0:00

So 79 year old female history of

0:03

right breast cancer status postmastectomy one

0:06

year ago presents with a palpable Mass on

0:09

her right? Axilla.

0:12

So

0:17

so she know she had mastectomy. So you're going to want to

0:20

start with an ultrasound in these patients.

0:22

And you can see this little

0:25

hypochoic, Mass.

0:27

It looks like it has some internal vascularity.

0:32

So certainly it's suspicious. If you have something in a

0:35

post mastectomy patient that does not clearly, you

0:38

know, it's not clearly a benign lymph node or fat necrosis.

0:41

You're going to want to buy it see it. Um,

0:44

we did an FNA and it was

0:47

positive her malignant cells adenocarcinoma new palpable

0:50

areas of concern following mastectomy are suspicious.

0:53

They must be evaluated under ultrasound. You might

0:56

want to even consider a mammogram. If you're thinking it might be

0:59

fat and acrosis you want to see if there's like a course calcification there.

1:02

Um, but they certainly do have

1:05

recurrences or like 10% left breast sitting on

1:08

the surgeon. There can be as much as like 10 to 20% less

1:11

of breast tissue and patients with

1:14

gonna affecting me are not routinely screened with mammogram. So

1:17

those patients are going to really present with the palpable if

1:20

concern

1:21

You certainly want to biopsy it if the Imaging appearances

1:24

not clearly benign and like

1:27

I said recurrence after mastectomy is usually palpable and

1:30

that's the reason they're usually fairly superficial just because

1:33

of the way they do the Reconstruction if they do a tram

1:36

flap, they have a little bit of native breast tissue on

1:39

the top and then under that is abdominal fat. So it's

1:42

going to be a bad like interface between where they do

1:45

the Reconstruction so they usually are palpable and

1:48

that's how you're gonna find a cancer in affect mutation.

1:53

Um, so this was again her PET CT you

1:56

can see this pet Advent Legion and the right exilla right

1:59

where she was feeling the

2:00

The lump and ended up being a cancer thought I

2:04

had a few more cases that I guess not.

2:08

so in terms of post-test questions

2:12

patient presents for the palpable area of concern diagnostic mammogram

2:16

is negative. What is the next best

2:19

appropriate step?

2:23

Good. So yeah,

2:26

you certainly want to do an ultrasound. I mean MRI not

2:29

really appropriate if we haven't done

2:32

an ultrasound yet. If you do a mammogram an ultrasound

2:35

and it's negative, but it's still suspicious. Then you

2:38

would consider maybe an MRI or surgical consult. There

2:41

is a very small risk of malignancy with a negative

2:44

mammogram and ultrasound. It's around it's under 4%

2:47

but that's a decent amount. So, you know, something is

2:50

it's suspicious on mammogram is something suspicious

2:53

on clinical exam and the mammogram and ultrasound are negative. Then

2:56

you might consider an MRI or surgical console,

2:59

but not you would want to go to ultrasound next.

3:05

Patient had a biopsy which revealed a typical ductal hyperplasia. What

3:08

is your recommendation?

3:14

Good. All right. So yeah atypical ductile

3:17

is a high risk lesion that you are going to want to

3:20

take it out. It would be surgical surgical excision with

3:23

needle. Look remember needleloak is that type of

3:26

procedure that we do that I showed you with an alphanumeric grid

3:29

where we're gonna put a needle in

3:32

and the wire and then they're gonna go to surgery. So ADH should

3:35

be taken out and most most

3:39

surgeons would take that out. That one's not as controversial as

3:42

alh or lcis.

3:44

All right.