0:00

So now we have a 63 year old female presenting first-graining

0:03

mammogram.

0:05

These are our only images.

0:08

I'll give everyone a little time to look them over.

0:15

Try to make sure everyone has enough time. I'm sure there's I

0:18

don't know. There's a feature for you to tell me a chat feature if

0:21

you don't but we'll move on.

0:23

So what is the finding on the mammogram?

0:28

Bilateral axillary adenopathy correct. So

0:31

I'll show you guys right here. We can see bilateral symmetric. Actually,

0:34

they're in large hard to see the hilum. So

0:37

these are not normal. So bilateral andopathy

0:40

is completely correct. What is the

0:43

appropriate virus category for this finding?

0:46

And please remember this is a baseline mammogram.

0:50

That these were we don't have another prior mammogram.

0:55

Exactly. It's by Red zero.

0:58

On if these were stable for multiple years and you

1:01

knew a cause of these it would be by rats too. But

1:04

because this is a Baseline and we have nothing to compare it to

1:07

me. We don't know if these are new or not. This is a fire red zero.

1:11

So now what is the net the appropriate workup for

1:14

this finding?

1:18

exactly

1:19

bilateral axillary ultrasound is the next most

1:22

appropriate workup.

1:24

So

1:25

and we'll talk about the hematologic workup in a minute.

1:28

But what is a common diagnosis

1:31

for the finding on mammogram given the patient's

1:34

age?

1:37

CLL, that is correct?

1:41

so the differential diagnosis for bilateral axillary an

1:45

It's dll most commonly seen in older women. So

1:48

this patient I think if I'm remembering correctly. I said 63 years

1:51

old. So older women it's usually CLL until

1:54

proven. Otherwise HIV if you

1:57

catch and this is typically in a younger person not to say older people

2:00

can't get HIV. Of course anyone can get HIV but an older

2:03

a younger person is less likely to have CLL. The first

2:06

thing you would think is that they're in the acute retrofile phase of HIV and

2:09

having systemic endopathy.

2:12

About electric. Nobody can also

2:15

be seen with granulomas diseases such as sarcoid and

2:18

TB and college and Vascular diseases such as ra and

2:21

systemic lupus.

2:23

You're always going to go with a systemic

2:26

disease when you see bilateral axillaryosophy first, because

2:29

that's the most common thing

2:32

metastatic disease from breast or non-breath

2:35

can happen. Usually breastmet effect disease is seen in

2:38

unilateral axillary adenopathy. However,

2:41

it's widely metastatic and has really, you

2:44

know, as we see the cats really out of the bag you can

2:47

see that effect disease in the axle on

2:50

the contralateral side, of course, there are things like

2:53

Other cancers like lung cancers or melanomas and

2:56

things like that where you can see also actually adenopathy depending on

2:59

the locations of these diseases and of course you can always have just reactive adenopathy.

3:02

Someone can have some kind of viral illness or something like that. That's

3:05

not HIV or other illness that could cause

3:08

these so that's why I want to go back here. So

3:11

let's go back to the other question. So

3:14

Dear virus zero now if you had multiple years of stability

3:17

of these and a documented diagnosis like TV

3:20

or sarcoid or

3:23

CLL, then you

3:26

can give it a buy red too. So if you have a documented reason,

3:29

but when you have no other priors as I

3:32

didn't show you and then I clarify that this is a baseline you need to

3:35

find out.

3:36

What's going on? You also have to make sure that these

3:39

are really abnormal lymph nodes because the the way to Best

3:42

evaluate axillary lymph nodes is by

3:45

ultrasound. Not mammal. Sometimes you can see lymph nodes

3:48

on mammal that lip prominent and we do the ultrasound and are

3:51

actually normal. So you always want to do an ultrasound. So you do a virus zero

3:54

and you get an ultrasound like in the second question

3:57

we talked about

3:58

talked about now hematologic workup

4:01

only comes after you do a biopsy of

4:04

these lymph nodes and you get

4:07

Um CLL, so what you would do you do the

4:10

axillary ultrasound if there are truly multiple abnormal

4:13

axillary lymph nodes. You can do an FNA

4:16

which you have to send not just for regular cytology

4:19

but flow cytometry as well. You can also do a

4:22

core biopsy of the lymph node as well for that when the

4:25

biopsy comes back.

4:28

At CLL, then you would recommend a full hematologic

4:31

workup or if there's any sort of abnormality in

4:34

the lymph nodes that suggest some kind of lymphoma. It can be

4:37

other lymphoma too. You would you would do the hematologic workup,

4:40

but you really want to do the extra ultrasound and biopsy

4:43

first.