0:00

Okay, so we are going to move on to the next.

0:04

case

0:06

so there's a couple good teaching points. I think with this case. So what

0:09

you should be able to see here is a

0:12

LMO. I'm sorry

0:15

left m l o view from a screening exam

0:18

in 2021.

0:20

With a prior from 2019.

0:23

And the next most recent prior was

0:26

from 2017.

0:29

So just take a look here.

0:32

Okay, I'm going to show.

0:34

The CC views now. So this is the left

0:37

CC View.

0:40

from 2021

0:47

Okay.

0:49

I'm sorry to keep everyone on their toes. I'm gonna have

0:52

before we move on. I'm gonna have people want

0:55

to write in the chat. Is there any area here that catches your

0:58

eye that you want to take a closer? Look at that you want to call her back for?

1:02

This is a tough case and it may not be easy to

1:05

see on the screen. So.

1:07

I was the one actually that read her mammogram and what

1:10

I thought I was seeing here was a really

1:13

good example of an involuting breast.

1:16

So the surrounding tissue out here is

1:19

slowly decreasing in density, but

1:22

there's basically this island of tissue here.

1:27

Around 12 o'clock.

1:29

That is persistently dense, and

1:32

now appearing denser than the

1:35

surrounding tissue.

1:37

So again, I'll go back to those mlos.

1:43

And I think this shows it well as well. So again,

1:48

the tissue is pretty uniformly dense here with this area looking

1:51

similar to the surrounding tissue. You can also see we change

1:54

equipment between these two years.

1:56

Same thing here. It looks pretty homogeneous. And

1:59

then now this is just looking much denser.

2:03

So I called her back.

2:06

And we did some additional views.

2:12

So that was a 2d screening

2:16

that we did.

2:20

So you'll probably just take a moment to load. So we brought her

2:23

back and did some Tomo synthesis.

2:26

There we go.

2:28

Okay, so there's that denser area.

2:34

And as I'm waiting here.

2:37

Basically, the tomosynthesis kind of showed more of

2:40

the same thing that there was just denser area of breast tissue.

2:44

Maybe some Distortion nothing terribly striking

2:47

though. Just more

2:50

of the same. So here we go.

2:53

Just that kind of diffuse area of

2:56

increased density.

2:59

Okay, so

3:02

pause that

3:08

We also of course looked with

3:11

ultrasound.

3:15

And the ultrasound actually wasn't terribly.

3:19

Impressive either just basically showed this vague hypochoic

3:22

shadowing area.

3:25

There we go. Some more just sort of this vague

3:28

hypoechoic shadowy area.

3:31

large area there should be

3:34

there some more

3:37

so it's really this whole area.

3:41

So the patient underwent an ultrasound guided biopsy using

3:44

a 14 gauge needle.

3:46

And a pathology came back.

3:49

atypical ductal hyperplasia

3:52

with apocrine features focally severe

3:55

atypia and sclerosing adenosis and

3:58

there is a note from the pathologist that

4:03

the atypia ranged from mild to

4:06

severe

4:08

and no necrosis was seen.

4:10

The findings are quite typical. I'm sorry

4:13

quite atypical but features particularly in light of

4:16

the apocrine cytology are not sufficient for

4:19

the diagnosis of ductal carcinoma incite you

4:23

so time for this polling question

4:26

for case 5

4:29

what do you want to do with those radpath results

4:32

those pathology results? How would you consider this

4:35

in terms of core concordance is this

4:38

discordant? And what next steps would you

4:41

want or do you think this is concordant and you want to do some follow-up

4:44

Imaging or just send her to surgical excision given

4:47

the fact that this atypia?

4:51

Sometimes severe vocally severe was present.

4:55

And I will say for this one. I think there's probably more

4:58

than one right answer.

5:02

Great. Okay, so everybody thought

5:05

this was discordant and whether

5:08

and these are exactly the two answers.

5:11

I was thinking either go to MRI to look for a better

5:14

Target to biopsy or sender to surgical excision because

5:17

we've already tried by out seeing

5:20

Okay, great.

5:22

So interestingly what was done in this case is the

5:25

radiologist who did the biopsy felt it

5:28

was concordant.

5:30

And just sent her for surgical excision for

5:33

atypia, and actually the radiologist who

5:36

recommended the biopsy did not think it was discordant. So

5:39

there was a difference of opinion.

5:42

So the patient ended up getting a surgical excision.

5:46

Which did indicate that there was extensive dcis.

5:50

so I will show so what you will see on

5:53

the MRI when I show it here is that there are also

5:57

post-surgical changes because the patient did have a

6:00

excisional biopsy.

6:05

So here's the post Contrast MRI. I'll just

6:08

take a moment to load.

6:10

I think the important thing here is

6:13

that

6:16

I would consider this discordant, especially when the findings

6:19

are pretty vague and over a

6:22

large area and you use a small 14

6:25

gauge needle.

6:28

I think you could send the patient to excision, but

6:31

I do think.

6:33

Probably ideally getting an MRI first would be

6:36

the best Next Step because you could do an MRI

6:39

Guided by Etsy actually similar to that case. We just

6:42

saw get a better sample and hopefully get get the

6:46

dcis because this patient actually as you'll

6:49

see here had very extensive enhancement and

6:53

ended up getting a mastectomy.

6:56

And the final pathology of the mastectomy showed over five centimeters

6:59

of high grade dcis.

7:02

So I'm going to try and window level this a bit.

7:06

If I can.

7:08

Well, I think you can see here. So again, she had

7:11

had surgery so some of this skin enhancement

7:14

and thickening is from the surgery, but you can see there's extensive

7:17

enhancement involving.

7:22

most of the upper breast

7:25

which corresponds well, I think to the mammographic

7:28

finding and then here's the MIP image.

7:33

Nothing's really nicely showing how extensive this is

7:36

involving most of the upper breast.

7:39

and this patient