0:01

So case number five 28 year old

0:04

female presenting with a palpable mass in the right breast. So by

0:07

definition, you know, when you reading a case you

0:10

think to yourself is this a screener or is this a diagnostic?

0:14

She's 28. What's the first test step?

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Is it going to be mammogram ultrasound MRI

0:20

or refer her to a breast

0:23

surgeon?

0:26

Good. So everyone got this right? So under age

0:29

30 if you see something if you see if a patient has something

0:32

I'm in they're under 30 years old. You're going to start with

0:35

ultrasound and go from there.

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and

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so this was actually a case.

0:41

That I had when I was first starting out

0:44

she presented with this kind of

0:47

cystic looking, Mass.

0:49

You know in retrospect I

0:52

would say that it has.

0:54

Sick internal Temptations, but I

0:57

thought it was like more of a minimally complicated cyst and

1:00

I gave it a virus three.

1:02

Which was not the right answer, but I

1:05

didn't know that at the time so she came back six weeks later

1:08

because I grew and I always tell patients when I give them a

1:11

buyer at three I said if it gets bigger or harder in between

1:14

now and then come back sooner. Okay, and this is

1:17

one of those cases. So now you can see that the lesion

1:20

has gotten a lot bigger and the thick internal citations are

1:23

are more evident. So now

1:26

we're worried if we weren't before and

1:29

she has a little bit of a thick and lymph node.

1:32

So in the 28 year old, you know,

1:35

of course, we're going to buy biopsy this but when you

1:38

see something suspicious and you've only done the ultrasound the

1:41

next best step is to get a mammogram because really you're looking

1:44

to see if this is a tip of the iceberg or

1:47

their house vacations everywhere and we're just missing it. So always

1:50

want to do a mammogram here. You can see that her right

1:53

breast. She's got skin thickening that we could not appreciate um

1:57

on the ultrasound and you

2:00

know, it's the right breast looks asymmetrically

2:03

more dense than the left breast. This is

2:06

where she's feeling that lesion you can see something there.

2:09

So this is now.

2:11

A bi-reds for it's a complex cystic mass. This

2:14

ended up being an invasive Delco cancer in

2:17

the 28 year old with metastatic cancer in her

2:20

axillary lymph node. This was a triple negative. So

2:23

this these tend to be aggressive more common

2:26

in African-American women they grow quickly and

2:29

yeah, they they typically in the

2:32

past. They've had a worse prognosis now, they have more targeted

2:35

therapy like herceptin that they

2:38

could use

2:39

So this is her MRI, you know,

2:42

I was seeing what you're usually seeing when you

2:45

see a complex cystic mass like that is essentially necrotic

2:48

tumor it grew so fast it cut off

2:51

its own blood supply and it becomes cystic so,

2:54

you know cyst don't always mean benign,

2:57

especially like in this case so you can see that

3:00

her her MRI showed this complex cystic

3:03

Mash. You also has all this asymmetric enhancement

3:06

her right breast is shrunk in and retracted her

3:09

nipples retracted. So this is multi-centric disease.

3:12

I just want to use this moment to just kind

3:15

of reiterate the difference between multifocal and multi-centric. So

3:18

multifocal is additional Society of

3:21

disease in the same quadrant and multicentric is

3:24

additional Focus both sides of disease in other quadrants, and

3:27

that usually precludes a patient from going to

3:30

breast conservation therapy not always I've seen people do

3:33

too lumpectomies and radiation, but

3:36

but usually that's classically not a

3:39

candid.

3:39

Breast conservation therapy, and also just want

3:42

to point out one more thing on her MRI.

3:45

The enhancement goes to her pectoralis muscle which look appears

3:48

tethered and I'm sure that the pectoralis muscles

3:51

involve. If you see a normal enhancement or thickening of

3:54

the pectoralis muscle that's usually your clue that there's some

3:57

muscle involvement.

3:59

So it's really important, you know for Cystic masses

4:02

that in order to be a simple cyst that they need for criteria.

4:05

It must be anechoic. Well circumscribed

4:08

round or avoid and

4:11

have an imperceptible wall with increased through

4:14

transmission of families. So if

4:17

it does not meet those four criteria, it's either a

4:20

complicated Sith which is a benign looking thing has

4:23

low level internal Echoes or some debris

4:26

that layers and changes with their position. It does

4:29

not not have thick walls

4:32

fix a patients or other discrete solid

4:35

appearing component. So if that if that has any

4:38

solid or thick patients, it's not a complicated cyst.

4:41

The written a complicated says could be followed by

4:44

Reds two or three

4:47

depending on if they have multiple similar appearing

4:50

cyst as opposed. I usually

4:53

say if it's if the patience doesn't matter where it's

4:56

newer enlarging just aspirated and just make sure that it's not bloody or

4:59

like that

5:01

complicated this is very different from a complex this

5:04

and my residents. I always yell at them because they sometimes use

5:07

it interchangeably and they cannot be used interchangeably complex. This

5:10

has thick walls fixations interest-distic

5:13

masses or to solid components. This is

5:16

what I mean when you say a solid and cystic mass.

5:19

So this is a complex this malignant the

5:22

rate of malignancy is very high. It's 23 to 31 percent.

5:25

So it's way above the two percent that was born a biopsy.

5:28

So tissue sampling is required.

5:32

So very important. So these are all cancers. So

5:35

this looks like assist but

5:38

you can see that it has like some solid portions some that

5:41

that did not layer. This is really not a

5:44

smooth round circumscribed lesion.

5:47

So already you're suspicious this these

5:50

are all cancers. So just you know CIS is

5:53

not always a benign thing. So you're really looking for

5:56

those thick dictations or solid portions.

6:00

These are all complex this required by its.

6:03

So just to reiterate that breast complaints under 30,

6:06

you're going to want to start with an ultrasound if there is

6:09

a suspicious Mass. You're going to work backwards and get a mammogram and

6:12

then ultimately you're going to do a biopsy breast cancer

6:15

is rare, but it definitely happens.

6:18

We see it often. I don't know if it's just our our

6:21

population here, but we see lots of cancers under the

6:24

age of 35. So a patient's age is

6:27

not a reason to just think it's benign, you know

6:30

the risk obviously to increases by age by the

6:33

time you're forties 1.5% developing cancer

6:36

in the next 10 years.