0:00

moving on to the next case

0:04

so you can start looking at these images. This patient

0:08

had moved from Scotland and we

0:11

had no prior mammograms on her.

0:13

The symptomatic side was the left side here.

0:16

You can see this BB marker here.

0:19

So you can go ahead and start taking a look at that and I

0:22

will give you her history. So as

0:25

I said we had no recent mammogram.

0:28

She is 55 years old the time of presentation and

0:31

several months earlier had noted

0:34

a tender palpable left breast lump in

0:37

her upper outer quadrant about one to two o'clock four

0:40

to five centimeters from the nipple.

0:42

On the left if I haven't said that already.

0:46

She said that lump and tenderness resolved

0:49

and a little while later. She started

0:52

noticing spontaneous bloody nipple discharge on

0:55

the left.

0:56

Subsequently she found that she was able to

0:59

reproduce consistently that Bloody nipple

1:02

discharge from a single duct.

1:04

When she palpated over the previous tender palpable

1:07

area which again had gone away by now.

1:10

No family history of breast cancer.

1:14

So I'm going to blow this image up so you can see a

1:17

little bit more clearly.

1:20

I can.

1:22

Okay. So again, here's the BB marker. She's pretty

1:25

dense. This was

1:27

just 2D mammogram that we had.

1:33

And I'll just show you in comparison. So maybe there's a

1:36

little bit of an asymmetry in the breast tissue and a little

1:39

asymmetry here.

1:42

So we went ahead and did some additional views.

1:46

Which I will show you.

1:49

So we did some spot compression views over

1:52

that palpable area.

1:54

And this was all interpreted as just

1:59

dense breast tissue

2:01

so really we didn't think there was any architectural Distortion no

2:04

Mass because of the nipple discharge

2:07

we also

2:10

Did magnification views under the nipple?

2:13

You can see here.

2:15

There's the BB marker again. We did not see any calcifications.

2:20

It's another image. Okay?

2:25

And then we proceeded to ultrasound.

2:29

And basically we did find find some

2:32

look like Bland ductasia leading

2:35

up to the nipple.

2:38

But really nothing else.

2:41

Again, that duct tictasia but no introductal masses.

2:46

I'm going to show cineclub here.

2:51

This again just shows that duct dictation. And

2:54

again, we didn't think there was anything focal to biopsy.

2:59

pause that

3:04

Okay, so I'd like to put the polling question up for this

3:07

one.

3:08

So for this patient just to review we have a

3:11

fairly suspicious clinical scenario.

3:16

So the question is what do you want to do in this patient?

3:19

We don't see anything definitely by mammogram or

3:22

ultrasound.

3:24

So what is the next best step?

3:26

how patient got a biopsy we can

3:29

go off of where we can reproduce that Bloody nipple

3:32

discharge.

3:33

duct excision for the bloody nipple

3:36

discharge

3:38

MRI or clinical follow-up

3:41

great 100% Everybody wants to go for the

3:44

MRI. Perfect. So

3:46

This what we did is send this

3:49

patient to our breast surgeon who physically did also

3:52

a physical exam and the discussion.

3:56

To decide to go to MRI basically revolved around

3:59

the fact that this area was sufficiently far away from

4:02

the nipple that doing a duct excision may not

4:05

include the area.

4:08

where palpation yielded the

4:11

Nipple reliably yielded the

4:14

nipple discharge, okay.

4:17

So I think again in this case the MRI MIP

4:20

is the best demonstration.

4:24

Of what we found at MRI, which was

4:27

a significant amount of non-mass enhancement

4:30

all in that upper outer

4:33

quadrant of the left breast extending close to the nipple.

4:37

And at this point we did an MRI guided biopsy which

4:40

yielded dcis and the patient

4:43

subsequently underwent mastectomy and

4:46

all it was found was extensive intermediate-to-focally high-grade

4:50

dcis. So this is

4:53

a striking case of mammographically negative

4:56

ultrasound negative.

4:58

extensive dcis so non-calcifying dcis

5:02

and I think this is an excellent use of MRI in

5:05

a highly clinically suspicious scenario where the standard

5:08

workup of mammogram and

5:11

ultrasound is not revealing.