0:00

Moving on to the next case. So the history

0:03

here. I'm going to start with the 2011 exam

0:06

this patient had at this time

0:09

was 44 years old and had a palpable left

0:12

breast lump.

0:15

And we had some images we had some difficulty getting the static images

0:18

to work and be de-identified. So what

0:21

I what I'm going to show you here is the cine clip.

0:24

The mammogram was done and just showed a large.

0:27

Well, circumscribed, Mass.

0:29

So I'm going to send you show you this cineclip and

0:32

over here is the measurements of this mass that

0:35

you'll see.

0:38

So there's the mass.

0:44

I'll pause it.

0:48

And get back to those measurements. So again, the measurements were 3.9

0:51

by 3.3 by 1.3 centimeters.

0:55

With a volume of just under 9 cc's.

0:58

So this underwent ultrasound guided biopsy and was

1:01

shown to be a simple fiber adenoma.

1:05

And she just returned to clinical and annual screening follow-up.

1:11

In 2014. I she saw

1:14

another primary care provider who felt this mess

1:17

and thought well, let's just take another look at this. It's been a

1:20

couple years. So again this the initial biopsy was

1:23

January 2011, and this is

1:26

Um, July of 2014 so you

1:29

can see I put the measurements here.

1:33

So to refresh your memory it previously measured

1:36

3.9.

1:38

By 3.3 by 1.3 centimeters and

1:41

the volume previously was almost nine CC

1:44

so it did get a little bit bigger mostly in

1:47

one dimension. Maybe a little bit in the other dimension.

1:51

But this was quite mobile and that was

1:55

felt to be part of the

1:57

Difference so I'll show you the clip here.

2:00

And I think you can visually see it's a bit taller

2:03

than it was before.

2:09

Okay.

2:11

So at this point, I'd like to show the polling question

2:14

for this case.

2:17

So what is the next best step in this patient we've had.

2:21

About three and a half years and a slight interval increase

2:24

in size maybe about 50% increase

2:27

by volume biopsy proven fiber adenoma.

2:32

Great. Okay, so pretty much.

2:36

Everyone who answered wants to biopsy

2:39

it again.

2:40

And I will say I think there isn't

2:43

a clear there's no clear evidence based

2:46

recommendation for what to

2:49

do. In this case. I will tell you I was

2:52

the one that interpreted this and felt

2:55

like it was visible on the mammogram and

2:58

she could feel it and just said

3:00

I think it's

3:02

an okay amount of growth and Let It Go.

3:06

Okay, and then I will just show you so she ended

3:09

up coming back about 10 months. Later.

3:13

And this is what we saw.

3:19

So this had rapidly increased

3:22

in size so

3:25

per the patient. She really hadn't felt any changes until very recently

3:28

after this where this just rapidly

3:31

increased in size. There was some history

3:34

of possibly a mild trauma.

3:37

So some thinking that maybe this could be hematoma, but

3:40

because it was so suspicious and the

3:43

patient really didn't have any bruising she underwent

3:46

biopsy.

3:48

Which was initially actually non-diagnostic and she

3:51

underwent subsequently a surgical excisional biopsy

3:54

which showed to be an aggressive

3:57

malignant philoides.

3:59

So this is a very sad case.

4:03

so I'll just start showing the

4:09

mips here. So just as we saw in that

4:12

MRI, this was benign over

4:15

here, but just as we saw, I'm sorry on the ultrasound. There's

4:18

a very large.

4:20

Mass

4:22

where this other where this fiber had had Noma

4:25

had been

4:30

And here's the t2 the surgeon said

4:33

when she went in and did the surgical excision. It

4:36

was very

4:38

soft

4:42

very soft tumor

4:44

So it showed.

4:47

pretty T2 bright here almost looks

4:50

like fluid

4:53

with some fluid around it

4:55

and as you can see from the mips that enhanced a

4:58

lot.

4:59

Here's a subtraction.

5:01

Okay, I'll just show the post

5:04

contrast.

5:05

Which not surprisingly just showed a lot of enhancement.

5:13

So and there we go. Lots of

5:16

enhancement.

5:20

and fallouty's

5:22

can have this kind of cleft this is

5:25

described at pathology this cleft appearance, which I wonder if

5:28

this is what we're seeing here on the MRI.

5:31

I think the main teaching point with this is

5:34

with this case

5:36

I'm just gonna bring this up again.

5:39

Certainly going forward. This was a very this was

5:42

a very large mass to begin with and

5:46

Again, when I looked into this, there's

5:49

not clear.

5:51

Guidelines set forth as

5:54

to what size these should be removed and I'm not

5:57

sure even if we had biopsied this in 2014 if

6:00

we would have gotten floaties.

6:04

But I think going at this point going forward. I certainly

6:07

would have rebiopsied it possibly just said, you know, this is

6:10

pretty big. It should just come out. Of course this case influences

6:13

me.

6:16

And the pathologist actually went back and looked at

6:19

the 2011 biopsy sample and said

6:22

no it just like fibroadnoma.

6:24

And it probably you know fibradenoma and

6:27

poloides are on the same spectrum pathologically and

6:30

there may just have been a small 40s segment that

6:33

kept growing and eventually became malignant.