0:04

Yes, this is a breast cancer patient, um, which

0:10

we should get more of.

0:11

We don't get a lot of, unfortunately. Right.

0:14

I wish we do get more of, okay,

0:20

what is the, let me see a little bit of history.

0:25

Triple-negative, right?

0:27

Usually more aggressive cancer, more hypermetabolic cancer.

0:32

Um, poorly differentiated, of course.

0:34

Um, coming for initial teething.

0:37

So we go over

0:39

and you see here is the interestingly, right, look at that.

0:42

This is biopsy. Of course you see

0:44

a, a clip, a surgical clip.

0:45

Here's the tumor, which is here not

0:48

as impressively hot, right?

0:51

And it is in, um,

0:53

and you know how the, you guys know

0:55

how the breast cancer usually, um, breast masses, um,

1:00

usually they like to either you, um, uh,

1:06

divide the breast into four, four quadrants

1:10

or like the clockwise.

1:11

So this is in the upper outer quadrant of the right breast.

1:14

And look here how it's like the whole breast is,

1:17

there's like kind of, um, diffuse low grade, uh, high DG

1:21

of the breast, right?

1:23

And just

1:30

this is the mass, this is the primary mass.

1:32

Here's the intense activity. Kind of intense activity.

1:36

Um, I'm not gonna throw in the volume of interest.

1:39

I already mentioned how hot it is. It's not that hot.

1:41

See, it's 4.7, which is really not impressively hot.

1:45

Maybe because of the, like, I don't know if they just,

1:48

this is not post-surgical, right?

1:50

It's not all right. It's just impressive.

1:53

Like how, see here in the map, it's impressive how the,

1:56

the primary site is not as hot.

1:58

But how, see how hot is the, the static lymph node?

2:03

It is, right? Okay.

2:06

Now you look at this primary site,

2:08

and then again, the staging is what we looking at.

2:10

So you look at the node dam metathesis

2:13

and accelerate lymph node is uh, three levels.

2:16

They divide them into three levels.

2:18

And the, the, the anatomic mar, um,

2:24

landmark is the pectoralis mine, which is this one.

2:26

This is pics major, right?

2:27

And here's your pictor mine, right?

2:30

So level one is lateral level two is is

2:34

posterior right?

2:37

And level three is medial.

2:42

Do you guys see that the three levels

2:44

of accelerate lymph node,

2:51

then you go up and we have the infraclavicular.

2:58

Yes, absolutely.

2:59

The DCIS are not very hot, but triple negative.

3:02

This is triple negative. This is not DCIS.

3:06

Oh, you mean the metastatic lymph node?

3:08

But the D-D-C-I-S-D-C-I-S will

3:10

have me metastatic lymph node.

3:13

Yeah, it's been a while since I did this breast.

3:19

I used to do breast more eye research.

3:22

I'm trying to think in DCIS,

3:28

doesn't it have to be in, doesn't it have

3:30

to have invasive component to have, uh,

3:31

metastatic lymph nodes?

3:34

Yeah, I mean, exactly. That's what I'm trying to say.

3:36

It has to have some inva, some invasive component

3:40

to have metastatic lymph node.

3:42

But this patient has triple negative.

3:44

I mean, I think maybe the cancer,

3:46

I have to dig into the pathology.

3:48

Maybe the cancer was small and, um,

3:51

and this is not the only, the first time in Dota teeth.

3:54

A lot of time the metastatic disease is

3:56

hotter than the primary site.

3:58

And especially in the small bowel.

4:00

Um, the med gut net, the primary site is not

4:04

as impressive, but the metastatic disease is

4:06

extensively hotter.

4:09

So it's not the first time I see that.

4:11

But I was impressed how the, here, in this case,

4:13

the primary site is really not impressive.

4:15

But the, the study is very hot. Right? Okay.

4:20

So, um, again, it's,

4:25

so this patient has, um, this,

4:28

this patient doesn't have any STEM metastatic disease,

4:30

but, um, it's all lymphatic,

4:32

but there's a lot of lymph nodes.

4:33

See, and in, in the breast cancer, uh, staging also,

4:36

they do care about the number

4:38

of lymph nodes in the N one, N two and N three.

4:41

But also once it gets into, um, the infraclavicular

4:45

and tub vicular and tub br clavicular, uh, lymph nodes,

4:48

it becomes in, uh, in two, I think

4:54

Two I think it becomes in,

4:59

um, in, yeah, infraclavicular is in

5:03

Three becomes in three in infraclavicular is N three A

5:08

and, and subra clavicular is N three B.

5:12

And these makes the cancer, um,

5:17

Stage three, stage three C basically.

5:23

So again, it's another, so just always know that, um,

5:29

the nodal disease is just not simply the, the pa the patient

5:34

is, there's metastas to the lymph nodes

5:36

and there's no distant mets.

5:38

Uh, no, which nodes are,

5:42

how far are the nodal metastasis go is important in the

5:46

staging of, uh, the patient as well.

5:48

This patient didn't have any distant metastasis. Okay.

5:52

And also, like a lot of time we can, oh,

5:54

another thing I wanted to show here is this,

5:56

because not a lot of people know about this.

5:59

These nodes here, do you see these nodes guys here?

6:03

It's in between the picts measure and pectoralis minor.

6:06

These are called, uh, pectoral

6:09

or, um, router, uh, nodes.

6:14

Um, so when you try to, um, assign the level, we know,

6:18

like I said, um, lateral tores, miner, Tora, minor media,

6:23

Tora, miner, um, these are the three levels.

6:27

But then you'll find those that are in between.

6:31

And in this case, you won't care much

6:32

because there are, they are not the hottest or the largest,

6:35

and you don't have to report them,

6:37

and you don't report all the nodes.

6:38

Usually I just give a big sentence in my reports

6:42

for the whole nodal disease

6:44

and then give the, you know, like two

6:46

or three examples, um, and move.

6:48

But, um, sometimes you might find a patient

6:51

that the only node is this node,

6:53

and then you have to describe where's this node.

6:56

So this is, this is why you have to know about this node.

6:58

And usually breast cancer patients, this is a node that is,

7:01

uh, known for breast cancer patient,

7:03

but it's an unusual node.

7:06

I think this is it about this patient.

7:07

Nothing special about this, this study, this patient, except

7:10

that.