0:00

case number seven is a 55 year

0:03

old presents with this new left nipple change

0:06

and this new this unilateral nipple

0:09

changes concerning for

0:13

a contact dermatitis melanoma nipple adenoma

0:16

or pageants

0:19

Great, so it is a classic for

0:22

page disease where you see it's crusty

0:25

eczema on

0:28

the Nepal whereas dermatitis it's

0:31

usually both nipple and areola nipple

0:34

adenomas is usually a lump on

0:37

the nipple rather than more like crusty Exodus changes.

0:42

So the next step would be to do diagnostic mammogram.

0:48

So on the diagnostic mammogram, what

0:51

is the best virus descriptor for these calcifications? The

0:55

answer would be fine linear

0:59

branching in segmental distribution here.

1:02

You could see that these calcification. This

1:05

is the nipple. I know it's an old picture, but you can

1:08

see these calcifications are extending to the nipple itself.

1:13

So again, the answer would be fine linear branching

1:16

in segmental distribution. And this is almost this

1:19

is a bi rats five category.

1:27

and

1:30

what is the next best up in this

1:33

case? The stereotactic biopsy would

1:36

be the next best step surgical consult

1:39

is not appropriate at this point when we can do a

1:42

needle biopsy successfully. It's obviously

1:46

not by rights three. It's almost

1:49

a Barrett's five lesion and

1:52

so be and D is

1:55

not approve. It's not the correct

1:58

answer.

1:59

And in this case the biopsyl did high grade

2:02

dcis.

2:05

So a few words about pageants it's about it's a

2:08

rare cancer. It's one to three percent of breast cancers, but

2:11

about 80 to 90 percent are associated with

2:14

underlying dcis or invasive cancer. Clinically. I

2:18

wanted you to guys to be be

2:21

aware of that for pageants.

2:24

You see the changes in the nipple first

2:27

and then the areola whereas I

2:30

see a lot of patients that has eczema. It usually

2:33

eczema usually involves both areola and

2:36

the nipple various pageants. It's always you can always

2:39

ask them. Was it just on the nipple first and then

2:42

it later on when in two areola then you

2:45

want to think about Pages at that time.

2:48

Again, they can present with nipple retraction and bloody

2:51

nipple discharge. So the treatment is mastectomy

2:54

versus breast conservation with complete

2:57

resection of the nipple areola complex followed

3:00

by the radiation therapy.

3:05

So here's a companion case where you see

3:08

smooth thick rod

3:11

like calcification which are

3:14

more dense, you know,

3:17

some of it can have like tapered and

3:21

And these are secretory calcifications

3:24

remember both dcis and

3:27

secretory calcifications can be

3:30

ductile in distribution. But when you

3:33

look at but in contrast you could see the calcifications associated

3:36

with dcis is more fine. It's

3:39

like less than 0.5 millimeters.

3:44

And the secretory calcification

3:47

is usually seen in older and older women

3:50

and the pathology is duct Asia.

3:56

So the next question is which by ride description of

3:59

calcifications has highest rate of malignancy and

4:08

Okay, great. So.

4:11

Fine linear and linear branching calcifications have

4:14

the highest rate for

4:17

malignancy.

4:21

So some of the numbers is

4:27

it's about this is just for the

4:30

Morphology not including the this is

4:34

not including the segment I

4:37

mean distribution. So it's about like 80% in

4:40

fine linear or linear branching

4:43

calcifications.

4:45

And it's about 40 to 50% in fine

4:48

pleomorphic calcification about 25% in

4:51

amorphous and about 13% in course

4:54

heterogeneous calcification. So you could

4:57

see the fine linear and linear branch in

5:00

calcification is the most suspicious out of all the suspicious calcifications

5:04

and the course heterogeneous calcification

5:07

is the least suspicious.

5:10

As far as the positive predictive value

5:13

for the distribution, the regional

5:16

and grouped is about 30%

5:20

and the linear is about

5:23

50% and segmental is about 80% pasta

5:26

predictive value for

5:29

malignancy again for as far as the distributions concerned. The

5:32

segmental would be the has the highest rate

5:35

for malignancy.