0:01

So case number three a 71 year old

0:04

female presents for screening mammogram.

0:08

So this is in 2016 and this

0:11

is in 2012. Okay, it's a

0:15

subtle difference, but I'm going to

0:18

point out the abnormality to you, which is right here.

0:21

You can see that it's

0:24

I would call this a developing asymmetry. It's

0:27

a new lesion.

0:29

Um on the mL of you in the right upper breast.

0:33

Really hard to see on the CC. It's really kind

0:36

of so far back. You probably don't see it. Well, she had

0:39

some kind of surgery in 2012. She had that scar

0:42

but it kind of went away. So based on this. What's

0:45

your appropriate virus? This is a screening test.

0:50

So the appropriate buyer ads here would be a thyroid zero

0:53

good. Yeah, so there's an abnormality.

0:56

It's a screening exam. We need to call her back.

0:59

for further workup

1:02

Okay.

1:05

So what views will you request and that gets a little bit complicated

1:08

or there's a few ways you can do

1:11

it right now. All we know is we see it on the mL of

1:14

you. We don't know where it is on, you know, so we know it's in

1:17

the upper breast. We don't know anything else about where it is if it's in

1:20

a lateral or medial breath.

1:21

And then that's where it gets a little confusing. So we're going

1:24

to get a stock compression to see if it goes away. We're gonna

1:27

get maybe get his homo synthesis that really helps

1:30

with triangulation and we've been doing tomosynthesis instead

1:35

of stock compression because if it's real it will

1:38

persist on the Thomas synthesis. Also, there's been some talk of

1:41

when you press on something even if it's a cancer it might look like it

1:44

goes away so you could be falsely reassured with a spot compression.

1:48

Um, so in this case, this is showing I

1:51

don't know if you're familiar with this image that

1:54

I'm showing you so this is an mlo tomosynthesis and

1:57

this is giving us triangulation information. So while

2:00

you're scrolling through the mlo image, it tells

2:03

you where you are in the breast. So in this case, we

2:06

know we're in the upper breath. So this line is saying it's

2:09

in the upper outer quadrant. So we never really saw

2:12

it on the CC, but we know it's in the upper outer quadrant. So

2:15

now if we want to go to Ultrasound we know exactly where

2:18

to look.

2:19

So I'd say it's probably like 10 o'clock and the

2:22

next step is going to be what's next

2:25

step. We don't need to do spot because it's pretty real. We

2:28

see it there, but we do want to go to Ultrasound. So on

2:31

ultrasound we see it at ten o'clock 10 centimeters

2:34

from the nipple. We've seen a regular hypochoic math. It's

2:37

taller than it is wide that corresponds.

2:40

We're going to look in the axilla because right now we're a

2:43

little suspicious.

2:45

And the bired would be a bi-rad's four or byrides five.

2:48

I think a buyer at 4 would be appropriate here because it's not a

2:51

slam dunk. This is considered a developing asymmetry and

2:54

one point. I just want to make let's say

2:57

you saw this on the mammogram you did an ultrasound and

3:00

you didn't see anything.

3:02

The buyer is still the same. The virus is still a

3:05

virus for

3:06

just because you don't see an ultrasound doesn't mean it's

3:09

not real but a developing asymmetry needs to be by at

3:12

seed. So you would buy it see this under stereotactic biopsy.

3:15

There's no need for Mr. We see it

3:18

correlate on mammogram. So this is very easy to buy it

3:21

standard stereo.

3:24

Um so asymmetry if I'm going to just go over some basic

3:27

lexicon, but asymmetry is an area

3:30

of tissue that you see on one View.

3:33

Focally asymmetry as opposed to any symmetry is

3:36

in a tissue that you see on two views.

3:40

A global asymmetry involves more than one quadrant, but

3:43

you see it on two views and then a mass

3:46

has convex borders. So it bulges outward. So

3:49

it's a true Mass rather than in a symmetry. And of course

3:52

you're going to see that on two views as well.

3:55

So developing asymmetry is a special type of situation. It's

3:58

a focal asymmetry that is new or increasing in

4:01

size.

4:02

It it really emphasizes the need

4:05

to compare to remote priors like this one in 2012. It

4:08

wasn't there. So now we have to take this seriously. This was

4:11

a slow. It can be a slow change. Like I

4:15

said focal asymmetry, you see it on two different views the risk of

4:18

malignancy give way above 2% So it doesn't need the

4:21

criteria for buyer has three so it needs to be biopsy. That's about

4:24

20 12 to 27 percent biopsy is

4:27

necessary whether it's under ultrasound or Tom or

4:30

a stereotactic biopsy if you couldn't find an ultrasound

4:36

So just want to emphasize the importance of the developing asymmetry now

4:39

if that was a Baseline and that was her

4:42

first one and you don't know if it's new or old then you

4:45

can give it a buyer ads three, but it increasing or

4:48

developing asymmetry is something that needs a biop.

4:51

Sy on so

4:53

Digital breast homosynthesis multiple Lotus images

4:56

are obtained in an arc about 15

4:59

to 60 degrees depending on the management manufacturer. It

5:02

makes a quasi 3D image. It's not a

5:05

true 3D image but it helps decrease the effect

5:08

of superimposed tissue. We we started doing

5:11

these in lieu of spot compression. So if we see something

5:14

on a mammogram on an mlo instead of

5:17

bringing them back for mllo spot compression, we'll just do

5:20

an ml to almost synthesis and repeat the image and see

5:23

if it persists if it's cancer or anything.

5:26

It will definitely persist. This really tells you where it is in the breast

5:29

especially if you only see the math on the envelope projection,

5:32

we now know what's in the upper outer quadrant. We know

5:35

where to look on ultra sound and it's really helpful in that

5:38

instant.