0:00

So we're moving on to the next case and you can see here on

0:03

the left is the screening mlo image

0:06

from the year before and this is the current

0:09

screening mammogram image.

0:12

This is a 70 year old woman.

0:15

Who is just like I said undergoing screening mammogram?

0:19

So take a look at these images.

0:23

also show you the

0:25

CC

0:27

Okay. And again, this was the this is the

0:30

current.

0:32

screening mammogram

0:34

image and the one-year prior

0:37

and I'm going to show you all four.

0:42

Okay.

0:43

So please show the polling question

0:46

for this exam.

0:49

Okay. So after you've reviewed these images, what would you

0:52

like to do with this patient? Would you like to bring her in for

0:55

a diagnostic mammogram and ultrasound of the

0:58

right breast and axilla or just look only

1:01

at the right low axilla?

1:04

Or do you think this all looks fine and you just have her go

1:07

back to screening or would you recommend an MRI

1:10

off of the screening exam?

1:13

Great. Okay. So all of you want

1:16

to bring this patient back and look at those axillary

1:19

lymph nodes and some of

1:22

you also want to look at the right breast. So that's perfect.

1:26

Okay, so we

1:29

called her back and

1:32

let me pull up.

1:35

The ultrasound images so we

1:38

actually I'm just going to show the ultrasound images. Those are

1:42

what are most useful Okay, so

1:47

We looked in the axilla and we found these two

1:50

areas.

1:54

and went ahead and

1:56

we're planning to do a biopsy.

2:00

Now, this is not a polling question. So, let's see.

2:03

Maybe we can have people.

2:06

Vote in another way, but I want to know was was there

2:09

any other area of the breast that you wanted

2:12

to look at?

2:14

Based on that mammogram. Let's see. I've got

2:17

one.

2:19

right upper outer quadrant

2:22

So you probably are looking at this great anything

2:25

else?

2:28

I'll just give it a moment and then I'll move on to.

2:32

What happened in this case? Okay, so I am just going to move on

2:35

so this

2:37

so when we brought this patient back all we did

2:40

was look at these lymph nodes. We didn't think there was anything else in her

2:43

breast and on the day of the biopsy the

2:46

patient actually said, well, what about

2:49

this area and the

2:52

inferior aspect around my nipple where I've had this discoloration

2:55

and skin thickening.

2:57

So despite having some new symptoms from her

3:00

breast. She hadn't mentioned them to anyone and including for

3:03

the screening mammogram. So

3:07

She mentioned this at the time of the biopsy so we went

3:10

ahead and looked.

3:12

At this area with with ultrasound and we

3:15

found this mass that was partly going up

3:18

into her nipple and extending in inferiorly into

3:21

the underlying breast tissue.

3:24

So I thought this

3:26

Was an interesting case it's a very subtle.

3:29

Change the two things. I want to show are.

3:34

I'll just go back and show.

3:36

the comparison images again

3:39

So I think this is a very subtle finding but you

3:42

can see there is a little bit of skin thickening and retraction.

3:47

right behind the nipple

3:50

This was the most recent exam.

3:55

That we did not appreciate.

3:57

Right there.

3:59

The other thing I thought that was interesting about those cases just

4:02

to show

4:05

How we biopsied this?

4:08

So there again is the mass we felt it was coming down into the breast

4:11

tissue there. So that's what was targeted and I'll just show you

4:14

the

4:16

there's a lymph node biopsy and then there's where we biopsied under

4:19

the nipple.

4:23

So this ended up being a papillary carcinoma that

4:26

arose in the nipple and metastasized to the

4:29

lymph nodes.

4:31

And I'll just show you.

4:34

I think the best image on the MRI is the MIP.

4:37

You can see this marked enhancement at

4:40

the base and extending into the nipple very asymmetric with

4:43

the other side.

4:45

And again, this is the the right side and then

4:48

you can see those.

4:50

lymph nodes up there