0:00

Okay, next case. So a 45 year old female presenting

0:03

with left breast rash for three months. No improvement

0:06

with antibiotics. So already you're starting to think

0:09

that something's going on. So this

0:12

is her mammogram. This is her CC View.

0:16

And then this is her mllo view.

0:20

So pertinent findings include which of

0:23

the above.

0:25

So diffuse tricular thickening skin thickening

0:28

breasts enlargement or All the Above.

0:31

kind of

0:38

an easy

0:39

So based on the appearance, it's leaks likely due

0:42

to

0:44

least likely

0:46

so the fact that it's unilateral is a important distinguishing factor

0:49

to differentiate between the four of these.

0:55

So based on the appearance, which is least likely

1:00

So congestive heart failure is usually bilateral exactly. This

1:03

is unilateral. So if we had a history of

1:06

math of radiation, then you know, we that

1:09

would certainly explain it. But the fact that she's had

1:12

mass that she's had this rash and it's got not gotten better

1:15

for three months and it's not improving on antibiotics. We're worried about

1:18

inflammatory breast cancer. So what is the name of

1:21

this clinical exam finding?

1:24

Good. So so this

1:27

is a pod aurange appearance of inflammatory breast

1:30

cancer patches disease is actually when

1:33

they kind of get eczema of the nipple and they

1:36

don't necessarily get a rash or enlargement,

1:39

but they may just have itchiness and eczema of the nipple and

1:42

some flaky skin changes.

1:46

And what causes this appearance?

1:48

What is the pathology?

1:52

That were that is diagnostic of inflammatory breast

1:55

cancer.

1:57

Good, so it's actually tumor limb

2:00

emboli and dermal lymphatics. So, you

2:03

know, I'm gonna the way that you would buy it see this or the surgeon

2:06

would buy it see this is they would do a punch by at Sea

2:09

and and that's the diagnostic to

2:12

be Diagnostic and I'm sorry breast cancer. They

2:15

have to see those tumor embley the dermal emphatics.

2:19

So based on this Imaging appearance, what is

2:22

the next best Imaging modality?

2:28

So in this case, we have bilateral skin and

2:31

trabecular thickening.

2:34

Yeah, so I mean the

2:37

It's usually congestive heart failure when it's bilateral

2:40

and symmetric. It would be unusual to get inflammatory breath

2:43

cancer by laterally.

2:46

So if you really want to impress your friends you want to recommend a

2:49

chest x-ray off of mammogram, which we

2:52

did in this case. And this was her chest x-ray. Oops. Nope.

2:55

I have it eventually. So this is our patient. You know,

2:58

she had this left breast thin skin thickening and enlargement

3:01

she had in a regular Mass. She had

3:04

a few regular masses. She's got a few skin thickening. She's got

3:07

axial lymphatinopathy which patients with inflammatory breast

3:10

cancer usually have so you're

3:13

by rides is going to be a four or five inflammatory breast

3:16

cancer.

3:19

We talked about these I'm going to run through this. So this

3:22

was actually her PET CT. You can see that her left breast is diffusely enlarge

3:25

and thickened. She's got multiple masses. She's got

3:28

multiple sub pectoral and axillary lymphadenopathy

3:31

bilaterally actually which often

3:34

happens

3:36

And you know inflammatory breast cancer can look like

3:39

mastitis initially though. They usually fail antibiotic therapy, you

3:42

know history is very important timeline. Once

3:45

it's starting to go on for a few months. You don't want to you know,

3:48

you're gonna treat it as in plans for your breath cancer until proven. Otherwise,

3:51

you know, the put a orange tumor

3:54

emboli. All these are buzzwords That You're Gonna Want To Remember

3:57

for the boards punch by and see

4:00

this is usually this is it usually pops up kind

4:03

of quickly. So, you know patients will say overnight it kind of got red

4:06

and full and and that's true. It doesn't really look like

4:09

this until it kind of involves the skin and then it gets really bad quickly.

4:12

These are Advanced and they're gonna need some kind

4:15

of neoadment chemo before they go to surgery

4:19

So this like I said bilateral symmetric skin thickening

4:22

and trabecular thickening. If you've got a chest x-ray would

4:25

notice that they had congestive heart failure. So really

4:28

what good way to be clinically relevant in

4:31

breast Imaging is to diagnose CHF of

4:34

a mammogram.

4:35

So when we talk about unilateral scanners

4:38

trabecular thickening, this is really the differential inflammatory

4:41

breast cancer needs to be excluded could

4:44

be mastitis or radiation, but you should have the history of

4:47

radiation lymphatic obstruction congestive

4:50

heart failure is usually bilateral

4:53

can be unilateral. But you want to rule out

4:56

some other things first SVC obstruction

4:59

greater than 2 millimeters of skin thickening

5:02

is abnormal.

5:03

When you have bilateral trabecular skin dickening

5:06

you want to think about congestive heart failure fluid overload

5:10

also lymphatic obstruction bilateral inflammatory breast

5:13

cancer very unlikely, it does happen often. It creeps

5:16

like across the kind of the cleavage and goes to the other

5:19

side. Which means I've seen that a few times.