0:00

This was a 42-year-old,

0:03

so she was young as well.

0:05

And, um, she had actually been wandering

0:09

around, being reassured over and over

0:11

again at the age of 42 that her palpable

0:13

mass in the right breast was fine.

0:17

Uh, which, of course, it turns out, not

0:18

to be, but there had been a much longer

0:20

program as compared to the last patient,

0:23

the 47-year-old, where there'd been

0:24

rapid enlargement of her breast mass.

0:27

This patient had not had a much slower program.

0:30

Um, had had a much slower program.

0:35

And, um, you can see why there

0:37

would be that may be difficult.

0:39

First of all, it almost

0:41

feels that it's too lateral.

0:42

It almost feels that it is literally in

0:44

the chest wall rather than in the breast.

0:47

But you can see in her right breast.

0:50

So, this is the right lower outer quadrant.

0:52

We have an enhancing mass.

0:55

She is small-breasted and this, um...

0:58

This window, I'm sorry, this

1:00

field of view is not acceptable.

1:02

I know we had a field-of-view question

1:04

a field-of-view case in week 3, but

1:07

this field of view is not acceptable.

1:09

Um, that being said, uh, it's,

1:13

um, a great example, and I'm

1:16

hesitant to use that term, but it's

1:18

true of both pectoral muscles.

1:22

And in her case, intercostal

1:24

muscle, we're going to look more.

1:26

So, at her images now, so she

1:30

has a speculated mass and it is.

1:36

So, this is her contralateral normal side.

1:39

I'm showing you that by design.

1:41

You can see quite nicely in the inferior,

1:45

um, quadrants, maintenance of normal,

1:48

uh, uh, fat and normal parenchyma and

1:52

respect for the boundaries of the chest wall.

1:55

And in contrast, Going to go through the

1:58

midline now, then we're going to come across.

2:02

This is also a really nice area to be able

2:05

to clear the internal mammary vessels as well.

2:08

Internal mammary lymph node chain.

2:11

This is the vessel and this explains

2:14

why you're able to trace it up and down and

2:16

the adjacent images and the sagittal image.

2:18

It's all laid out as the single

2:19

vessel, the internal mammary artery.

2:22

Just keep going here.

2:27

So, now we've scrolled far enough laterally

2:30

and believe me, it's very lateral.

2:32

We're barely seeing the subdermal fat of only

2:35

part of the right breast, but you can see quite

2:38

readily a speculated avidly enhancing mass.

2:43

And there is no, there's no separation

2:46

whatsoever from the thin wisp of

2:50

pectoral muscle that still exists there.

2:52

There's very little there, but the thin

2:54

wisp of pectoral muscle and certainly the

2:57

intercostal muscles, you can see the, the, the

3:00

mass actually invades almost, seemingly almost

3:03

through the entire chest wall at that point.

3:05

So certainly through the muscle.

3:07

That bore out on, um, in particular,

3:11

ultrasound as well.

3:13

It was plastered, um, plastered against the

3:15

chest wall on ultrasound, and, as importantly,

3:19

clinical exam where there was a fixed mass.

3:21

So it was fixed to the chest wall.

3:22

So all those things together, um, uh,

3:26

indicate, uh, uh, chest wall involvement.

3:29

So, uh, pectoral muscle only

3:32

is not chest wall involvement.

3:34

Uh, it requires, as in this case, an example

3:37

of intercostal muscle or transversus muscle

3:40

involvement and fixation, a fixed finding on

3:45

clinical exam, as long as the patient, um, as

3:50

long as the mass is able to be felt clinically.

3:52

This is an example of locally

3:55

advanced breast cancer.

3:56

It is in contrast to the inflammatory

3:58

breast cancer of the last patient.

4:00

These patients don't have photurange, uh,

4:03

they typically have a longer time frame.

4:05

These are not rapidly growing masses

4:08

by any stretch of the imagination.

4:09

The, uh, um, histology is typically favorable

4:14

in the sense that, um, they're often lower

4:17

grade and have been growing for a while.

4:19

But these are the two.

4:21

Locally advanced are the tumors that have

4:22

invaded the chest wall and or invaded the skin.

4:26

Um, it's also a stage three breast

4:28

cancer and a very curable stage.

4:31

Uh, locally advanced breast cancer

4:32

is even more, is, is, is, is even,

4:36

uh, much more curable, uh, typically.

4:40

Then is inflammatory cancer, both of which

4:42

are actually stage 3 tumors, and both of which

4:46

require, um, a whole-body staging. Inflammatory

4:51

cancer is far more likely to have, oh no, a

4:54

stage 4 component to it with distant metastasis.

4:58

Locally advanced breast cancer, by definition,

5:00

does not have, does not have metastasis.

5:04

They could have delayed bone metastasis,

5:06

but again, typically patients do very well.