0:00

Okay, moving on to the next case.

0:04

okay, so this is a

0:09

These images here from a 38 year old woman who noticed a

0:12

right breast lump in the shower about a month ago

0:15

a little bit achy, but not particularly painful

0:18

or Tender on physical exam.

0:22

the

0:25

nurse practitioner

0:27

who she saw really didn't feel much maybe a

0:30

vague mass at 12 o'clock.

0:34

Notably the patient has a

0:37

fairly significant family history in multiple maternal

0:40

relatives. So maternal Aunt maternal

0:43

grade and maternal grandmother great-grandmother. Her mother

0:46

did not have any history of

0:49

breast cancer and actually had been tested for the bracha genes

0:53

and was found to be negative.

0:57

So again, this was a right palpable Mass.

1:00

I'll just

1:02

show you the

1:04

right side here.

1:07

So there's the BB and you can see she's very dense, and there's

1:10

really nothing.

1:12

very visible on the 2D mammogram

1:19

And there's the mlo.

1:23

We did do tomosynthesis. So I will.

1:27

So again, we're going to be looking up in here. That's where the symptom.

1:31

The lump is hopefully this will load.

1:36

Okay, here we go.

1:40

You can see maybe there's some an oval Mass

1:43

there.

1:49

But really not seeing much.

1:54

I'll show the CC Tomo.

2:00

Okay, again, we're looking at this 12 o'clock area.

2:05

And there you can see these partially I would say obscured

2:08

what margins we can

2:11

see look pretty circumscribed and a dense round, Mass.

2:16

So, of course we want to ultrasound.

2:24

okay, and

2:26

I'm going to just scroll through these ultrasound images.

2:31

So here's what we're looking at.

2:33

You can see very dark anechoic portion.

2:37

Pretty well circumscribed margins and then this hypochoic portion.

2:43

and

2:45

we looked with very low flow sensitive settings to see

2:48

if there was any flow in any of these peripheral hypo

2:51

click portions, and we did not see any she had

2:54

no abnormal lymph nodes.

2:57

And here's a semi clip.

3:05

Which I think shows the characteristics of this very well.

3:09

Okay, and again, there was no blood flow in any

3:12

of those peripheral parts.

3:16

Okay, so can I have the polling question for case

3:19

six?

3:21

Thank you.

3:22

Okay. So what do you want to do with this patient? 38 year

3:25

old palpable lump?

3:27

So is it a complicated cyst to wanna

3:30

try and aspirate it?

3:32

Follow it or just go straight to YFC.

3:38

Okay, great. So everybody wants to

3:41

try to do.

3:43

some more diagnostic

3:45

stuff so

3:47

it looks like either attempt to aspirate it and if it

3:50

doesn't collapse biopsy it or just go straight to biopsy great.

3:54

okay, so what we did is

3:58

I actually was the one that did her biopsy.

4:02

And I wanted to try and aspirate it first so

4:05

I have an image here.

4:08

This is actually.

4:11

Me injecting lidocaine into the kind of capsule of

4:14

it. So I'm going to play this for you.

4:19

And I think it's really nicely shows that the anticoic

4:22

part is just kind of swirling around but you can see there

4:25

these hypochoic parts, which really aren't moving

4:28

at all.

4:34

Okay, and then I'll

4:39

and this is my after I gave the

4:42

lidocaine I attempted to aspirate.

4:47

And you can see it did get smaller but there's definitely it did

4:50

not collapse totally.

4:52

So I went ahead and did a core biopsy.

4:56

And this ended up being a triple negative

4:59

high grade.

5:01

invasive ductal carcinoma

5:03

So you all made the right choice, so I

5:06

was just going to show the MRI because I think it has some interesting.

5:11

and typical

5:14

features of high grade

5:17

Invasive ductal. So this is the t2 sequence and

5:20

not surprisingly especially given on that

5:23

given the appearance on the ultrasound. There is too bright.

5:27

material that probably represents necrosis

5:31

You can see the marker clip from the biopsy.

5:35

And the lesion is almost all T2 bright

5:38

with some areas of very hyperintense T2,

5:41

which probably corresponds to that necrotic

5:44

material. But even the tumor itself is pretty

5:47

T2 bright.

5:50

And then this is the first post contrast.

5:54

It did show some wash out and I'll just show you the

5:58

basically, it shows Rim enhancement which also fits really

6:01

nicely with the

6:03

with the ultrasound appearance

6:06

So you can see here this but the key differential here

6:09

is that this Rim enhancement here. It's pretty

6:12

smooth and uniform but here it becomes very thick and irregular.

6:17

And near the top of it. It's they're going to regular so that all fits

6:20

really nicely with the

6:22

ultrasound images

6:26

and she underwent neo-adjuvant chemotherapy

6:29

and had a complete pathologic response.

6:32

So good news for her.