0:00

So case number one a 58 year old female presents for

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Baseline screening exam and when you're reading these cases,

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it's really important to note whether they're a

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screening or they're a diagnostic case.

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It helps you with what birads you're going to give. So in

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this case, it's a baseline screening.

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So here's her CC View.

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And here's hero View and if

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it's not projecting well.

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There are some calcifications in the

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left lower Central breath kind

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of middle to post your third. So like

0:36

I said, she's a screening exam.

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So therefore what is the appropriate by

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Red category?

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So office screening exam the the appropriate criteria

0:49

would be by Reds would be a zero actually

0:52

because

0:54

They are suspicious. There's no doubt about that. But there are

0:57

screening exam. So first you need to call them back and then

1:00

you're going to give them the bireds for or the five

1:03

depending on what how you're feeling.

1:06

So is that that appropriate buyer? I

1:09

would be a zero you need more imaging.

1:11

So even if a cancer is obvious on a screening

1:14

exam you're going to want to give them a zero. Nobody wants to get a letter in

1:17

the mail thing. You have highly suspicious for cancer. So the

1:20

zero allows us to well number

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one, you can be fooled but clearly these are cancer. It's also

1:26

going to allow you to establish a relationship with

1:29

a patient before telling them that they have cancer. So you're

1:32

gonna bring them in get additional views, which we're going to

1:35

go over and then you'll tell them that they need to buy

1:38

it.

1:39

So what views should we be getting so these are

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magnification views whenever you have

1:45

calcifications. You want to get a magnification to use we're going to talk about that more

1:48

but you can see that there is lots

1:51

of calcifications. I'm going to give you a minute to look at this these images

1:54

and I want you to think about what the scriptures

1:57

you would use to describe these calcifications.

2:01

Um, so, you know when you're talking about morphology and

2:04

distribution, so I think

2:07

there's this is a multiple choice question. So I think there should

2:10

be a polling feature here and the answer

2:13

in your head. But really you the thing we're

2:16

going for here is course heterogeneous and segmental. So

2:19

you obviously want to pick a suspicious type of

2:22

calcification this trophic

2:25

or not suspicious popcorn or not suspicious so that already excludes

2:28

to and then so it's between

2:31

fine pleomorphic linear or course heterogeneous segmental.

2:34

I mean, both are

2:37

right because they're ultimately going to lead to buy it see but these are more of course

2:40

heterogeneous. So What by Reds is this going

2:43

to be?

2:45

Leave it up for a minute. Remember now, this is a diag.

2:50

Good. So everyone got that, you know, these are highly suspicious

2:53

calcifications. Now, you can give them the bi-reds five

2:56

that we wanted to give them before so highly

2:59

suspicious. So I just want to

3:02

go over the byrides Lexicon. They

3:06

were updated in 2014. There's a

3:09

few types of changes a few important changes in

3:12

that update. There's clustered is

3:15

no longer a category. It's now grouped instead and

3:18

instead of they used to have benign into

3:21

sorry intermediate and suspicious now,

3:24

they just have the nine and suspicious. So

3:27

a more efficient course heterogeneous got bumped up. So now

3:30

they're suspicious. So whenever I tell the pay my residence

3:33

if you're using the words, of course heterogeneous, the next

3:36

word that of your mouth should be biopsy. So if you think it's

3:39

like a fiber adenoma don't use the words, of course heterogeneous

3:42

use the words popcorn or course, you

3:46

know, so it gets a little confusing there.

3:50

So eggshell and Lutheran centered

3:53

calcifications are now called Rim calcifications and

3:56

round and punctate are now just round.

4:00

And in terms of distribution it goes

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from you know least suspicious to most suspicious

4:06

so diffuse and Regional when they're kind of all throughout the

4:09

breath. That's not that suspicious. It gets more suspicious

4:12

as they become grouped or a linear

4:15

or segmental like in our case. These would be the suspicious.

4:19

The suspicious distribution and

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I just want to remind you that that morphology

4:25

and distribution Trump stability.

4:28

So if there's course heterogeneous calcifications that

4:31

had been stable for a few years. It

4:34

still can be dcis and it still May warrant a

4:37

biopsy I've seen if we've had a few cases like that

4:40

where you know, we're all the first person doesn't recommend

4:43

to buy it see and then they're kind of we're all kind of falsely reassured

4:46

that they're okay and then five years later they're still

4:49

there, but they've never really been addressed and they biopsied

4:52

them in their dcis. So, you know, it's important. We always

4:55

say the bill morphology from

4:58

stability.

5:00

Okay next case. So these are segmental, you

5:03

know course heterogeneous or pleomorphic calcifications, but

5:06

they're not linear in this case.

5:09

So you really would want to do this if you

5:12

had the ability to do a stereotactic biopsy. You

5:15

would want to do that. In this case

5:18

when there's six centimeters of calcifications. Typically, we

5:21

biopsy the front and the back so we'll buy a C2

5:24

areas. And the reason we do that is because if a

5:27

patient wants to be

5:28

Candidate for breast conservation therapy you need

5:31

account you need to document the extent. So in this case six centimeters

5:34

is these that's typically not a good

5:37

candidate for breast conservation therapy. We usually say under

5:40

five centimeters, you know or localized field

5:43

quadrant of the breast that's very surgical dependent and

5:46

patient-dependent. Like if the patient has a large breast you might

5:49

be able to do some segmental lumpectomy, but in

5:52

most cases that's a criteria to do a mastectomy.

5:56

So it's always really important to document the

5:59

extent of calcification. So if you see a large area biopsy two

6:02

that one in the front one in the back if it

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is greater than two centimeters and they are going to

6:08

go to breast conservation therapy. We usually put in two needles

6:11

and wires on the day of their needle localization

6:14

to make sure that all the calcifications are removed.