0:01

Okay case number three. So 71 year

0:04

old female presenting for annual screening mammogram.

0:08

so this is her mammogram in 2016,

0:11

and it's

0:14

kind of a subtle finding so I'm going to draw your attention

0:17

to it, but

0:20

It's in the right upper breath. So you really

0:23

see it up here. This is here from 2010

0:26

you something in between that is from

0:29

2012?

0:31

So you can see that.

0:35

Well, let's see what you see. So the Salient finding so

0:38

we see it on one View and it's been

0:42

kind of growing or becoming more conspicuous over

0:45

time.

0:48

So would that be an evolving asymmetry focal asymmetry

0:51

mass, or architectural distortion?

0:54

Good good, so, I'm

0:57

glad somebody got this wrong because you guys were doing too well

1:00

and you didn't even need to lecture. But yeah, so in a

1:03

symmetry is something that you're gonna see on one of you and it's

1:06

not a math a mass has convex borders.

1:09

So if we go back to just look at that that lesion

1:12

you could see we only saw it

1:15

on the we really didn't know where it was on the CC view.

1:18

We saw it in the right ever breast.

1:20

And you can't really call it mask because

1:23

the mass you have to see on two views and you can't really call a focal

1:26

asymmetry also because you have to see that on two views so really it

1:29

meets the criteria for developing a symmetry like we

1:33

said, so the appropriate buyer ads.

1:37

here

1:40

good. Yeah, so developing asymmetries are

1:43

suspicious and you would want to call her back

1:46

to kind of work that

1:49

up further, you know by red one is negative. So

1:52

it certainly not negative Pirates 2 is benign thyroids 3

1:56

is probably benign you really can't give that office screener. There are

1:59

certain circumstances where you can but this is not one of them. So

2:02

in terms of what you want to bring the

2:05

patient back for all we really know is that there is an

2:08

asymmetry. We know it's in the upper breast.

2:10

Um, I like to do tomosynthesis, I mean

2:13

you could do this by compression as well. But really we

2:16

don't know where it is except that it's in the upper breasts and it's

2:19

really small. So if we need to kind of know what quadrant is

2:22

in so it's almost emphasis is going to give that a set location

2:25

information that's going to be really helpful to determine, you

2:28

know, where it is in the breast. Can we buy it to get

2:31

under ultrasound if necessary, so

2:34

Almost synthesis. So this is an ML. And actually

2:38

sorry, this is the mlo and this is actually an image from

2:41

an mlo tomosynthesis.

2:43

And I don't know if you've ever paid attention to this

2:46

as you scroll

2:49

through a Tomo you're going to see something that looks like this

2:52

clock and the line and so this is a

2:55

really helpful tool to help triangulate where

2:58

you are in the breast.

2:59

So in this case, where is

3:02

the abnormality located?

3:05

So I want you to tell me which quadrant this is the right

3:08

breast.

3:09

But now what quadrant is it? What are you going to tell the

3:12

tax to look for?

3:16

Okay good. So, I'm glad some people got this wrong. So.

3:20

What this is telling us is that we know it's in the upper

3:23

breath, right? So the correct answer is actually 9 to 12.

3:27

So actually I don't think I don't think anyone got that right? So it's

3:30

good that we're getting something wrong. So we're going

3:33

to learn something so we know what's in the upper breath, right? Here's her

3:36

nipple. If we go straight back then we know it's in the upper breast. So

3:39

already we either know it's in this quadrant

3:42

or this quadrant and this line is telling you that this

3:45

is where we are in the upper rest. So it's you know, it's not a straight

3:48

up and down line and oblique because the mlo is oblique. So

3:51

what this is telling us that it's in this quadrant the nine o'clock

3:54

to 12 o'clock. It's in the upper breast and we know it's in

3:57

the outer breast if it was in the lower breath.

4:00

Like let's say it was below the nipple that it would actually begin

4:03

the three to six o'clock range. So this is a really

4:06

helpful tool. If you see something on one view, you know in the

4:09

past we would get true lateral to see if it

4:12

drops or if it rises to see if it's in the medial or

4:15

lateral breath, but this is a great tool that so tomosynthesis

4:18

is really helpful for triangulation. So now

4:21

we're going to tell the tech to look in the nine o'clock to 12

4:24

o'clock.

4:25

Range, so the tech

4:28

goes in you know, really she shows me a negative picture, but I'm

4:31

worried so I go back in and I find this very

4:34

very subtle thing at 10 o'clock 10 centimeters

4:37

from the nipple. It's slightly irregular, but it's

4:40

really the right location and

4:45

We think of corresponds to the mass again.

4:48

We always look in the lymph node. That looks

4:51

fine. So that would be a buyer ads for.

4:54

And you know, it was suspicious and it ended

4:57

up being invasive ductiles.

4:59

So evolving focal or evolving a

5:02

symmetries?

5:04

Are a new or in our new

5:07

or increasing in consequute insides or

5:10

conspicuity compared to Prior mammograms? So in

5:13

this case it was developing. You

5:16

know, it got more conspicuous over time. The risk

5:19

of malignancy is high for developing asymmetry certainly over

5:23

the two percent that would warrant a biopsy. So this would certainly be

5:26

a buyer and for and if you didn't see it

5:29

on ultrasound

5:31

Then you would buy up see it under stereotactic biopsy.

5:34

I don't want you recommending an MRI really you

5:38

should be able to biopsies you don't you see it well enough

5:41

on a mammogram that you go by see under

5:44

the mammogram, but developing a symmetries have a very high risk

5:47

of malignancy certainly well over the 2% that

5:50

we would you know accept for probably benign.

5:54

So that would need to be biased.

5:56

Um a folk asymmetry

5:59

on a baseline is a different situation. So if you have a focal asymmetry

6:02

on a Baseline and you do the appropriate workup, you

6:05

get stock impression views and you do an ultrasound. There's

6:08

nothing there then you could say it's probably benign by Red 3, but if

6:11

it's a growing or new focal asymmetry or asymmetry that

6:14

needs to be addressed so that is suspicious and

6:17

should be biased one way or another.

6:20

And this is actually a great article and Radiology

6:23

the developing asymmetry. We're visiting a perceptual

6:26

and diagnostic challenge. So if you need some nighttime

6:29

reading I recommend this.

6:31

So she goes on to have breast conservation therapy,

6:34

right? It's one small little area. What

6:37

can we do in Radiology to take

6:40

out the tumor?

6:43

And I'm going to give you a minute to

6:46

answer this

6:49

so I will give you a hint. This is what it would look like if you

6:52

do this procedure.

6:56

Good.

6:58

Glad some people got this wrong. So.

7:01

And you know on the board they can certainly show you something

7:04

that looks like this alphanumeric. Grid when you

7:07

see an alphanumeric red, you know, it's a needle localization.

7:10

So need a localizations are done before surgery to

7:13

help localize something that we can't see that the

7:16

surgeon can't see or feel stereotactic biopsy

7:19

on the other hand. I wish I put a

7:22

picture of my lecture but it looks different. It's going

7:25

to have a little box. You

7:28

know what I should I'll add that for the next time but when

7:31

you see an alphanumeric grid, you know, what's a needle look and that

7:35

is what we do in mammogram and

7:38

breast Imaging to help localize it

7:41

something before surgery. You could do an or mammogram.

7:44

You can do it under ultrasound. You can do it under MRI. If you have the capability you

7:47

can put a tag in and then they take it out later. So

7:50

be familiar with those procedures because

7:53

it's something we do often.

7:57

and my question to you is

8:01

I I want people actually this is

8:04

very interactive. So I want people to jump in and if they have any questions about anything

8:07

I'm talking about. I don't know if you

8:10

guys are in practice or your residents, but certainly if

8:13

there's something I talk about you're not familiar with and you want

8:16

more information. Please let me know feel free

8:19

to ask so we want to know what size needle

8:22

are we using and what approach?

8:24

for our needle localization

8:30

good. All right, so we have things all over the

8:33

board. So I'm so happy about that and let me take a minute to explain

8:36

what is going on here. So this is the ml this

8:39

is her cliff and this is the CC view.

8:43

So what you're trying to do when you're planning for a needle Locus

8:46

you want to find the shortest skin surface.

8:49

So, you know certainly is in the upper outer breast. So

8:52

if we measure from the from the superior breast it's about seven

8:55

centimeters. If you measure from the lateral breasts, it's

8:58

4.2. So already we know we want to come from

9:01

lateral. That's just the closest skin surface. Now you

9:04

want to talk about what size Mutual you need for a needle

9:07

Loop. Typically they come in three five

9:10

seven and a half or 10, but the the real

9:13

underlying theme is that you need something that's long enough

9:16

to reach the I'm sorry. The answer

9:19

is five centimeters from lateral. It needs to be long enough that

9:22

you reach the lesion. It's okay to go past it,

9:25

but you don't want to be too short. So a three

9:28

would be too short seven and a half would be really

9:30

on you would need to pull it back because really you're

9:33

going to want the hook right kind of at the tip. So we're

9:36

going to come from Lateral with the five.

9:39

This always trips up patients residents. But

9:42

if you're coming from lateral, you're going

9:45

to be positioning the patient LM. Okay. So for

9:48

some reason it didn't show up well, but let's say that the

9:51

the clip is right here. So

9:54

you would go in at e

9:58

0.5. So that would be right here and you

10:01

basically go in straight straight with

10:05

your needle at one. Sorry. It's 0.5

10:08

in E. And then you're going to take a picture to see

10:11

that it looks like it's straight and right on top of your lesion. So

10:14

in this case it is

10:16

so all we know is is in the same plane as our

10:19

lesion, but we don't really know how deep it is

10:22

yet until we take the patient out of LM and then

10:25

put her in CC.

10:26

Okay, and so you can see that the needle goes right

10:29

to where we want it to so it's the five centimeter

10:32

is just perfect. You know, if we went

10:35

seven and a half it would be a little too deep. So once you confirm

10:38

that the needle looks good, then you're gonna put the wire through

10:41

that needle and it's going to look something like this. Okay.

10:44

So it's at our institution the

10:47

patient will go to surgery with both the needle and wire into

10:50

in their breasts. They put a little Dixie cup

10:53

and they wheel them over they usually go to same day surgery they go

10:57

to surgery and then they're going to send you a post after surgery.

11:01

They'll send you a post surgical specimen. So you're gonna you're

11:04

when you do a specimen you're making sure that you have the mass

11:07

and the clip and the whole needle and wire sometimes

11:10

make a break in the breast.

11:13

So you want to make sure that you don't leave any fragments of

11:16

that and yeah any

11:19

questions about this, this is a really important concept.

11:22

I would love you to understand so

11:26

Take a minute to look at this.

11:30

Okay, if anyone has

11:33

any questions, like I said, please feel free to ask okay?