0:01

Well, thank you so much for having me really excited to

0:04

be here today. This lecture is

0:07

for it's a

0:10

very general overview of breast cases. We're gonna

0:13

run a wide spectrum of things. I don't know where people are in

0:16

their training or if they're post training, but I think everyone will

0:19

get something out of this lecture. Hopefully, I have

0:22

lots of cases and I have lots of questions as

0:25

a follow-up more board Style just

0:28

because I know our residents

0:31

are, you know have the boards on their mind. So I hope that

0:34

you find this helpful and if you have any questions or any feedback,

0:37

please don't hesitate to message

0:40

me or you know, turn on your microphone and

0:43

ask a question. I'm very okay with this being interactive. All right

0:46

without further Ado. Let me see if

0:49

this is working.

0:51

Okay. So a 26 year old female presents the

0:54

palpable lump. What's the first what's there for appropriate

0:57

first? Imaging test?

1:00

Okay, and I'm going to give everyone a minute

1:03

to answer.

1:06

Who's in panelists can?

1:10

Does that come up on your screen to answer?

1:14

Yeah, so we've got a few people answered. We'll

1:17

give it a couple more seconds and then I'll let you see the results of it.

1:20

Okay, great.

1:23

Okay, good. So everyone got that right? So the first, you know under 30,

1:26

you want to start with an ultrasound first and this

1:29

is what the ultrasound looks like, which of

1:33

the following is considered a malignant feature on ultrasound.

1:38

Lesion that's wider than tall angular margins

1:41

two or three gentle ovulations ellipsoid homogeneous.

1:44

Echogenic Echo texture

1:47

with the best answer.

1:50

a malignant feature

1:54

good. So most people said angular margins a lesion

1:57

that's wider than tall. I usually think of fibroadenoma.

2:00

So things

2:03

that are benign typically grow along the breastplane things

2:06

that are taller than wide means that they're growing fast. They're

2:09

breaking through planes. So that's usually a malignant

2:12

feature. So maybe you kind of read that wrong but angular margins

2:15

is the answer that we're looking for and just

2:18

so you know, this isn't a regular hypoc Mass. You can

2:21

see lots of punctate calcifications in it. Certainly this is suspicious in

2:24

this 26 year old female so

2:30

So this is what her mammogram looks like one of the questions I

2:33

would ask you is. What is the next best? I

2:36

mean what what's the next best step? And you know, I think people

2:39

are often tempted to say biopsy which is true. But you

2:42

also want to make sure you're getting a mammogram because this could be you know,

2:45

the tip of the iceberg. There may be Cancer all over and we're

2:48

just looking at one area. So you always want to make sure

2:51

that you know, even if you're if you have things suspicious on ultrasound you

2:54

always want to get a mammograms to see if there's any suspicious things on mammogram

2:57

that you don't see an ultrasound. So

3:00

this is what her me immigram looks like you could see she's extremely

3:03

dense and right where she has this palpable area of concern

3:06

and her left breast. She's got these calcifications. I'm

3:10

gonna ask you some more about the calcifications.

3:13

And but what views would you get to

3:16

further evaluate calcifications?

3:20

You see an mlo spot mag CC and CC and

3:23

ml spot mag.

3:25

xccl or CC and ml

3:28

Spa compression views

3:29

Okay, see where people said.

3:33

I'm sorry, I didn't mean to do. All right good. So,

3:36

um going back to that question. I'm glad that

3:39

people are getting things wrong. So you always want to get CC

3:42

and whenever you see calcifications, you always want to

3:45

get a cc and true lateral. So automatically you

3:48

can get rid of mlo because there's really no reason to get

3:51

an mlo the whole point of getting an ml mag is

3:54

because you're trying to see if this is milk of calcium. So a

3:57

cc, you know CC on

4:00

typically that if it is milk of calcium, they'll

4:03

look smudgy on the CC and then you get a true lateral

4:06

you kind of shake the breast and hold compression for about five minutes

4:09

and let them layer and they make a teacup kind of

4:12

appearance so you whenever whenever you

4:16

see I'm alone you can automatically glue that there's really no need for mlmags.

4:19

So that really makes you down to be and d

4:22

and really we want to get magnification not

4:25

compression compressions more for an asymmetry. So

4:28

that's why B is the correct answer.

4:32

So using by Red's descriptors, how would

4:35

you describe these calcifications?

4:37

And I want you to kind of think of head like these

4:40

are suspicious. So you

4:43

want to use words that kind of go with that.

4:46

So what would you pick to describe that?

4:51

We're going to try to move rather quickly because I

4:54

have lots of questions and I don't want to purse every

4:57

it on each one. So

5:00

that's the answer and go good. So everyone

5:03

picked course heterogeneous and grouped, you know, people typically say

5:06

courts heterogeneous, and they say that they're benign but

5:09

actually course heterogeneous falls into that suspicious category. And

5:12

so that would be a bi Reds,

5:15

you know, four or five. Sorry. I just gave away

5:18

the answer. So what's the buyer ads based on these

5:21

Imaging features? These are suspicious.

5:24

you'll notice that I left at 5 because I think that

5:28

you know when you get to suspicious findings, it's it's

5:31

controversial of what they're gonna give it a you know, I'll let

5:34

you guys answer this but

5:37

kind of gave you the answer.

5:39

Good. So everyone got there? Oh wait, sorry. So it's

5:43

by Red. It's by Red's four or five but I start

5:46

purposely didn't put five to not confuse you. All right.

5:49

And what moodality would be best to buy a Cicely? I'm

5:52

not actually gonna open this up for a question because really you

5:55

could buy idea under any of these ways except MRI because

5:58

we didn't do an MRI certainly you could buy

6:01

it see under stereotactic by Etsy because you have calcifications but

6:04

one given the option if you have something that you can see on ultrasound or

6:07

mammogram, it's better to buy at

6:10

Sea Under ultrasound because if there is an invasive component

6:13

in the cancer you want to know about it and the best way to

6:16

really Target to know if there's an invasive components Target

6:19

the math

6:21

So I would typically kind of aim for the bottom of the

6:24

math with that has both the calcifications and the

6:27

mass you may get a you may get a specimen

6:30

radiograph some if you're looking for calcifications. I

6:33

often do that especially with this, you know mass that

6:36

has calcifications just to make sure you got that too. But this

6:39

will kind of give you the best most representative piece of

6:42

tissue. So I want to give them the option by Sandra ultrasound.

6:46

All right, pathology comes back as a typical

6:49

doctor hyperplasia. What is your recommendation? And

6:52

I will ask for a question here.

6:55

So as a concordant.

6:59

Is it?

7:00

what are you going to recommend and this is a lot

7:03

of you know, mammo is a lot of

7:05

is a lot of management questions. So these are definitely answers

7:08

that questions that they can ask on the boards.

7:14

All right, so you should be finishing up.

7:18

Let me move it so you can actually see the image.

7:23

All right. Let's see what people said.

7:29

Good. So the answer is D. So it is I mean

7:32

you couldn't I guess you can say it's concordant but this doesn't look

7:35

like this looks like a cancer so really I mean

7:38

ultimately the most important thing is that you want to recommend to buy

7:41

it see that you want to take it out to me.

7:44

I would call this discordant because I don't think atypical Ducks little

7:47

hyperplasia. It's usually not this math like and suspicious. So certainly,

7:50

you know, the most important thing is

7:53

that it comes out, but I would call this discordant.

7:56

looking forward

7:58

Okay, so I'm going to skip these because I go over them. I

8:01

will point out this slide which is establish criteria.

8:04

I've talked to my residents about this extensively but this

8:07

is a good article from 95. It's how

8:10

we it's sonographic characteristics of

8:13

benign versus malignant lesions when I

8:16

took the boards, we had a like recite this but basically you want to

8:19

dress and memorize like what the suspicious features are on

8:22

ultrasound speculated angular margins Mark typo academicity

8:25

shadowing cow punctate calcification

8:28

Delta extension branching

8:31

and micro liabilated. And if any of those

8:34

things are present, then he can't consider it benign.

8:37

Okay, good moving on.

8:39

So I always want to get a true lateral and we

8:42

talked about this. So this is just kind of a quick overview of how you

8:45

do an ultrasound guided biopsy. You're going to find the mass

8:48

on ultrasound. You're going to numb the skin and deeper tissue with

8:51

1% lidocaine. We often numb the tissue

8:54

the deeper tissue with Lido with EPI, and that's to minimize

8:57

bleeding you want to make sure you don't give it in the skin because it

9:00

could cause skin necrosis. We typically

9:03

use a nine 12 or 14 gauge needle here

9:06

at Cooper. You could use any sort

9:09

of needle, you know, if it's the patients on antichoagulation you

9:12

might want to use a smaller one like a 14 I've seen

9:15

even people use 16 or 18, but this is what we typically use you always

9:18

want to place a clip you always want to get a post biopian

9:21

mammogram and comments on whether the clip is representative bad

9:24

things happen when you don't put a clip and you don't

9:27

get a mammogram after