0:02

Hello and welcome to Case Crunch Rapid case

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review for the core exam hosted by Medality.

0:07

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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After a quick answer explanation, it's onto the next case.

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Questions will be covered at the end if time allows.

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Please remember to use the Q and A feature

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to submit your questions so we can get

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to as many as we can before time is up.

0:33

Without further ado, please enjoy this case review.

0:36

Well, thank you so much for having me.

0:38

I'm really excited to be here today.

0:41

Um, this lecture is for—it's a very

0:46

general overview of breast cases.

0:48

We're gonna, uh, run a wide spectrum of things.

0:50

I don't know where people are in their training or

0:52

if they're post-training, but I think everyone will,

0:55

um, get something out of this lecture, hopefully.

0:57

Um, I have lots of cases, and then I

1:00

have lots of questions as a follow-up.

1:02

Um, more board-style.

1:04

Um.

1:05

Just because I know our residents are,

1:07

you know, have the boards on their mind.

1:09

So I hope that you find this helpful, and

1:11

if you have any questions or any feedback,

1:13

please, um, don't hesitate to message me.

1:16

Um, or, or, you know, turn on

1:18

your microphone and ask a question.

1:19

I'm very okay with this being interactive.

1:21

All right.

1:22

Without further ado, let me see if this is working.

1:27

Okay, so a 26-year-old female

1:29

presents with a palpable lump.

1:30

What's the first—what's the

1:32

appropriate first imaging test?

1:34

Okay. And I'm gonna give everyone a

1:39

minute to answer. Post and panelists can—

1:46

Does that come up on your screen to answer?

1:50

Yup.

1:50

So we've got a few of the people answered.

1:52

We'll give it a couple more seconds,

1:53

and then I'll let you see the results of it.

1:55

Okay, great.

1:58

Okay, good.

1:59

So everyone got that right?

2:00

So the first, um, you know, under a 30,

2:01

you wanna start with an ultrasound first.

2:04

Um, and this is what the ultrasound looks like.

2:07

Um, which of the following is considered

2:09

a malignant feature on ultrasound?

2:14

A lesion that's wider than tall.

2:16

Angular margins 2 to 3

2:18

Gentle lobulations, ellipsoid,

2:20

homogeneous echogenic echotexture.

2:22

What's the best answer?

2:26

A malignant feature.

2:29

Good.

2:30

So most people said angular margins.

2:32

Um, a lesion that's wider than tall,

2:34

I usually think of, uh, fibroadenoma.

2:37

Um, so things that are benign

2:39

typically grow along the breast plane.

2:41

Things that are taller than wide means that they're

2:44

growing fast, they're breaking through planes.

2:46

So that's usually a malignant feature.

2:48

So maybe you kind of read that wrong, but it—

2:50

um, angular margins is the answer that we're looking for.

2:53

Um, and just so you know, this

2:54

is an irregular hypoechoic mass.

2:56

You can see lots of punctate calcifications in it.

2:58

Certainly, this is suspicious,

3:00

um, in this 26-year-old female.

3:03

So, um.

3:06

So this is what her mammogram looks like.

3:08

One of the questions I would ask you is, what is the

3:10

next, um, best—What, what's the next best step?

3:13

And you know, I think people are often tempted

3:15

to say biopsy, which is true, but you also wanna

3:18

make sure you're getting a mammogram because

3:20

this could be, you know, the tip of the iceberg.

3:21

There may be cancer all over,

3:24

and we're just looking at one area.

3:26

You always wanna make sure that you know, even if

3:27

you're—if you have something suspicious on ultrasound,

3:29

you always wanna get a mammogram to see if there's

3:31

any suspicious things on mammogram that you don't see,

3:34

um, on ultrasound.

3:36

So this is what her mammogram looks like.

3:38

You could see she's extremely dense and right where she

3:40

has this palpable area of concern in her left breast,

3:43

she's got these, uh, calcifications.

3:45

Um, I'm gonna ask you some more about the calcifications.

3:49

Um, but what views would you get

3:51

to further evaluate calcifications?

3:55

CC and MLO spot mag. CC and M—CC and ML

3:59

spot mag. XCCL, or CC and ML spot compression views.

4:05

Okay, see what people said.

4:09

I'm sorry, I didn't mean to do that.

4:11

All right, good.

4:11

So, um, going back to that question, I'm

4:14

glad that people are getting things wrong.

4:16

So you always want to get CC, and whenever

4:18

you see calcifications, you always

4:20

want to get a CC and true lateral.

4:22

So automatically, you can get rid of MLO

4:25

because there's really no reason to get an MLO.

4:27

The whole point of getting an ML mag is because

4:30

you're trying to see if this is milk of calcium.

4:32

So a CC, um, you know, CC on—

4:36

typically, if it is milk of calcium, they'll look

4:39

smudgy on the CC, and then you get a true lateral.

4:41

You kind of shake the breast and hold compression

4:44

for about five minutes and let them layer

4:46

and they make a teacup kind of appearance.

4:48

Um, so you—whenever, um, whenever you see

4:51

MLO, you can automatically exclude that.

4:53

There's really no need for MLO mags,

4:55

so that really makes you down to B and D. Um,

4:59

and really, we want to get magnification, not

5:01

compression. Compression's more for an asymmetry.

5:04

So that's why B is the correct answer.

5:07

So using BI-RADS descriptors, how would

5:10

you describe these calcifications?

5:13

And I want you to kind of think

5:14

of head like these are suspicious.

5:17

Um, so you want to use words that kind of go with that.

5:22

So what would you pick to describe that?

5:27

We're going to try to move rather quickly because I have lots

5:30

of questions, and I don't want to perseverate on each one.

5:34

So.

5:36

Best answer and go.

5:38

Good.

5:38

So everyone picked coarse heterogeneous and grouped.

5:41

You know, people typically say coarse heterogeneous

5:43

and they say that they're benign, but actually, coarse

5:45

heterogeneous falls into that suspicious category.

5:48

Um, so that would be a BI-RADS, you know, four or five.

5:52

Sorry.

5:52

Uh, it just gave away the answer.

5:54

So what's the BI-RADS based on these imaging features?

5:57

These are suspicious.

5:59

You'll notice that I left at

6:01

five because I think that, um,

6:04

you know, when you get to suspicious findings, it's, it's

6:07

controversial, but they're gonna give it a, you know, I'll

6:10

let you guys answer this, but I kind of gave you the answer.

6:15

Good.

6:15

So everyone got that.

6:16

Oh wait, sorry.

6:18

So it's BI-RADS, it's BI-RADS four or five, but

6:21

I purposely didn't put five to not confuse you.

6:24

All right.

6:25

And what modality would be best to biopsy this?

6:27

I'm not actually gonna open this up for a

6:29

question because really you could biopsy

6:31

under any of these ways except MRI,

6:33

'cause we didn't do an MRI.

6:35

Um, certainly you could biopsy under stereotactic

6:38

biopsy because you have calcifications.

6:39

But one given the option,

6:41

if you have something that you can see on

6:42

ultrasound or, um, mammogram, it's better to biopsy

6:46

under ultrasound because if there is an invasive

6:48

component in the cancer, you wanna know about it.

6:51

And the best way to really target, to know if

6:53

there's an invasive component is to target the mass.

6:55

So I would typically kind of aim for the bottom of the

6:59

mass that has both the calcifications and the mass.

7:03

You may get a, um, you may get a specimen radiograph some—

7:06

um, if you're looking for calcifications, I often do

7:09

that, especially with this, you know, mass that has

7:12

calcifications, just to make sure you've got that too.

7:15

Um, but this will kind of give you the

7:16

best, most representative piece of tissue.

7:18

So I wanna give 'em the option.

7:19

Biopsy under ultrasound.

7:22

All right, pathology comes back

7:24

as atypical ductal hyperplasia.

7:26

What is your recommendation?

7:27

And I will ask for a question here.

7:31

So is it concordant?

7:34

Is it—what, what are you gonna recommend?

7:37

And this is a lot of, you know, mammo is a

7:40

lot of, um, is a lot of management questions.

7:43

So these are definitely answers that—

7:44

questions that they can ask on the boards.

7:50

All right, so you should be finishing up.

7:54

Oops, let me move it so you can actually see the image.

7:59

All right.

7:59

Let's see what people said.

8:04

Good.

8:05

So the answer is D. So it is, I mean, you can,

8:08

I guess you can say it's concordant, but this

8:10

doesn't look like—this looks like a cancer.

8:12

So really, I mean, ultimately the most

8:14

important thing is that you wanna recommend

8:16

a biopsy, that you wanna take it out.

8:18

Um.

8:19

To me, I would call this discordant because I

8:21

don't think atypical ductal hyperplasia, it's

8:23

usually not this mask-like and suspicious.

8:25

So certainly, um, you know, the most

8:28

important thing is that it comes out, but I

8:29

would call this discordant. Okay, moving forward.

8:34

Okay, so I'm gonna skip these because I go over them.

8:37

I will point out this slide, which is the Stavros criteria.

8:40

I've talked to my residents about this

8:41

extensively, but this is a good article from '95.

8:45

It's how we, um, it's, uh, sonographic

8:48

characteristics of benign versus malignant lesions.

8:51

Um, when I took the board, we had to like recite

8:53

this, but basically you wanna just memorize like

8:56

what the suspicious features are on ultrasound.

8:58

Speculated angular margins, marked hypoechogenicity.

9:02

Shadowing, punctate calcifications, ductal,

9:05

extension, branching, and micro-lobulated.

9:08

Um, and if any of those things are

9:10

present, then you can't consider it benign.

9:12

Okay, good.

9:13

Moving on.

9:14

So, um, always wanna get a true lateral.

9:17

And we talked about this.

9:18

So this is just kind of a quick overview

9:20

of how you do an ultrasound-guided biopsy.

9:22

You're gonna find the mass on ultrasound.

9:24

You're gonna numb the skin and

9:26

deeper tissue with 1% lidocaine.

9:28

We often numb the tissue, the deeper tissue, with

9:31

lidocaine with epi, and that's to minimize bleeding.

9:33

You wanna make sure you don't give it in the

9:35

skin 'cause it could cause skin necrosis.

9:37

Um, we typically use a 9, 12, or

9:40

14-gauge, uh, needle here at Cooper.

9:43

Um, you could use any sort of needle.

9:45

You know, if it's, if a patient's on anticoagulation,

9:47

you might wanna use a smaller one, like a 14.

9:50

I've seen even people use 16 or 18.

9:52

But this is what we typically use.

9:54

You always wanna place a clip.

9:55

You always wanna get a post-biopsy mammogram, and

9:57

comment on whether the clip is representative.

10:00

Um, bad things happen when you don't put a

10:01

clip and you don't get a mammogram after.

10:04

Okay.

10:05

Um, okay, next case.

10:07

So, a 45-year-old female presenting with left breast

10:10

rash for three months, no improvement with antibiotics.

10:13

So already you're starting to

10:15

think that something's going on.

10:17

Um, so this is her mammogram.

10:20

This is her CC view, and then this is her MLO view.

10:26

Um, so pertinent findings include which of the above.

10:31

So diffuse, trabecular thickening, skin

10:34

thickening, breast enlargement, or all of the above?

10:38

Kind of an easy one, but good.

10:40

So everyone got that?

10:42

Okay.

10:45

So based on the appearance, it's

10:47

least likely due to least likely.

10:52

So the fact that it's unilateral is

10:54

an important distinguishing factor to

10:56

differentiate between the four of these.

11:01

So based on the appearance, which is least likely.

11:06

Good.

11:06

Yeah.

11:06

So congestive heart failure is usually bilateral.

11:09

Exactly.

11:10

Um, this is unilateral.

11:11

So if we had a history of mass, of radiation, then

11:15

you know, we, that would certainly explain it.

11:17

Um, but the fact that she's had mass, that she's

11:19

had this rash and it's not gotten better for

11:21

three months and it's not improving on antibiotics,

11:23

we're worried about inflammatory breast cancer.

11:26

Um, so what is the name of this clinical exam finding?

11:31

Good.

11:31

So, um, so this is a peau d'orange appearance

11:35

of um, inflammatory breast cancer.

11:38

Paget's disease is actually when

11:39

they kind of get eczema of the nipple.

11:42

Um, and they don't necessarily get a rash or

11:45

enlargement, but they may just have itchiness in the

11:47

eczema of the nipple and some flaky skin changes.

11:51

Alright, and what causes this appearance?

11:55

What is the pathology?

11:58

That we're, that, um, is diagnostic

12:00

of inflammatory breast cancer.

12:04

Good.

12:04

So, um, it's actually tumor lymph,

12:07

uh, emboli and dermal lymphatics.

12:09

So, you know, I'm gonna, um, the way that

12:11

you would biopsy this or the surgeon would

12:12

biopsy this, is they would do a punch biopsy.

12:16

Um, and, and that's the diagnostic, um, to be

12:19

diagnostic of inflammatory breast cancer, they have

12:21

to see those tumor emboli in the dermal lymphatics.

12:24

Okay.

12:25

So, um, based on this imaging appearance,

12:28

what is the next best imaging modality?

12:35

So in this case, we have bilateral skin and trabecular.

12:37

Thickening.

12:41

Yeah.

12:41

So I mean, it's usually congestive heart

12:45

failure when it's bilateral and symmetric.

12:47

It would be unusual to get

12:49

inflammatory breast cancer bilaterally.

12:51

Um.

12:53

So if you really want to impress your friends,

12:54

you want to recommend a chest x-ray off a

12:56

mammogram, um, which we did in this case.

12:59

And this was her chest x-ray.

13:01

Oops.

13:01

Nope, I have it eventually.

13:03

So this is our patient, you know, she had this

13:05

left breast thin skin thickening and enlargement.

13:08

She had an irregular mass.

13:09

Um, she had a few irregular masses.

13:11

She's got diffuse skin thickening, she's got

13:14

airy lymphadenopathy, which patients with

13:15

inflammatory breast cancer usually have.

13:18

Um, so your BI-RADS is gonna be a four or a five.

13:22

Inflammatory breast cancer.

13:23

Um, uh, we talked about these,

13:26

so I'm gonna run through this.

13:28

So this was actually her PET CT.

13:29

You could see that her left breast

13:31

is diffusely enlarged and thickened.

13:32

She's got multiple masses.

13:34

She's got multiple subpectoral and, um,

13:37

axillary lymphadenopathy bilaterally, actually.

13:40

Um, which often happens.

13:42

Um, you know, inflammatory breast

13:44

cancer can look like mastitis.

13:46

Initially, though they usually fail antibiotic therapy.

13:49

Um, you know, history is very important timeline.

13:52

Once it's starting to go on for a few months, you

13:53

don't want to, you know, you're gonna treat it as

13:55

inflammatory breast cancer until proven otherwise.

13:58

Um, you know, the PUD, or tumor emboli, all these are

14:01

buzzwords that you're gonna want to remember for the boards.

14:05

Uh, punch biopsy.

14:06

This is usually, this is, um.

14:08

It usually pops up kind of quickly, so, you

14:10

know, patients will say overnight it kind

14:12

of got red and swollen, and that's true.

14:14

It doesn't really look like this until it kind of

14:16

involves the skin and then it gets really bad quickly.

14:19

Um, these are advanced and they're gonna need some kind

14:21

of neoadjuvant chemo before, uh, they go to surgery.

14:25

So this, like I said, bilateral symmetric, skin thickening

14:29

and trabecular thickening, if you've got a chest x-ray

14:31

would notice that they have congestive heart failure.

14:33

Um, so really what good way to be clinically and relevant

14:37

in breast imaging is to diagnose CHF off a mammogram.

14:42

Um.

14:43

So when we talk about unilateral skin or trabecular

14:45

thickening, this is really the differential.

14:48

Um, inflammatory breast cancer needs to be excluded.

14:50

Could be mastitis or radiation, but you

14:52

should have the history of radiation.

14:54

Um, lymphatic obstruction.

14:57

Uh, congestive heart failure is usually bilateral.

14:59

It can be unilateral, but you'd wanna

15:02

rule out some other things first.

15:04

Um, SVC obstruction.

15:06

Greater than two millimeters

15:07

of skin thickening is abnormal.

15:10

Um, when you have bilateral trabecular skin

15:12

thickening, um, you wanna think about congestive heart

15:14

failure, fluid overload, also lymphatic obstruction,

15:18

bilateral inflammatory breast cancer, very unlikely.

15:20

It does happen often.

15:22

It creeps like across the kind of the cleavage and goes

15:24

to the other side, which we, I've seen that a few times.

15:29

So a 56-year-old female with bilateral

15:31

breast implants presents for a screening

15:33

mammogram and survey breast ultrasound.

15:36

Um, so this is her CC and MLO views.

15:42

I'm just gonna give you a minute to look

15:43

at those to kind of get your bearings.

15:45

Um, and then these are the implant

15:47

displaced views, which we typically get.

15:49

Um, you can see that there is this dense mass.

15:53

Um.

15:55

Um, in the right inner breast.

15:58

Um, so based on this appearance,

16:01

what type of implants are these?

16:05

So we've got retropectoral,

16:06

silicone, retropectoral, saline, um,

16:12

uh, retroglandular silicone and retro saline.

16:15

Oh no, hold on.

16:16

I'm sorry.

16:16

Let me get off this actually, I don't

16:18

think anyone's here watching it.

16:20

Um, so what's the best answer?

16:23

Good.

16:24

Um, wait, so I actually blocked myself.

16:27

So these are retropectoral silicone.

16:29

Good.

16:29

So you see the pec muscle coming around the implant,

16:32

you know it's silicone because it's high density and

16:36

you can't really see through it, and you don't see that

16:38

typical nozzle, which you'll see with a saline implant.

16:40

And I'll show you another case of that.

16:43

Um, so what's the best imaging modality

16:46

to assess for rupture of these?

16:49

Um.

16:51

Of these, um, implants.

16:55

I'm gonna open this up.

16:56

Is it MRI, mammogram, ultrasound, or none of the above?

17:03

Good.

17:04

So MRI is the best.

17:06

Um, mammogram, you really can't tell.

17:08

In this case, you can kind of get the sense that

17:10

there's some something going on oopsies, sorry.

17:12

Um, but you don't exactly know for sure.

17:16

Um, you can go to ultrasound.

17:18

Ultrasound will be helpful, but um, also,

17:21

uh, you're really gonna wanna do an MRI.

17:23

So this is our patient.

17:25

Um, you know, we did a survey, ultrasound, this

17:27

is of her right breast and oh my god, sorry.

17:31

I don't know what just happened.

17:33

Oops.

17:35

So based on this appearance, findings are

17:38

concerning for a witch, intracapsular silicone

17:42

rupture, extracapsular silicone rupture,

17:45

extracapsular saline rupture, or is it A and B?

17:53

Little bit of a trick question here.

17:57

So, yeah, the answer is D and most people got that.

18:00

So the, um, if you're gonna have extracapsular,

18:03

so if you're gonna have extracapsular rupture,

18:05

you have to have intracapsular rupture.

18:07

So that will make it a little bit easier for you.

18:09

Um, so if you see the extracapsular, you know it's

18:12

intracapsular and that's why it's A and B, and not just B.

18:15

Um, you know what, I wanted to, and what

18:18

is the name of this ultrasound appearance?

18:22

Is this the Linge sign, the

18:23

new new sign, the keyhole sign?

18:26

Or is this a snowstorm appearance?

18:31

Okay, good.

18:31

So this is a snowstorm appearance and we're gonna go

18:34

through all of the appearances of the different types.

18:37

Um, but I'm glad that some people are, don't

18:39

know everything and they're here to learn.

18:41

Um, so this is the snowstorm.

18:45

Um, so, um, this is an MRI on the same patient.

18:50

And, um, let's open the, um, the poll again.

18:57

So based on this appearance, the, the, you

19:01

know, the real problems on the right, uh, as

19:03

we've seen and we kind of know what's going on.

19:05

So if you've gotten 'em right to this

19:07

point, you probably can get this right too.

19:10

Um.

19:13

Good.

19:14

So everyone knows now.

19:15

So you see extracapsular silicone rupture over here.

19:19

That's that mass that we were seeing.

19:21

You see this, um, we're gonna talk all

19:23

about that, but those are the linge signs

19:25

of, um, of, um, intracapsular rupture.

19:30

So a referring clinician is concerned

19:32

about saline implant rupture.

19:33

What study should he order?

19:36

Oops, let's open up the poll here.

19:39

Saline implant rupture.

19:43

Good.

19:44

None of the above.

19:44

So no one fell for it yet.

19:46

It's, you don't need an exam to tell you that

19:48

you have implant rupture, a saline implant rupture.

19:50

It's AFLs like a balloon.

19:51

The patient will tell you that she had it.

19:53

Um, okay.

19:54

What is the MRI finding on this axial

19:56

stir image on a different patient?

20:02

Okay, let's close it.

20:06

So these are normal radial folds.

20:08

And what um, you know, I think that people often

20:10

get confused between this and intracapsular rupture,

20:13

where you have some silicone in, um, you make, that

20:17

makes a little loop like a knee, a keyhole or no sign.

20:20

These are actually normal radial folds.

20:22

Um, so it's normal to see that, but you're

20:24

looking for that silicone in between the folds.

20:27

Okay.

20:29

Um, what is the finding and

20:31

significance on the axial stir image?

20:34

So what are we seeing here?

20:37

So is this Aling sign?

20:39

That means intracapsular Linguini sign.

20:41

That means extracapsular snowstorm.

20:43

That means intracapsular or

20:44

snowstorm. That means extracapsular.

20:51

Good, so you're getting the hang of it.

20:52

This is in Gini linguini sign of intracapsular rupture.

20:55

So it looks like a big ball of spaghetti in the implant.

20:58

That's not normal.

21:00

Okay, so to review our case, you know this, like I said,

21:03

this is, um, these are retropectoral silicone implants.

21:06

You can tell that because they're really high density and

21:09

you don't see the nozzle, the pec goes in front of it.

21:12

So if you treat, I always can, I can only tell on the

21:14

MLO when I see the pec kind of going around the implant.

21:18

Um, here you see a dense mass medially.

21:20

You're starting to be suspicious for extracapsular rupture,

21:23

but really you can't diagnose this on a mammogram.

21:25

You could be suspicious and recommend an MRI.

21:28

Um, you know, ultrasound is definitely helpful.

21:31

Um, so I'm just gonna go through these.

21:33

This is a snowstorm appearance of extracapsular silicone.

21:37

If you have extracapsular silicone, you know,

21:40

you have intracapsular silicone rupture too.

21:42

Um, so you have to have one for the other.

21:46

So this is, like I said, this is the

21:48

extracapsular silicone you're seeing.

21:50

This is the folded-up implant amongst itself.

21:52

This is intracapsular rupture.

21:55

Um, saline implant rupture is a clinical exam finding.

21:58

Um, and the saline, uh, I've seen MRIs ordered

22:02

for this and that it's totally not indicated.

22:04

This is what it will look like.

22:05

You could tell that this is a saline implant because

22:07

you could see the nozzle, you can see through it.

22:10

It's a little bit less dense than the silicone implant.

22:13

Um, and this is actually a pre-pectoral, so, or

22:16

a retro glandular that those are another term.

22:19

So you can see the pec here kind of goes behind it.

22:22

So in the other case, it went in front of it.

22:24

Um, so this is a good case for that.

22:27

These are just normal radial folds.

22:29

Like I said, you don't see the silicone within the folds.

22:33

This is a linguini sign, an intracapsular

22:35

rupture, and just, you know, when we talk about

22:37

a capsule, there's an outside fibrous capsule

22:39

and then there's an implant, um, inside of it.

22:43

And once it gets outside of the fibrous capsule,

22:45

that's when it's considered extracapsular.

22:48

Um, so extracapsular means beyond that fibrous capsule.

22:52

And just to show you three examples next to each other.

22:56

'Cause I think this is helpful.

22:58

So these are normal radial folds in the middle,

23:01

but as you can see, and when there's intracapsular

23:04

rupture, you'll see this silicone within the folds.

23:07

This is called a keyhole or new sign.

23:10

Looks just like that versus, um, and this is the L sign.

23:14

This is when it's really bad.

23:16

So on ultrasound, you might see this stepladder

23:18

appearance of, um, intracapsular silicone rupture.

23:23

Um, and on, uh, MRI you might see in this case, you can

23:27

see silicone extending beyond the capsule of the implant.

23:30

This is extracapsular and intracapsular rupture.

23:34

All right.

23:35

So just to reiterate, um, I think

23:37

this is a good, uh, summary slide.

23:40

Um, so you know intracapsular rupture,

23:43

you'll see the keyhole and the no weenie sign.

23:45

On ultrasound, you may see a

23:46

stepladder sign for extracapsular.

23:49

You may see silicone outside the implant,

23:51

may see in the lymph nodes like we did.

23:52

Um, it can have a snowstorm appearance on

23:55

ultrasound, and you must have intracapsular

23:57

rupture to have extracapsular rupture.

24:00

Alright, moving up on the next case, a 66-year-old

24:04

female presents for baseline mammogram.

24:08

So this is her MLO,

24:12

this is her CC.

24:15

I'm gonna give you a minute to just look at this.

24:17

This is like her MLO and her CC.

24:22

Um, so based on this screening

24:24

examination, what is the appropriate BI-RADS?

24:29

Okay, good.

24:31

Um, so the finding here is really

24:34

unilateral axillary lymphadenopathy.

24:37

Um, so that is never a normal finding.

24:41

This is really breast cancer until proven otherwise.

24:45

Um, so really, you know, and then she

24:47

also has these two masses that you can

24:49

see that are, um, asymmetric to the left.

24:52

Um, so you certainly would want to give her a BI-RADS zero.

24:55

We need more information for sure.

24:58

Okay.

24:59

Um, I answered this already so I'm not gonna

25:02

even open the poll, but the most likely cause

25:03

of this finding is inflammation, um, sorry.

25:05

Metastatic breast cancer.

25:06

When you have unilateral axillary lymphadenopathy, um,

25:10

you wanna make sure that it's not, you need to exclude malignancy.

25:13

Breast cancer, what is this imaging modality?

25:18

Many of you may not have seen this

25:19

before, but my residents definitely have.

25:24

So is it digital breast tomosynthesis, MRI

25:27

contrast-enhanced mammography, or none of the above?

25:29

I'm sorry.

25:30

I'm freezing.

25:34

Okay.

25:37

Good.

25:38

So this is a contrast-enhanced

25:39

mammogram if you've never seen it.

25:40

These are actually the subtraction images

25:43

from a contrast-enhanced mammogram.

25:44

I don't know how much they ask you on the

25:46

boards, but it's definitely fair game.

25:48

So if you've never seen it, this is what it looks like.

25:50

Um, so findings are suspicious

25:53

for now, read this carefully.

25:55

Let's say that these are both cancer.

25:57

Is it multifocal, multicentric,

26:00

contralateral, or inflammatory breast cancer?

26:06

Sorry, I'm gonna move this box so

26:07

we're not securing the findings.

26:12

Okay.

26:14

Good.

26:15

Um, so this is multicentric breast cancer.

26:17

They're in different quadrants, um, multifocals

26:20

when they're in the same quadrant, and multicentric

26:22

is when they're in different quadrants.

26:24

So this would definitely be multicentric.

26:27

Um, so you can see she's got an irregular

26:29

speculated mass at three o'clock.

26:31

She has another ill-defined mass

26:32

in the right breast at 10 o'clock.

26:33

So another quadrant.

26:35

Um, and she also has what looks

26:37

to be an abnormal lymph node.

26:39

Um, what is your BI-RADS for this?

26:42

Sorry, I answered that quickly, but

26:43

this is gonna be a four or five.

26:44

You know, you're certainly suspicious you would at

26:46

least want to biopsy one of the masses and the lymph

26:49

node, but ideally you'd like to biopsy all three.

26:53

Um, we typically don't do more than two

26:55

on the same day, but not for any other

26:56

reason than insurance doesn't pay for it.

26:58

And patients can't often tolerate three biopsies, but

27:01

certainly that's the most appropriate thing to do.

27:04

This is suspicious for multicentric

27:06

metastatic breast cancer.

27:07

Um, we ended up biopsying on the same day we did that.

27:10

This is the regular mass and the right lymph node,

27:13

but the one at 10 o'clock was also breast cancer.

27:18

Um, so you definitely want to give it a screening

27:20

and, you know, it's really important to

27:21

know are they a screening or are they diagnostic?

27:23

Because if this is a diagnostic, you can give it a four.

27:27

But if this is a screening, you want to give it a zero.

27:29

You need more information.

27:30

Um, unilateral x-ray, lymphadenopathies,

27:32

metastatic breast cancer until proven otherwise.

27:35

If you don't see, I had her case recently where she had

27:38

unilateral X or lymphadenopathy, nothing that I could see

27:40

on my MO, but we brought her back for a survey, breast

27:43

ultrasound, and of course, we found a little cancer hiding.

27:46

Um, and it ended up being metastatic breast cancer.

27:49

So you gotta find that pa, you've gotta find that cancer.

27:52

If you don't see it on old survey ultrasound, then

27:54

you'd want to do an MRI and you'd also biopsy the

27:57

lymph node to make sure that it's not something else.

27:58

'Cause other things can metastasize to the axilla as well.

28:02

Um, most likely cause is metastatic breast cancer.

28:06

This is a contrast mammogram.

28:07

These are the low-dose subtraction images from contrast.

28:11

Um, this is suspicious for multicentric

28:13

breast cancer, as we talked about.

28:16

So multicentric involves more than one quadrant.

28:20

Multifocal involves two masses in one quadrant.

28:23

Synchronous means two tumors diagnosed

28:26

within six months of each other.

28:29

Metachronous means two tumors diagnosed greater

28:33

than six months apart from each other.

28:37

Okay, next case.

28:39

Oh, well, it's related case.

28:41

So, 42-year-old comes in for a screening mammogram.

28:44

What's the appropriate BI-RADS?

28:46

Um, sorry for the old, these are very old images.

28:50

Um, but you get the point of the finding.

28:53

I think when I move my poll box.

28:58

This.

29:00

Okay.

29:01

So, you know, this is a little controversial, but

29:03

technically this is a chevron, but you want to put something

29:06

in your report that this is, that, um, you know,

29:08

they need to have some underlying systemic disorder.

29:11

Like, um, well, let me get to the next question.

29:15

Um.

29:16

So, I'm not gonna even open this up, but like Lupus,

29:21

HIV, um, inflammatory diseases can cause this.

29:24

Um, Dilantin is a drug that can cause

29:27

this, but breast cancer should not cause

29:29

bilateral, um, axillary lymphadenopathy.

29:33

It should really cause unilateral.

29:35

Um, so breast cancer would be least

29:37

likely cause of this appearance.

29:39

Um, but certainly, you know, for bilateral axillary

29:42

lymphadenopathy, it's usually something not breast

29:44

cancer, but it doesn't mean it's not important.

29:45

This could definitely be lymphoma.

29:47

So often it requires just a conversation

29:49

with the doctor who ordered it.

29:51

You know, I look through their chart sometimes,

29:53

I know they have Sjögren's or rheumatoid, and that

29:56

would explain it, but I'll put that in my report.

29:59

But otherwise, you wanna make sure that

30:00

it's not lymphoma, but it's still a two.

30:02

Um.

30:03

Even if you saw this and the patient really didn't have

30:06

anything, then I would kind of be a call to the doctor.

30:09

We could always sample one of them if they,

30:11

you know, didn't have anything identifiable,

30:13

and you wanted to make sure it wasn't lymphoma.

30:15

Um, but you know, it's not breast cancer.

30:20

So the least likely cause is not breast cancer.

30:22

So these are some bilateral axillary lymph node causes.

30:24

Like I said, systemic diseases like sarcoid, mixed

30:27

connective tissue disease, granulomatous disease,

30:30

you might see some coarse calcifications in them also.

30:34

Lymphoma or leukemia can certainly cause this.

30:36

And drug reaction from Dilantin is a classic

30:39

um, cause.

30:41

Um, but unilateral axillary lymphadenopathy, you

30:43

wanna make sure, like I said, that it's not

30:45

primary breast cancer with ipsilateral spread.

30:48

Um, also infection or granulomatous disease can cause

30:52

that, or an extracapsular silicone leak, but that

30:55

would usually be like a high-density lymph node.

30:58

Um, okay, great.

31:02

Moving on.

31:03

Um, so, you know, axillary lymphadenopathy, some suspicious

31:06

features you're gonna have, they're gonna be large.

31:08

You're gonna have loss of the normal fatty hilum.

31:10

You may see calcifications.

31:12

It's always better evaluated with ultrasound.

31:14

So when in back you might wanna call

31:15

them, but when in doubt you might wanna

31:16

call them back for, um, an ultrasound.

31:22

Okay, so this is another case.

31:24

I'm gonna withhold the history,

31:27

but take a minute and look at this.

31:29

Um.

31:31

What causes this appearance?

31:36

So I'll open this up.

31:42

Is it gonna be radiation, mastitis,

31:44

breast cancer, or gynecomastia?

31:48

Good.

31:48

So everyone got that right?

31:49

So yeah, this is flame-shaped gynecomastia.

31:52

Um, you know, if it's a classic

31:54

gynecomastia case on physical exam, it

31:56

doesn't even need a, um, a mammogram.

32:01

But it, if you do your, what would your BI-RADS be?

32:07

Based on this, good.

32:10

You know, so it's not negative 'cause there is a finding.

32:13

So I typically, you know, reserve a

32:14

negative for a true negative study.

32:16

This is a guy, guy and he's definitely

32:19

got gynecomastia, he has a finding.

32:21

So I think this is a two.

32:23

Um, I mean it's not, it's certainly benign or

32:26

you know, so, but it technically would be a two.

32:31

All right.

32:31

This is a different patient.

32:32

Um, this was an 80-year-old male that

32:35

presented with a right breast mass.

32:37

Um, and, uh, his left breast is

32:40

all, you know, he's got bilateral.

32:42

So what causes this appearance?

32:50

Gynecomastia?

32:51

Yeah.

32:51

Breast cancer, both or neither.

32:56

Oops, I'm sorry.

32:56

That was, yeah, so, um, so it actually, their correct

33:02

answers actually see, so one person got it right,

33:04

and I want, I'm showing you this because I think

33:07

this is a great case of, on the left, ah, sorry.

33:11

On the left, he's got gynecomastia.

33:14

He's got that flame-shaped retro or density,

33:17

but on the right he's got a true mass

33:19

where, you know, there are real borders.

33:21

You could, it's not, uh, an

33:23

asymmetry, it's more of a mass.

33:25

So when it's a mass, you

33:26

definitely wanna do an ultrasound.

33:27

So I, you know, we'll talk a little bit

33:29

more about gynecomastia and ultrasound.

33:31

Um, but this is actually both because the right side

33:34

is breast cancer and the left side is gynecomastia.

33:37

So I'm gonna save the question just for the sake of time,

33:41

but your BI-RADS, I mean, this is not gonna go Maia.

33:44

I mean, it could be, but you

33:46

definitely would like to biopsy it.

33:47

So in this case, you really wanna give it a four.

33:50

Gynecomastia does not look this mass

33:52

like it can and like the nodular phase.

33:54

But, um, you would really wanna

33:56

confirm this with a biopsy.

33:58

This was a case of male breast cancer,

34:00

so this would be a BI-RADS four or five.

34:04

Um, so like I said, this is gynecomastia.

34:07

This is a BI-RADS two.

34:08

This is bilateral, it's right

34:10

breast cancer and left breast.

34:12

Um, gynecomastia.

34:14

This is definitely gonna be a four or a five.

34:17

Um, so.

34:19

In terms of, um, imaging for, um, for

34:23

males, you always wanna start if they're

34:26

over age 25, you wanna start with a mammogram.

34:30

Um, a mammogram is usually the most

34:32

diagnostic imaging modality for gynecomastia.

34:36

Ultrasound can be really confusing.

34:38

So I don't always do an ultrasound.

34:40

I do an ultrasound if it's not a hundred

34:41

percent, um, gynecomastia on mammogram, but

34:44

the ultrasound picture might be more confusing.

34:47

So, um, you know, in that second case where it was

34:50

breast cancer, you definitely wanna do an ultrasound

34:52

'cause it certainly does not look like gynecomastia.

34:54

But if it's gynecomastia on mammogram

34:57

stop, don't do anything else.

34:58

It's a BI-RADS two.

34:59

Next case.

35:00

Nothing else to do.

35:02

The differences between gynecomastia.

35:04

Gynecomastia is usually bilateral, but asymmetric.

35:07

So there's usually one side that's worse than the other.

35:09

Usually see subareolar flame-shaped densities.

35:12

Like I said, the mammogram is usually diagnostic, ultrasound

35:15

can often be confusing, um, as opposed to breast cancer.

35:19

So breast cancer is usually unilateral.

35:22

You're gonna see a mass with true borders.

35:24

Ultrasound is necessary.

35:26

If the mammogram is not diagnostic, which it

35:28

should not be in, um, breast cancer cases,

35:30

it's 'cause it's not, uh, gynecomastia.

35:33

Um.

35:34

Causes of gynecomastia.

35:36

So most commonly it's just idiopathic.

35:38

Um, we always like to make jokes about, you know, drugs

35:41

cause it like marijuana, prostate, cancer meds, anything

35:44

that really messes with your estrogen, estrogen and

35:47

testosterone levels, um, will cause there to be a, um.

35:52

That can cause extra estrogen, can cause gynecomastia.

35:56

So liver disease, testicular adrenal disease,

35:59

and also male breast cancer causes can cause

36:02

gynecomastia on the other side 'cause of the hormones.

36:05

Um.

36:06

So male breast cancer accounts

36:08

for 1% of all breast cancers.

36:10

Most are gonna be invasive.

36:11

Ductal men don't have lobes, so they

36:14

don't get invasive lobular cancer.

36:16

They also don't get benign masses

36:18

like cysts or fibroadenomas.

36:19

If you see something and it's not gonna go mass, you

36:21

probably wanna biopsy it, unless it's clearly

36:23

like an intramammary lymph node or something like that.

36:26

Um, and males tend to have a worse prognosis.

36:28

And certainly when a male gets breast cancer, their whole

36:31

family is gonna be genetically tested because it's unusual.

36:34

Um, though I've seen a few cases.

36:38

Okay, so what type of procedure is this?

36:44

Let me open this up.

36:50

It was a stereotactic needle localization, post

36:53

ultrasound-guided procedure or galactogram.

36:59

Okay, good.

36:59

So this is actually, wow, I'm, I'm kind of, I'm

37:02

glad that some people are getting this wrong.

37:04

So this is actually a needle localization

37:06

procedure, and whenever you see that alphanumeric

37:09

grid, you know it's a needle localization as

37:11

opposed to a stereo, which I want to show you after.

37:14

I don't think I have it, but I will.

37:17

Um, so, um, so a patient comes in.

37:22

If you don't know this, you're probably

37:23

gonna lose you here, but this is good

37:25

because I want you guys to learn something.

37:27

So, if a patient comes in for a needle

37:28

localization, what's the best approach?

37:31

Let's pull up the poll here.

37:33

Do we wanna come from lateral, from

37:35

medial, from above, or from below?

37:40

So this is the CC and this is the MLO.

37:48

Or ML? It should be an ML.

37:52

Okay, so let's close the poll.

37:59

Okay, good.

38:00

So the two people that answered got it right,

38:03

so the shortest distance is from lateral, so

38:06

you always wanna go for the shortest distance.

38:08

Whenever you're doing a needle

38:09

localization or stereotactic biopsy, you

38:11

always wanna do the shortest distance.

38:13

Um, and what size needle would you use?

38:17

Would you use a 3, 5, 7, and a

38:20

half or 10-centimeter needle?

38:25

We're gonna go over all this, so you're

38:26

gonna be pros by the time we're done with it.

38:31

Okay, good.

38:31

So the three people answered it, and got it right.

38:34

So yeah, you're gonna wanna use a five in this

38:36

case 'cause you want it to be long enough.

38:38

This was four and a half centimeters.

38:40

You want it to be long enough to get to the

38:41

lesion, but not too much longer than that.

38:44

So you always wanna size up a little bit.

38:46

So when it's four and a half, you wanna use a five.

38:48

Um, and how will you tell the

38:50

tech to position the patient?

38:52

This is where I lose everybody,

38:54

so we're coming from lateral.

38:56

How are we going to position the

38:58

patient for their needle look?

38:59

Procedure,

39:03

LM ml or cc.

39:07

Okay, good.

39:09

I'm so glad that nobody chose the right answer.

39:11

So it's lm so this is how I remember it.

39:15

So, um, so if you're coming from lateral,

39:20

I think that what confuses people is.

39:23

You're, you think because the shortest skin surface

39:25

is on the cc, it's from the lateral view,

39:29

but you actually place it like an orthogonal.

39:32

So let me show you how we actually

39:33

do a, um, a needle lo.

39:37

So we talked about this.

39:38

So the patient comes from needle lo, you

39:40

wanna choose the shortest skin surface.

39:41

In this case, it's lateral.

39:43

You are using a five-centimeter needle and you're gonna

39:45

tell the patient, the tech, to position the patient ln.

39:48

So I always think of it as a side that you're coming

39:52

from as a letter that you're gonna start with.

39:53

So if you're coming from lateral, it's gonna be ln.

39:56

If you're coming from medial, it's gonna be

39:57

ml. So that's an easy way to remember it.

40:00

If you're coming from above, the patient is gonna

40:02

be positioned in CC and you're coming from above.

40:06

Same if they're coming from below, you're gonna position

40:08

them cc, but it all matters where the actual, um,

40:11

alpha-numeric grid is open, um, versus the receptor.

40:16

So, um.

40:18

If you haven't seen one, I really urge you to

40:20

see one in person because I think it'll make

40:22

a lot more sense once you see it in person.

40:24

I always tell my residents to come in

40:25

and see, because when we plan for it.

40:27

So let's talk about this.

40:29

So this is actually a case where I'm coming from lateral.

40:33

So, um, I'm targeting this clip right here.

40:36

Um, so, um.

40:39

So if we're coming from lateral, we're gonna be

40:42

positioned, LM, we're gonna put our needle in.

40:45

We already measured, we know that

40:46

we need a five-centimeter needle.

40:48

So, um, we're gonna use a five

40:51

and we're gonna go in all the way.

40:52

So in this case, I would go in B, I'm sorry,

40:55

B and a half, and one and like a quarter.

40:58

So you basically put your needle in all the way.

41:02

Um, so we put the needle in right where the, the clip is,

41:06

and now all we know is that it's in the same plane as it,

41:08

we don't know where it is or how deep it is until we

41:11

take them out, and then we put them in the CC compression

41:14

and then we could actually see where our needle is

41:17

in relation to the, um, the clip in the mass.

41:20

So in this case.

41:21

I really wish I had a better image, but you can see that

41:23

the mass, that the needle goes beyond the clip in the mass.

41:26

And once you confirm that the needle is beyond

41:28

the clip in the mass, then you're gonna hook it.

41:31

Um, you're gonna put the hook wire through the

41:32

needle and the patient goes across the hall.

41:36

To surgery, um, with the needle and wire in their breast.

41:40

And then they go to surgery and the surgeon takes it

41:42

out and then they're gonna send you something like this.

41:45

This is called a specimen radiograph. If

41:47

you've never seen one before, um, the patient

41:49

goes to surgery, they take out the clip.

41:51

And so when we check a specimen radiograph,

41:54

we're looking for a few things.

41:55

We're looking for the clip and the wire.

41:57

Um, we're looking to make sure that we got the biopsy, the

41:59

mass, and that, um, you know, it's not butting the edge of

42:03

the margins because we're really going for, for negative

42:06

margins in this patient that's going for lumpectomy.

42:09

Um, so this is really how you do a

42:11

needle localization procedure for my residents.

42:13

Come in the room with me.

42:14

It'll make a lot more sense after you see

42:16

it if you haven't seen one in a while.

42:19

So needle localizations are performed

42:21

when the surgeon cannot see or feel the

42:23

tumor, or they need a surgical biopsy.

42:26

Let's say you get atypical ductal hyperplasia.

42:28

They want to take out more tissue,

42:30

they're going to go to the OR.

42:31

So we do a needle localization.

42:33

You can do needle localization under

42:35

any modality of where you see it best.

42:37

So if you see it best under mammography,

42:38

because you have a clip there, that's

42:40

one that's great to do under mammogram.

42:42

I like to do it on ultrasound whenever I can.

42:44

'Cause I really want to target that mass.

42:47

Um, or you could do it on an MRI, but you

42:50

need an MRI-compatible, um, needle and wire.

42:53

Um, so we don't typically do them here at Cooper.

42:57

These cases are usually performed on

42:59

the morning of the patient's surgery.

43:01

They come to radiology immediately before their surgery.

43:04

You put the needle and wire in and then they

43:05

go straight across the hall towards the OR.

43:08

Um, they go to the OR with the needle and

43:10

wire in the breast that the surgeon removes.

43:12

You know, newer technologies are way better for patients.

43:15

Um, it's all done the same way.

43:17

But in this...

43:18

Type of, uh, in the newer technologies here, we use,

43:21

um, something called, um, a radiofrequency tag, but

43:25

they also have tags that are magnetic or are radioactive.

43:29

And basically, um, we're going to place a little chip.

43:33

A little tag right where the, the cancer

43:36

is or the thing that needs to be removed

43:38

and the patient can leave with that.

43:41

We take the needle and wire out.

43:42

They just put a clip right where it is,

43:44

and then the surgeon can come back a week.

43:46

The patient can come back a week later, two

43:48

weeks later, kind of indefinitely later.

43:50

We try not to put it in more than a month in advance, but

43:53

then the surgeon, when they go to the OR, the surgeon has.

43:56

Um, a receptor, whatever it is.

43:58

In our case, they have a radiofrequency receptor,

44:01

uh, or a detector, or you can have a magnetic

44:04

detector or radio i, a radioactive C localization,

44:08

and they find where it is in the breast and then

44:11

they remove it and they know they got it because

44:13

then it, you know, it beeps when it's taken out.

44:15

It's kind of like the gamma camera.

44:17

Um, with a sentinel lymph node injection.

44:20

Um, so, you know, just to summarize how you do a

44:23

needle localization procedure, you're going to want to find the

44:25

shortest skin surface and measure the distance.

44:27

Needles come in three centimeters,

44:29

five, seven and a half, or nine.

44:31

You always wanna make sure you, um, you, you

44:34

know, if you're coming from lateral, you're gonna

44:35

position them LM, you're coming from medial.

44:38

You're gonna position them ML, and if you're coming from

44:40

above or below, you're gonna position them CC and just.

44:43

Simmer on that for a little bit.

44:45

Um, think about that.

44:46

Um, you're gonna basically, um, find, find your target

44:52

and determine your coordinates, but you're gonna

44:54

put the needle on straight as, straight as you can.

44:57

Then you're gonna take them out and put

44:58

them in the other orthogonal direction.

45:00

So if you're in LM, you're gonna

45:01

put 'em in CC and vice versa.

45:03

If you're in CC, you're gonna put in ML or LN.

45:06

Um, you're gonna place the wire through the needle

45:08

and remove, and then the patient's gonna go to surgery

45:10

and you're gonna check the specimen radiograph.

45:14

Okay, so 64-year-old female presents

45:18

with a palpable mass in the left breast.

45:21

Um, this is what her mammogram looks like.

45:23

You can see she's got some masses in the left breast.

45:27

Um, a little bit of skin thickening here.

45:31

Um, so this is what her mammogram looks like.

45:35

What is your next step?

45:43

Gonna go to biopsy, ultrasound,

45:44

MRI or no further workup needed.

45:51

Good.

45:52

So everyone did get that right?

45:54

So you're gonna wanna go to ultrasound.

45:56

Um.

45:57

You know, if this was a screener, then you

45:59

would call her back, you'd give her a zero.

46:00

But she's a diagnostic because of palpable mass.

46:02

She should be a diagnostic.

46:04

So you're just gonna go into ultrasound.

46:06

Um, I'm just gonna, um, describe this,

46:09

but this is a complex cystic mass.

46:11

It's mixed cystic and solid.

46:13

It's certainly large.

46:14

This obviously needs a biopsy.

46:16

Um.

46:17

I just wanna take a minute to, I talk to my

46:20

residents about this a lot, but the difference

46:21

between a complex versus a complicated cyst.

46:25

So complicated cysts are, you know, probably benign.

46:28

You could even call it a BI-RADS 2 or 3 depending

46:30

on how you're feeling or how many the appearance

46:32

or what, how many others she has in the breast.

46:34

If it's palpable stuff like that,

46:34

1103 00:46:36,525 --> 00:46:38,625 um, you know, they have low-level internal

46:38

echoes, maybe some thin internal septations,

46:40

but nothing that looks suspicious.

46:42

It's reasonable to give it a two or a three.

46:44

But a complex cyst has a really

46:46

high percentage of malignancy.

46:48

Complex cysts have solid components.

46:50

They've got nodularity, they've

46:52

got thick internal septations.

46:54

Those definitely need to be biopsied,

46:56

so, you know, cannot use the word

46:58

complicated and complex interchangeably.

47:00

This would certainly be a complex mass and you would

47:02

wanna biopsy it, see it, so it'd be a BI-RADS four or five.

47:05

Um, so all of the following are well

47:10

circumscribed cancers, except open the panel here.

47:19

Use medullary, tubular, papillary, or invasive ductal.

47:28

Good.

47:29

So, um, yeah.

47:30

Okay, good.

47:30

I saw I said accept.

47:32

Yeah.

47:32

So tubular is typically a slow-growing, speculated mass.

47:36

All the others, uh, medullary, mucinous,

47:40

papillary are all subtypes of an invasive

47:42

ductal that are well circumscribed.

47:44

So the reason invasive ductal

47:46

fits on here is because there are, you know,

47:49

these are all types of invasive ductal.

47:51

So they're subtypes and because invasive ductal,

47:54

um, well, I'm gonna leave this question here.

47:56

The most common type of, well

47:57

circumscribed cancer is which.

48:02

Yeah, so invasive ductal is the most common

48:04

because it's just the most common overall.

48:07

Um, you know, triple negatives tend to be

48:09

the most common invasive ductal that are

48:11

round balls that grow so fast they don't even

48:14

have time to become regular and speculated.

48:16

Um, so yeah, invasive ductal gonna be the most common.

48:19

And like I said, all of these

48:20

are subtypes of invasive ductal.

48:22

So yeah.

48:23

So going back to this case, she's 64.

48:25

It's a palpable mass in her left breast.

48:27

That means she's a diagnostic mammogram.

48:29

So you're gonna wanna go to ultrasound next?

48:32

Um, certainly it's gonna need a biopsy.

48:34

This is a BI-RADS.

48:35

Four or five.

48:36

This is a complex cystic mass.

48:38

Um, tubular is not well circumscribed.

48:41

It's a slow-growing, irregular speculative mass.

48:44

Uh, invasive ductal is most common.

48:46

This is what her T1 pre-contrast looked like.

48:50

So, you know, this is what?

48:51

Fat subtraction.

48:52

So what's bright on T1 pre, uh, we've got.

48:56

Blood, uh, blood or protein.

48:59

So mucin, mucin is T1 bright.

49:01

So this is a mucinous cancer.

49:03

Um, and just to show you, this is what our path looked like.

49:06

So it says invasive D, invasive

49:08

ductal cancer, mucinous type.

49:10

So that's why it's a subtype of, um, invasive ductal.

49:15

Okay, so.

49:17

Um, I'm gonna stop here to open it

49:20

up for any questions if you have any.

49:22

Um, please feel free to unmute

49:23

yourself and ask a question.

49:25

Um, if you have any questions that you don't

49:28

wanna ask out loud, you could email me.

49:31

Always follow us on Instagram at the Booby Docs.

49:34

Um, and I hope you found this helpful.

49:38

Thank you so much for this case review and for

49:39

everyone in the audience for participating.

49:42

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49:44

You can register for those at medality.com

49:46

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49:48

on future lectures and case reviews.

49:51

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