36:53

degrees, so, I'm sorry, plus and minus 15 degrees.

36:55

So it's a degree of separation

36:57

of 30 degrees between the pairs.

37:00

Um, let me skip this part.

37:03

So the, like I said, this is a stereo,

37:05

this is a 30 degree separation.

37:08

Um, I wanna quickly show you, I think that these are.

37:14

Um, I don't know if you guys have come across this

37:17

question, but stereotactic errors are a really big

37:21

important concept that I want you to understand.

37:23

And I really didn't even understand it

37:25

myself until I made this lecture, so this

37:28

is actually from another one of my lectures.

37:30

But, um, when you have a stereotactic error.

37:34

Basically, the lesion should look correct.

37:37

On both, it should look in the trough.

37:40

On both a positive and minus 15 degrees.

37:42

So, if it's not correct on both of these, you know,

37:46

it's, there's some error, some stereotactic error.

37:49

So, in this case, you could see that the trough

37:52

is too far to the right on both of these.

37:55

So, that is telling you that it's an X error, and it's

37:57

a positive X error because it's too far to the right.

38:00

If it was too far to the left,

38:01

it would be a negative X error.

38:04

Okay, so this is an important concept.

38:07

Um, when it's either in front of

38:10

it or behind it, it's going to be a Y issue.

38:13

Um, it's easier to describe when first recognizing if it's an X or a Y,

38:18

um, error.

38:22

And then you have to decide if it's positive or negative.

38:25

Ma'am, these stereo errors are based on a prone table.

38:29

So when the patient is lying on their belly,

38:32

and their breast is hanging through, so I

38:34

always want to say that this is a negative.

38:36

Why error?

38:37

This is a Y error because it's

38:39

either behind it or in front of it.

38:41

In this case, I want, everyone always thinks that this

38:43

is a, you know, negative Y error, but it's actually a

38:45

positive Y error because the patient is actually prone.

38:49

So it kind of goes opposite of what you think.

38:52

Um, in this case, the trough is too far to the left on

38:55

both of them, so it's going to be a, um, negative X error.

39:02

Okay.

39:03

Um, I'm going to skip this one question 'cause I think it's

39:06

worded wrong, but this one, it looks like it's too far

39:09

to the right on one and too far to the left on another.

39:12

It actually is just telling you it's

39:14

not deep enough, so it's a Z problem.

39:17

So it's a negative Z problem.

39:18

'Cause really you need to go in deeper.

39:20

You're not deep enough.

39:22

Um, so again, and this one is.

39:27

It's too far to the left and one too

39:28

far to the right on the other.

39:30

This is telling you it's too deep,

39:31

so it's a positive Z problem.

39:34

So it's a, um, so I hope that makes sense.

39:38

Like I said, this one, the trough is

39:40

too far to the right on both of them.

39:42

It's a positive X error.

39:45

Um, and this one.

39:47

Like I said, it's behind it, so you, you know, it's a Y

39:51

issue, but in this case, it's a positive Y issue and that's

39:54

based on the fact that the patient is usually prone.

39:57

We use an upright table, but this

39:58

is all based off of the prone table.

40:01

Um, in this case, it's too far to the left on

40:04

both, so it's gonna be a negative X error.

40:07

Um, I'm skipping this one 'cause

40:10

I think this is poorly worded.

40:12

Again, this is, um, not deep enough.

40:15

It's too far to the right on one and

40:17

too far to the left on the other.

40:18

You really just need a, it's a negative Z error.

40:20

It's not in far enough.

40:22

You would, you would fix that by going in further

40:25

and the Z you would go positive Z, and here it's

40:29

too deep, it's too far, too much positive Z, so

40:32

you would, you would turn it to the negative Z.

40:36

So I hope that makes sense.

40:38

Um, are there any other questions that I could help?

40:42

Um, oh, my, my Instagram, Facebook address is the

40:47

Boobie Docs at, at, um, on Instagram, on Facebook,

40:50

it's the TAG Boobie, B-O-O-B-I-E and Docs, D-O-C-S.

40:57

Uh, that's really it.

40:59

Does anyone have any further questions?

41:02

All right.

41:03

Well, thank you so much for your time.

41:04

I really hope you learned something from this talk.

41:10

Thank you so much for this case review and for

41:12

everyone in the audience for participating,

41:14

be sure to join us for upcoming webinars.

41:16

You can register for those at medality.com

41:19

and follow us on social media for updates

41:21

on future lectures and case reviews.

41:23

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