0:01

Hello and welcome to noon conference hosted by

0:04

MRI online noon conference connects the

0:07

global Radiology community Through free live educational webinars

0:10

that are accessible for all and as an

0:13

opportunity to learn alongside top Radiologists from around the

0:16

world. We encourage you to ask questions and share ideas to help

0:19

the community learning grow.

0:21

You can access the recording of today's conference and previous new conferences

0:24

by creating a free MRI online account.

0:27

You can also sign up for a free trial of our premium membership to

0:30

get access to hundreds of case-based micro learning

0:33

courses across all key Radiology piece of Specialties today.

0:36

We are honored to welcome Dr. Robin Roth

0:39

for a lecture on the best of the breast cases Dr. Roth

0:42

completed her Radiology residency and Women's Imaging

0:45

fellowship at the University Hospital of University of

0:48

Pennsylvania in 2014.

0:51

She works at Cooper University Hospital in Southern New Jersey

0:54

where she serves as Women's Imaging Fellowship director over 15,000

0:57

of her closest friends call her at the

1:00

booby docs her popular social media account that discusses breast

1:03

cancer in a fun and educational way.

1:06

At the end of the lecture joined Dr. Roth in a Q&A session where

1:09

she will adjust questions you may have on today's topic.

1:12

Please remember to use the Q&A feature to submit your questions so we

1:15

can get to as many as we can before our time is up with that.

1:18

We're ready to begin. Today's lecture Dr. Roth. Please take

1:21

it from here.

1:22

Great, so welcome everyone Thanks for tuning in. Today. We're

1:25

going to be covering some high-yield breast cases that we

1:28

really see in clinic actually three of these cases I saw this

1:31

morning. So the first three cases are going to be real life

1:34

cases that hot off the press. Okay. So

1:37

we're gonna start without further Ado. Let me

1:40

see how this is.

1:44

So case number one 72 year old female presenting for

1:47

annual screening. I'm going to go quick for

1:50

the purpose of time just because there's a lot to cover.

1:53

So this is a woman whose mammogram this

1:56

is her ml view. So this is 2016. But if

1:59

you look from 2012, there's a very subtle difference,

2:02

but it's a very important difference.

2:04

And so I'm going to let you look at this for

2:07

a second, but I really want to draw your attention to

2:10

this asymmetry up

2:13

here and I call it an asymmetry because they only see it on one view.

2:16

I'm going to show you the the CCU right

2:19

now, but really there's really no

2:22

correlate for the finding on the CC view

2:25

we can see that she's had surgery before

2:28

that's resolved a little bit but we don't see that asymmetry that

2:31

we saw in the upper breast. So what would

2:35

your bi Reds be in this case for I would

2:38

call this an evolving asymmetry. So we

2:41

would of course want to get that a buyer at zero and needs additional

2:44

Imaging and now my question I want you to think about is

2:47

let's say that the what are we

2:50

going to ask for right now? We only see it on one view. We only see it on the

2:53

ml view on the ml view. So a few things that we can ask for

2:56

so we know we can ask for a true lateral view because if it's

2:59

in the if it's in the lateral breast it will fall because remember muffin rise

3:02

and Lead Falls.

3:04

So we can definitely get spot compression or

3:07

in this case. We did ml tomosynthesis, which is what we do

3:10

a lot at our Institution.

3:12

You can see that the asymmetry still persists

3:15

and what the tomosynthesis is

3:18

telling us is that we know it's in the upper breasts. Okay,

3:21

because it's above the nipple but it's telling us that it's

3:24

in the upper outer quadrant. So the tomosynthesis is really helpful for

3:27

triangulation. It could help you identify which quadrant

3:30

is and of course we see that this is a real finding at this

3:33

point. You're going to say

3:35

you're by Red whether or not we find it on the ultrasound really

3:38

needs to be a virus for okay,

3:41

because if you it's a new ace imagery, so

3:44

if you don't find an ultrasound that we have to buy that

3:47

we have to buy it see this under stereotactic biopsy. I've

3:50

seen this recently. I've seen this kind of missed a

3:53

lot with a new asymmetry giving it a three but by the

3:56

definition and asymmetry can only be a three if

3:59

it's on a baseline, so if it's a new asymmetry that's called

4:02

an evolving asymmetry, that's more suspicious.

4:04

So, of course, we now know it's in the upper outer quadrant. We're going

4:07

to go send the patient to ultrasound and thankfully

4:10

actually the first picture they showed me

4:13

nothing but then I went back in and scanned we found this very small

4:16

Mass here at 10 o'clock 10 centimeters in the nipple.

4:19

We buy it Seated on ultrasound. It was a small invasive

4:22

ductal cancer.

4:24

Um, so just want to reiterate so obviously that to

4:27

be a bi-red for if we didn't see an ultrasound we would buy a seat

4:30

under stereo.

4:31

So just to go over some basic definitions and

4:34

asymmetry is an area of tissue seen on

4:37

one view focally symmetry would be on two views and

4:40

a global Ace industry is when it involves more than one

4:43

quadrant and you see it on two views as opposed to

4:46

a mass which has convex borders and you're going to see that on

4:49

two views. So in this case, I would call it involving asymmetry. We only saw

4:52

it on one View and developing asymmetries are

4:55

important. So like I said that they're either

4:58

new or increasing in size you need to make sure you

5:01

compare it to Old priors in this case. It was a slow change.

5:05

So focal asymmetry, like I said to use so

5:08

is risk of a cancer in a developing asymmetry

5:11

is 12 to 27 percent. So way over

5:14

that, you know 2% that we're willing to accept

5:17

for probably benign. So it does not deserve a

5:20

thyroid screen. Like I said, that's only really reserved for the Baseline. So

5:23

biopsy is necessary. If you don't see an

5:26

ultrasound you're going to want to do a stereotactic biopsy.

5:29

So again, this is a 3D image. I'm not going to go over

5:32

this but this will tell us that you know, it's in the upper outer quadrant

5:35

and we've been using this more and more rather than

5:38

just homocent then spot compression because oftentimes the

5:41

focal asymmetry might look like it's going to go away on a

5:44

spot compression. But really it's true finding and ml Tomo shows

5:47

you that

5:49

Okay, so next case. So this was actually a case from earlier today

5:52

that this woman

5:55

has extremely dense breast. One of

5:59

the other Radiologists looked at this first and she didn't really see

6:02

anything but then the tech told me that she had a survey ultrasound and

6:05

she found something so I had to look at it again. So, you know

6:09

We do a lot of survey ultrasounds in

6:12

the setting of dense breast tissue, which will talk about more and more

6:15

we're getting it and this is why so on ultrasound the

6:18

technologist found this little

6:21

hypochoic mass at 7 o'clock seven centimeters in

6:24

the nipple. It was a real finding I went in there myself. If you

6:27

kind of go back to the mammogram knowing where it was it's in

6:30

the lower inner quadrant again, I think it's

6:33

a little it's very hard to see especially in these patients with extremely

6:36

dense for us from come up. It is a real finding in retrospect.

6:39

And obviously that's a thyroid for

6:42

she's gonna get the biopsy this was from this morning.

6:45

So a little plug on Ben's breast tissue as we

6:48

know dense breast tissue, which is extremely heterogeneously or

6:51

extremely dense it makes it harder to see small cancers

6:54

on mammography alone. And additionally it's

6:57

an independent risk factor for developing breast cancer.

7:00

So having breast tissue increases your

7:03

risk of developing breast cancer. So that is

7:07

something important to consider. I got my video working. So

7:10

how

7:11

and and so we would either

7:15

So for people that are proactive I always tell them add ultrasound

7:18

or MRI. If you have a 20% lifetime risk

7:21

of breast cancer You're Gonna Want MRI. If you have dense breast tissue and

7:24

you want the earliest cancer finding capabilities possible.

7:27

So adding supplemental Imaging allows

7:30

us to find smaller node negative cancer than an

7:33

earlier stage. So that may potentially help people

7:36

avoid chemotherapy. Like if we missed it

7:39

this year we might see it next year. We might see if you're after that but it's

7:43

obviously only going to get bigger with time. The cons

7:46

of of any supplemental. Imaging test is that

7:49

we might find something that warrant to buy it see that is not cancer, but we

7:52

can't tell that by looking at it. So like a false positive so something to

7:55

consider but I will tell you that more and more as we

7:58

educate more and more women about this and more of them are

8:01

choosing to get supplemental screening and it doesn't lead

8:04

to so many by red threes or by Reds for is

8:07

that I've experience that are kind of false. I think we're getting more

8:10

confident with them at our institution. We do handheld whole

8:13

breath Soldier sound.

8:15

So moving on.

8:17

So this was unfortunately a case from this morning of the 28

8:20

28 year old female who was presenting with bloody nipple

8:23

discharge her right breast was getting bigger for a

8:26

month and her doctor felt a lump. So,

8:29

you know, of course we're under 30, we're going to start with an ultrasound we

8:32

get this ultrasound which shows in a

8:35

regular hypochoic math with some vascularity obviously,

8:38

very suspicious. It's a little even hard

8:41

to gauge what it how the true size of it. We do,

8:45

you know, we see some think calcifications actually

8:48

you can see these little white dots those are the

8:51

califications. So we're starting to get worried. So

8:54

obviously we're gonna buy it see it but something that we need to do before we

8:57

even do the biopsy is what right

9:00

these 28. She has something that looks like a cancer you're

9:03

gonna want to really get a mammogram at this point. Okay. So

9:06

yeah, she needs a biopsy but she also needs an

9:09

immigrant because we want to know what we're really looking at. So again, you

9:12

can see some calcifications behind the nipple a very enlarged lymph

9:15

node. We're starting to get very worried.

9:17

Next steps would be obviously a mammogram and you

9:20

can see that she has an entire breast filled with

9:23

calcification standing from her breasts from

9:26

her nipple to the chest wall and she's getting

9:30

worked up right now. But unfortunately

9:33

we've seen a lot of young women with

9:36

breast cancer that you know, but below the screening

9:39

age, they're going to feel it which is why it's really always important to take,

9:42

you know, patients complaint. Seriously,

9:45

you know, it's very easy to rule

9:48

out if it's something suspicious by Imaging

9:52

Okay the next case.

9:56

so

9:57

you've got a bilateral mammogram kind of

10:00

has a funny appearance bilateral. I'd

10:03

say that there is global asymmetries. Bilaterally. It's kind

10:06

of like a hazy appearance not something we're typically used to

10:09

be seeing and I'm going

10:12

to tell you this is Aunt Minnie for something. So just

10:15

think what think for a second week that come what comes

10:18

to mind.

10:19

I'm going to give you a hint. This is the ultrasound.

10:22

Okay, so you'll notice that classic snowstorm appearance

10:25

that will tell you that she's had silicone

10:28

injections. These are free silicone injections. This is

10:31

what they look like a mammogram. The snowstorm appearance is

10:34

really what gives it away on ultrasound. It makes

10:37

it impossible to find cancers on ultrasound

10:40

because you're just going to get complete snow therm appearance of

10:43

the breast.

10:44

This is a pot. This is a similar case

10:47

you could see that this woman has very old. They're they're

10:50

prepectoral. So here's the pack

10:53

you can see that they're in front of the pack. So we call that three pectoral or

10:56

retro glandular implants. They are

10:59

silicone. I could tell that because you can't see through them and you

11:02

can't see that novel that's classic of a of a

11:07

saline implant. And again, it looks

11:10

like that there are some Contour more usually you can't tell on

11:13

the mammogram and ultrasound that something is ruptured. It might get some hands

11:16

but this is a classic case of a rupture you could see

11:19

that it's going beyond the Contour of the implant and you

11:22

know, it's more dense surrounding that it looks like a

11:25

kind of exploded that's what it looks like on ultrasound. She's got

11:28

that snow storm appearances classic of a extra

11:31

capsular silicone implant

11:34

ruptures.

11:35

If you see a silicone, if you see an extra capsular rupture, you

11:38

know, they have an intercapular rupture they go hand in

11:41

hand, but you can have an injured half the rupture without

11:44

an extra.

11:45

Kepler

11:46

okay, but of course, like if you couldn't tell

11:49

us something if a silicone implant was ruptured then you would want to

11:52

do an MRI.

11:53

using silicone implant protocol

11:57

So next case kind of a adjuvant case.

12:01

So again, these are retropectoral. So

12:05

now we see that it goes it's behind the pack they're

12:08

silicone because I can't see through them and there's

12:11

like it almost looks like there's a little bit more tissue

12:14

around that but let's just say you didn't know and you're going

12:17

to get an ultrasound.

12:19

So actually you could see actually that her her.

12:24

Implant is actually kind of pressed down. Like it looks

12:27

like it's partially collapsed and she had some soft tissue masses

12:30

kind of surrounding the Peri implant

12:33

capsule. So let's say this is the capsule there's fluid inside

12:36

that looks more than simple. There's some

12:39

Mass Effect on the implants and we're starting to get worried. So

12:42

there is a common unfortunately, there's a

12:45

increasing awareness of you know,

12:49

obviously we want to buy it see this at this point

12:52

and we're a little bit worried about the implant itself. So right

12:55

now we know this is what the MRI look like. So she has this

12:58

complex fluid collection around the implant.

13:01

She had some enhancing masses as

13:04

well. I'm going to show you what the myth look

13:07

like. You can see that she's got these enhancing masses and you

13:10

know, overall this whole picture is really

13:13

concerning for something that is specific to implants.

13:17

Um, so she ended up having mastectomy. It was

13:20

rest implant Associated anaplastic large

13:23

cell lymphoma. So Bia LL you'll see

13:26

that kind of in the news and this was

13:29

all anaplastic large cell lymphoma.

13:32

We and we now know that so let's

13:36

talk about Dia alcl or breast implant

13:39

Associated and a plastic large cell lymphoma usually occurs

13:42

in patients that have textured breast implants both

13:45

silicone and saline in 2019. They were

13:48

all they no one should really have these anymore because they

13:51

were recalled back in 2019. It's not

13:54

a breast cancer. It's really a cancer of the immune system though. They're treated

13:57

kind of similarly in some ways the patients

14:00

usually present with breast enlargement pain a

14:03

symmetry their breast gets larger lumps skin

14:06

rash and on ultrasound what you're

14:09

really going to see and this is what is concerning is that you're gonna see

14:12

a large fluid collection around the

14:15

implant that comes

14:17

The year after getting the implant so a few years out. You shouldn't be

14:20

seeing these, you know complex fluid collections

14:23

that you might see in the immediate post-operative period but this is

14:26

a concerning finding we had one the other day that looked just like

14:29

this and part as part of the usually comes

14:32

out like eight to ten years after their implants have

14:35

been in they have to get them removed and now there's

14:38

a new association with squamous cell carcinoma with

14:41

both smooth and textured implants. So

14:44

We're gonna be seeing more of this I think in the coming years, unfortunately, and

14:47

it's definitely something to consider for anyone who's

14:50

considering getting an implant.

14:53

Um, okay. So this was a 65 year

14:56

old female history of left breast cancer after mastectomy, and

14:59

she's presenting with a lump on the chest wall. Okay. So

15:02

after mastectomy, we're

15:05

really we don't image people usually of thermostat

15:08

to me. It's going to be more of a clinical exam finding because

15:11

any recurrence would be kind of near that skin tissue

15:14

interface, so it'd be pretty superficial. So

15:17

why it's why we don't typically image patients

15:20

at their mastectomy and you know, even if they had reconstruction,

15:23

but physical exam is even

15:26

more important. So we're going to start with an ultrasound in this case.

15:28

So this was her back in 2022

15:31

of last year, so she came in August. She had

15:34

this lump.

15:36

The radiologist was like pretty convinced that

15:39

they saw a skin tract.

15:41

And they said it was a sebaceous cyst.

15:44

And come back in six months.

15:46

Okay, and that is the

15:49

wrong by Reds, I mean retrospect Is 2020 but still

15:52

any any mass that you

15:55

know, the this is in the skin but it's extending

15:58

beyond the skin. Okay. So that's important number one and number

16:01

two anyone with a history of breast cancer and a new

16:04

lump. You got to be a little bit concerned so she comes back six months

16:07

later and you could see that it's much bigger just to give

16:10

you a side-by-sides. Let me show you so that now it's up to

16:13

like 1.2 centimeters previously. It was five

16:16

millimeters. I understand why someone might think that is a sebaceous

16:19

cyst if they didn't have this history, but in the setting

16:22

of all this it's really, you know

16:25

concerning for a recurrence which is what it was, you know,

16:28

this is like a solid and cystic mass. Now. This was

16:32

the biopsy it said recurrence residual / residual

16:35

invasive Dental carcinoma grade two involving the

16:38

skin. So, you know, I think going back I think

16:41

that the fact that it extends beyond the skin surface makes

16:44

it not a sedation.

16:46

Not class excavationists. Not that it is

16:49

in but you would want to you know sample that especially if they have a history of

16:52

cancer.

16:54

So I'm going to keep going I see some things popping up

16:57

in the chat, but I promise you we're going to get to all of it.

17:00

But please feel free to submit some questions in the

17:03

Q&A box that I'm going to try to get to at the end of the lecture.

17:07

Okay, so moving forward. Sorry, okay.

17:12

Moving on. So let's talk

17:15

a little bit about breast cancer recurrence. So anyone of

17:18

the risk for developing breast cancer recurrence more commonly,

17:21

if you're young when you develop breast cancer, that's

17:24

usually because they have a more aggressive breast cancers, like

17:27

inflammatory and triple negative cancers, which are also a risk

17:30

factor for developing recurrence when someone

17:33

has that those types of pathologies that usually

17:36

occurs in the first five years. So we

17:39

had one yesterday. So it is something that we see

17:42

a lot unfortunately, you know often it's

17:45

if they didn't have radiation or something that they didn't do

17:48

standard of care that's usually where we see

17:51

it, but it can happen even if despite like

17:54

perfect care. So something

17:57

that could be considered something the United States these compliance

18:00

seriously if someone has a breast cancer history

18:03

All right. So this is more of a case in Show and Tell. Okay. So this

18:06

woman came in for her screening mammogram. She

18:09

had a history of like some excisional biopsies some

18:13

like once he was 18 that somebody

18:16

else now you sure yeah coming out now.

18:19

Okay. Yes sure do that. Sorry. Okay,

18:22

so she was extremely dense

18:25

and actually somebody was smart enough to

18:28

call her back for they saw actually this area of

18:31

architectural Distortion in the last upper outer quadrant. Posteriorly

18:34

that's concerning and also the circumscribed

18:37

math so concerning but we have bilateral findings and

18:40

this patient with extremely dense reference. So something we

18:43

do a lot here. Obviously, we're gonna give her a zero you're gonna bring her back,

18:46

you know, you could do the standard diagnostic work up

18:49

with spots and ml Tomos but something that

18:52

we had at Cooper that I really love is contrast the

18:55

monography so we called her back for contrast me immigrant because

18:58

we can okay and I'm a big contrast mammal girly.

19:01

I love it. I think there's a lot

19:03

Of role for it and this is what the mammogram this is

19:06

what the contrast mammogram looked like. Okay. So not only does

19:09

she have you know, this patchy linear enhancement

19:12

right where she had this architectural assortion. She's got this

19:15

large bright breast cancer that I think is totally

19:18

obscured if we go back a slide just to show

19:21

you what it looks like. I mean even on your best day, I

19:24

think it'd be really hard to call this prospectively. It's like here that's

19:27

the problem with extremely dense breast from comma

19:30

and this contrast mammo really

19:33

shows the the importance of breast density and

19:36

how obscured things can really be. So has these

19:39

low level I'm going to show you what the case is read is so so

19:42

just to go

19:45

over her findings on the contrast ammo. So

19:48

we see a speculated Mass like a four

19:51

point seven centimeter speculated mass in the right upper Central breast. She's

19:54

additional low-density circumscribe masses with

19:57

low level enhancement that look a little bit different if you're going to push me

20:00

on it, but then she also has two.

20:02

Is a non-math enhancement one in the

20:05

Last Supper outer breasts where we thought that was a lot of non-massive enhancement 7.3

20:08

centimeters where we saw that Distortion and then

20:11

she also has some linear nomath enhancement medially where

20:14

we didn't see any mammographic correlate. So, of course we're going

20:17

to go on to ultrasound and on ultrasound we find some good

20:20

correlates for the findings on the right. I'm going to do the right

20:23

side first. So we see that the regular speculated mass at 12

20:26

o'clock six centimeters and nipple that measures about 2.9 centimeters.

20:29

She had a few circumscribe masses

20:33

that eventually we're by at CB buy it see this one. It was a fibroadenoma, which

20:36

she reported that she has so these

20:39

all ended up being fiber atenomas. So remember this is

20:42

a 40 I think 42 year old invasive ductal

20:45

on the right and on the left. She had this,

20:48

you know, non-ass enhancement a little bit of a mask, but certainly

20:51

not as big as we see in the contrast mammogram and abnormal

20:54

lymph node this pathology ended up being invasive lobular

20:57

cancer. So two separate types of subtypes of

21:00

breast cancer on both sides and

21:02

young woman without a history breast cancer

21:05

What I've done here is I've taken the contrast mammogram and kind

21:08

of flipped it and oriented it. So it looks like an MRI and just to

21:11

show you how it looks compared to an actual MRI. So

21:14

you could see that the contrast mammogram on top has a

21:17

lot less background enhancement and kind of shows similar

21:20

things that the MRI does to me. It's almost a little

21:23

bit clearer because it's you know, it is hard to figure out what's going on here. But the

21:26

one thing one limitation that contrast mammography can

21:29

knock you is it doesn't get far back so you don't see the axilla

21:32

but you would look at an under ultrasound so you can see that she's got

21:35

some positive lymph nodes and that was

21:38

just a really nice case of how we

21:41

use contrast mammography. We typically I have a whole

21:44

I actually gave a prior lecture here of how we use contrast mammography

21:47

if you're interested. I highly recommend looking at that but

21:50

it is something we can do that day. I'm actually

21:53

doing it right now on a 40 year old that looks like she has a breast cancer

21:56

as well. It just really helps you figure out the forest from

21:59

the trees and someone with dense breast tissue and like multiple findings.

22:02

Okay, so moving on 29 year old female presenting with

22:05

a palpable mass and the left breast. This is pretty similar to our earlier

22:08

case. So we're gonna start with an ultrasound.

22:12

So an ultrasound you see at one o'clock three centimeters of nipple.

22:15

You see in a regular vertical breast Mass.

22:18

That's suspicious and you also see

22:21

a lymph node. Of course, we're going to recommend biopsy.

22:24

Of course, we're going to recommend mammogram, but in our

22:27

institution, I think we recommended a contrast mammogram because we

22:30

kind of assume she'd be dense and let's why not. Let's get the best test.

22:33

So just to show you what her

22:36

palpable looks like.

22:40

She I'm not like okay great and we're done.

22:43

I'll look at in a minute. Okay, sorry. Um,

22:46

all right, so you could see that that

22:49

she has a palpable marker right there. There's nothing really on mammogram

22:52

again. Nothing really on mammogram that

22:55

we saw and then we do the contrast mammogram and

22:58

that's when everything gets real so, you know right where

23:01

she had the palpable lump she has this enhancing math.

23:04

You can see that it's multifocal and it's also

23:07

Contra lateral. She has enhancing masses

23:10

on both sides 29 year old

23:13

female again looking back at the mammogram and maybe

23:16

on your best day. You might be able to call this.

23:18

But I really don't see anything right where

23:21

the cancer is. I'm sorry. I still shouldn't be overlapping

23:24

like that. But again bilateral invasive vessel

23:27

cancer in the 29 year old again I've reoriented

23:30

so it looks like an MRI and you can see it's pretty exact

23:33

to the MRI and but with a contrast

23:36

mammogram we have the advantage that we could do it that day and

23:39

do it before any biopsy before any Intervention which

23:42

will maybe fall asleep increase your

23:45

size of breast cancer after a

23:48

bias. You might look bigger because of the post-bites you changes

23:51

and everything. So it is a great test that we can do before we even

23:54

touch the breast so we can really get an accurate sense of

23:57

size. And if there's anything else we need to be worried about

24:00

Okay, so moving on.

24:03

84 year old presenting with a palpable lump in

24:06

the left breast. So obviously this is a diagnostic. She's coming

24:09

in with the symptoms and she

24:12

has a large circumscribed mass

24:15

in her left breast right where

24:18

she's feeling the palpable. I don't

24:21

know if you get the sense, but she's got some skin thickening and it's really

24:24

hard to tell him this but this is something I like to do a lot. So I like to

24:27

turn on the information and look at the thickness of

24:30

the breath so you can see that her right breast is compressed the

24:33

3.6 centimeters. Her left breast is compressed to

24:36

10.8. So it's about three times bigger than

24:39

her right breast. So if you were to actually like go look at the patient

24:42

and look at their breasts and you would see that it's much

24:45

like bigger and this is pretty concerning for an

24:48

inflammatory breast cancer. She's got that diffuse skin thickening

24:51

and her breast is completely enlarged.

24:54

All right, so on ultrasound

24:56

It has an interesting appearance, right? So it's a

24:59

complex to stick massive.

25:02

No, no, I need you right. Can

25:05

you tell if you

25:08

Okay. So, um

25:10

So this woman has a complex cystic math.

25:13

I'm saying complex cysted as opposed to complicated cyst

25:16

complex means it's cystic and solid. It's

25:19

suspicious complicated is not so obviously we're

25:22

worried about this complex system mass and this

25:26

ended up being an inflammatory breast cancer.

25:30

Again, this is kind of a companion case similar 29

25:33

year old less breast lump for one month again. She's

25:36

coming in. We start with an ultrasound because

25:39

she's under age 30. She has what I would call complex systemic

25:42

Mass. I've seen this given a Byer

25:45

of three before which is wrong because if

25:48

you really see, I think that things that tell you that's wrong

25:51

would be like these nodular areas and areas

25:54

that don't

25:57

look not thin citations. So it looks ugly

26:00

this thing you need to buy red four as well. She had a lymph node.

26:05

So again, this was her mammogram, you know was she's 29

26:08

we start with the ultrasound you could see that they have this math where she

26:11

feels the lump and that's what

26:14

it looks like. It's a little bit of regular on the mammogram. So, of

26:17

course we're going to give this a byrides at least four, maybe five and

26:20

this came back as an invasive cancer as well.

26:24

So I just wanted to take a minute to go over cystic masses

26:27

which my residents even do this. They kind of use the

26:30

words complicated and complex interchangeably, but they're

26:33

very different meanings. So a complicated this

26:36

means that it has low level internal Echoes or

26:39

some debris May shift when you move the patient does not

26:42

contain thick walls fix it patients

26:45

or any other solid components malignancy rate

26:48

is less than 2% So you are

26:51

as reasonable to give it a two or three depending on what it looks

26:54

like and if they have any other things in the breast as opposed,

26:57

I would say that if it's symptomatic or

27:00

newer enlarging you might want to offer a needle aspirations.

27:04

See no steps to use a bias. Yeah, ultrasound.

27:07

Thank you. Okay, so obviously if it's

27:10

newer symptomatic or enlarging I usually offer the patient aspiration, even

27:13

if it's just for symptomatic relief.

27:16

As opposed to a complex this okay. So complex this

27:19

has thick walls six Sensations intersistic

27:22

masses any solid components. Those are

27:25

worried some signs the risk of that being malignancy is over

27:28

20 to 30 percent. So you definitely

27:31

need to do tissue sampling in that case in both of those room

27:34

decent ductile cancers the most common type of

27:37

cancer that these cystic Cancers get are just

27:40

you know, usually they're in invasive. That's all

27:43

which is a common most

27:44

Most common overall often they're like triple negatives and

27:47

they're essentially necrotic and it's because they're growing so fast that

27:50

they just necross themselves. So so complex

27:53

to sick masses are concerning because

27:56

it also be an abscess. But either way I think you do need a tissue in

27:59

those cases.

28:00

Okay. So moving on this

28:03

is actually a great article. If you want if you need more information about this

28:06

complex cystic breast masses diagnostic approach

28:09

and radiographics.

28:11

Okay, so

28:13

next case history withheld.

28:16

Okay.

28:17

so

28:18

what we notice about are you spoker?

28:21

Okay, thank you. So what you notice about this case they have

28:24

very large pectoralis Muslims. I'm telling you this.

28:27

Because this is a man. Okay, so if you didn't know

28:30

that they had this claim shaped retro or density and

28:33

the right that is pretty classic of gynecomastia. But

28:36

on the left they have more of

28:39

a math right that have condex borders. We can

28:42

see that it's causing some skin thickening and

28:45

going to the nipple. This is concerning also

28:48

on the mlo you can see that they have some pathological impatinopathy.

28:51

That would be concerning as well on the

28:54

left. We got an ultrasound you can see some nodularity and

28:57

then there's this large left breast Mass it obviously

29:00

a suspicious 6.2 centimeters and abnormal lymph

29:03

node. This ended up being a metastatic male

29:06

breast cancer.

29:09

Um, you know males are diagnosed at later stage because

29:12

most men are not getting screening mammograms, even though I

29:15

don't know if you saw but the ACR now supports screening

29:18

mammography and men who are at

29:21

high risk. So either have a genetic mutation or have a

29:24

first degree relative with breast

29:27

cancer, then they should consider screening mammogram

29:30

starting at age 50, but this is

29:34

what it looks like when it's aggressive and spread so you can see

29:37

has a malignant plural fusion and plural thickening. There's

29:40

that gynecomastia and definitely different

29:43

from the guided math. Yeah.

29:44

This is another case. It's not uncommon for

29:47

men to have both gynecomastia and breast cancer, which

29:50

makes it a little confusing but clearly, you know, this has

29:53

been a mastias that flame shaped retro or density. And this

29:56

is more of a mass of calcifications. This was another

29:59

case of male breast cancer. You can see that he has

30:02

calcifications.

30:04

So fun fact about breast cancer male breast

30:07

cancer. Beyonce's dad had breast cancer. He's actually bracket two

30:10

positive. I don't know she's been tested but I'd be dying

30:13

to know Brett male breast cancer accounts

30:16

for about 1% of breast cancer is it used to be one in a

30:19

thousand one in like 850 men get

30:22

invasive ductal. They don't have lobules. They usually have a

30:25

worse prognosis. It is a significant amount

30:28

of month. Not men over 2,700 men are diagnosed

30:31

with breast cancer each year in about 530 men

30:34

die each year from the disease. They're more likely to have genetic

30:37

mutation. So it is indicated to have genetic screening

30:40

for the men and their offspring. Like I

30:43

said, you're gonna start screaming mammography and

30:46

males of braca or 10 years before their first degree relative. So age

30:49

50 or 10 years before first three relatives.

30:51

And I'm not sure most places are doing

30:54

that but we're going to start it here. So again,

30:57

just to go over the findings. So gynecomastia is

31:00

usually bilateral. It's usually worth on

31:03

one side flame shapes retro or densities. Mammo

31:06

is diagnostic ultrasound will be very confusing. So

31:09

in then we start with a mammogram

31:12

over age 25

31:14

And below that we're going to start with a ultrasound in

31:17

many cases. If I don't if it's

31:20

pretty classic of gynecomastia on the mammogram, I won't even

31:23

do the ultrasound because it can actually, you know muddy the

31:26

water and look confusing and as opposed to

31:29

breast cancer. Like we said breast cancer is usually unilateral. You're

31:32

gonna see a true mass of borders ultrasound not

31:35

necessary if the mammogram is Diagnostic and I think that's an important

31:38

distinction. I feel like a lot of men are often sending with the ultrasound

31:41

script and not a mammogram and it's always a battle with the referring positions.

31:45

So something to think about

31:47

So, you know the common causes of gynecomastia

31:50

usually just say, you know have a conversation with your doctor some

31:53

medications can really cause this and if you stop the medication it's

31:56

improved. So idiopathic most commonly drugs will

31:59

be no marijuana prostate cancer meds is

32:02

a big one estrogen anything that causes estrogen excess. So

32:05

if you have a testicular adrenal tumor or liver

32:08

disease or if a man is taking exogenous

32:11

hormones for transition. So we see

32:14

that more and more now also, nope. Also

32:17

male breast cancer can cause gynecomastia

32:20

just because of the hormones associated with it.

32:23

All right. So this is a little bit of a round robin in

32:26

case I know on the board sometimes I'll just show you one picture and say

32:29

what is this and what are we looking at? So just I'm gonna

32:32

leave it up for a second and what am i showing you so is this from

32:35

a needle Loop a stereo biopsy ultrasound Guided

32:38

by FC and none of the above. Well, so

32:41

if we're taking the boards you could pretty much knock at

32:44

ultrasound because it's obviously mammogram and

32:48

the box and the calcification should really tell you something. So

32:51

think about that for a minute. I'm going to show you another thing. So if

32:55

you couldn't figure out that one this is another type of

32:58

procedure that often gets confused if they're looking at so this

33:01

one you're going to see an alpha in America grid and this is a needle

33:04

look so we're gonna tell them where to put the the grid and

33:07

where where you want what crosshairs you're

33:10

gonna put the needle in, you know, we often do

33:13

a needle Locus. Someone has a cancer and it needs to come out for lumpectomy. And

33:16

this of course is a stereotypic. So you'll

33:19

notice that there's that square that the calcifications have

33:22

to be in so that's pretty Telltale.

33:26

So something that I wanted to show you because I didn't know this until I

33:29

was an attending I asked for it. But so this is a tangential

33:32

view you can see that there's the skin

33:35

calcs and there's a little BB on it what I never

33:38

really understood was actually how we get tangential views

33:41

and what they do is they actually put them in the needle

33:44

localization grid, like they're getting them. I need

33:47

a loop and instead they're putting that a BB on the calcification. So

33:51

in this case, we put a BD right on F4 right

33:54

where the cows vacations are. You can see we put a BB

33:57

right here and then we shoot orthogonal to that and that's how

34:00

we get tangential views. So if

34:03

you've never been in the room with a test, I recommend you do

34:06

this is what it looks like. So it almost looks like a needle localization procedure.

34:09

So again, let's talk

34:12

a little bit about needle looks something. We do a lot as a

34:15

breast radiologist. So needle Locs are done for surgical

34:18

biopsies or for breast cancer that need

34:21

to be excised. You're always going to want to choose the shortest

34:24

skin surface, okay.

34:26

So in this case the shortest skin surface is from lateral.

34:29

Okay. So if you come from above it's a seven from here.

34:32

It measures 4.5 centimeters. So in

34:35

this case, we're going to come from lateral.

34:37

And what I always lose people with so if they're if you're

34:40

coming from lateral.

34:41

Then the patient needs to be positioned in

34:44

the LM projection. Okay, so it's opposite of

34:47

what you think. So if you see it on the CC you're going to come from the opposite and

34:50

seeing if you're coming from above they're gonna be positioned CC

34:53

and I think that's something that you need to sit with and think about so in

34:56

this case, we're gonna come from lateral we're going to use you need

34:59

it to be long enough. So needles come typical needle

35:02

localization needles come in three, five

35:05

seven and a half and 10. So in

35:08

this case you want to be long enough. So if you use a three would be too short, but

35:11

you're gonna put in a five You're Gonna Go they'll be positioned in the

35:14

LM projection. Okay. So LM because

35:17

I always remember it that the that the

35:20

the way you're coming from starts first.

35:23

So that's where the opening is. So if I'm coming from lateral and

35:26

that, I'm sorry Ln. I'm coming from medial ML. And

35:29

if you're coming from above or below you're gonna

35:32

put them in CC. So in this case we've come from Ln.

35:35

And this is what it would look like. So I'm going to go quickly

35:38

through these we would go from Lateral with a five you tell

35:41

her to do LM. So this is what it looks like. So the patient positioned LM

35:44

in the alphanumeric grid, that's how we

35:47

know. It's a needle look and we swore and put our needle in

35:50

right here.

35:52

Right here. So about like one and a

35:55

half and B and a half and you're gonna go all the way in with

35:58

your five. Okay. This is not perfect, but we'll take it.

36:01

There's nothing. This is one in front of what from when I was a fellow really you

36:04

won't be right on it. But in this case, you know,

36:07

we put it all the way in and we don't know how all we

36:10

know is that it's in the same plane as the cancer

36:13

but we don't know how deep it is until we actually take her out

36:16

and put her in orthogonal. So in this case, you can see we

36:19

probably should get an xccl so we can see more tissue we

36:22

can see that the math the needle goes right Beyond The Mask. So

36:25

then you're gonna hook it you may or may not leave in the

36:28

needle we leave them in here. But at Penn we took them out and the

36:31

patient's gonna go to the or with the needle

36:34

and wire in their breath. They remove it you check the specimen

36:37

to make sure a few things that you're looking for the entire wire

36:40

the math and the clip

36:43

and that it's not near any of the margins like

36:47

so if you saw it extending to a margin you might want to tell the surgeon. Hey,

36:50

it looks like it's close to

36:52

Going to buy the hook wire takes some more tissue there our

36:55

surgeons kind of give us like a clip. They give us

36:58

put like one for anterior two for medial. So we kind of know have

37:01

some orientation when we're looking at it. So that's helpful.

37:04

So like I said, this is done for it's usually

37:08

done on the day of surgery for for cancers that we can't

37:11

does surgeon cannot see or feel can be

37:14

done under any image of modality mammogram ultrasound or

37:17

MRI. It's usually performed in the morning of surgery and the

37:20

patient goes right to the or with the needle and wire

37:23

in the breast there is newer technology available, which

37:26

I highly recommend that everyone, you know starts converting

37:29

to because it definitely is easier for patients and for

37:32

scheduling for surgeons. So radio frequency

37:35

tag, we use that here magnetic tags, like

37:38

a MAG seed radioactive speed localization all of

37:41

them have their pros and cons but all of them you could do

37:44

A few days to weeks before the breast

37:47

cancer surgery and then

37:50

they don't have to have a needle of utilization the day of so

37:53

I'm going to show you a tag procedure. So in this case, this

37:56

was the cancer we put a tag. I think it was

37:59

this one. That's the cancer. We put a tag right here again. This is

38:02

doing that. It's exactly performs exactly like a needle localization

38:05

except that when we are done we're going to deploy it

38:08

and leave it right there. So now the surgeon can use

38:11

a radio frequency. I

38:14

don't remember what the counter is, but they could use in the OR to find

38:17

the tag using radio frequency. It gives

38:21

them some death information does take some time to get used to or surgeons

38:24

are kind of still working through that but it is

38:27

great for patients and for surgeons alike and it

38:30

really opens up scheduling possibilities something

38:33

to consider when you with the radio

38:36

frequency and magazine you kind of want to make sure that they are

38:39

done with any

38:40

Imaging like MRI because these do cause a

38:43

lot of artifact which is why we don't put it at the time of biopsy of

38:46

the category 5 lesion because it will cause major artifacts on subsequent

38:49

MRIs. So something to consider and also

38:52

radio frequency. I'm sorry the the nuclear

38:55

tag require like a whole nuke Med

38:58

safety program in place. So it does have more barriers to

39:01

jump through. So this is a tag.

39:05

So again, you know tag localization radio frequency

39:08

magnetic or nuclear. They can be performed a month

39:11

before surgery both sides confirm

39:14

the signal so we confirm the signal when they're done

39:17

and then the surgeon will confirm the signal in the or

39:20

if you place it. It should come out every so

39:23

often, you know, patient changes their mind and they're like,

39:26

you know what I'm not gonna get this surgery. I'm just gonna watch it

39:29

and it's not so much of a problem unless it's

39:32

a nuclear medicine tag those has to be removed. So that

39:35

is another thing to consider.

39:37

Moving on we're doing great with time.

39:40

So this is kind of an ant Mini case. I'm going to give you a minute

39:43

to look.

39:44

at the

39:46

at the finding but

39:48

so

39:49

for those who haven't found it yet. We see a peck here.

39:52

We are missing a pectoralis muscle here.

39:55

You know, it's good technique because you kind of see those posterior folds

39:58

and they look pretty even so this is a classic

40:01

case another this is another case with the same

40:04

finding.

40:06

And this is what the chest x-ray looks like. If you

40:09

haven't figured out yet. You can see that there's like a

40:12

brush Shadow over here and it's a little bit denser. It's

40:15

a little bit more clear here. This is a case of

40:18

Poland syndrome.

40:19

So when a patient is born with missing or

40:22

underdeveloped pectoralis muscle on one side of the body, they

40:25

have abnormalities that can affect their arms chest

40:28

shoulders even their hands. They may have webbing of

40:31

the fingers of the hand on the same side can vary depending

40:34

on the severity. It tends to be on the right side and

40:37

is more common in boys and girls did not know that

40:42

Piece nine, we're moving right along. So it looks

40:45

like this is a diagnostic study a patients coming

40:48

in with the palpables. I would say they're heterogeneously dense

40:51

you can see kind of an obscure Mass right

40:54

where they're feeling the lump in the right retro or region laterally, so

40:57

we're going to Ultrasound this and this is

41:00

a again probably a complex

41:04

cystic mass or solid Mass with six

41:07

cystic portions. Obviously. This is you know

41:10

concerning this was

41:13

a case of angiosarcoma and I

41:16

just want to show you because the MRI was very impressive, but that's what it

41:19

looks like.

41:20

And this is what it looked like after new admin chemotherapy. So

41:23

really responded well to chemotherapy. This was

41:26

her final pathology though, even though it

41:29

didn't

41:30

Even though it looks like on the MRI that is completely resolved. There

41:33

was still residual angiosarcoma and it

41:37

just shows you that you know MRIs cannot really

41:40

evaluate whether there's been complete

41:43

pathologic response. That's something that's done at surgery, you

41:46

know, sometimes things might not enhance for different reasons, like

41:49

we killed off the blood flow to them. So it might not enhance it

41:52

still may be viable. So that's what was happening

41:55

in this case.

41:56

So I'm going to just keep going because we're doing good.

41:59

If so, I'll leave about 10 minutes at

42:02

the end for questions. So maybe one or two more cases so you

42:06

could see it's a normal mammogram. You see a lot of dilated vessels,

42:09

but then, you know three years later she comes in.

42:12

And you could see that just bilateral trabecular thickening.

42:15

The breasts are overflowing with fluid.

42:18

I would call this, you know bilateral trabecular

42:21

and skin thickening. It's a

42:24

very differential is very differential if

42:27

it's unilateral versus bilateral you could

42:30

see that she's developed a lot of atherosclerosis in the

42:33

meantime. So this is kind of telling you that you might have underlying renal disease

42:36

and this is all related to fluid overload.

42:39

So you can see these ultrasound you'll see the skin thickening

42:42

you'll see giant effusion. If you want to be impressive Radiology.

42:45

If you say get a chest x-ray off the mammogram and

42:48

we did that and you know, we saw that there were CHF

42:51

we saw that there is societies everywhere. So this

42:54

is confluid overload. And in this case it was

42:57

due to renal failure. Like I said, the differential

43:00

diagnosis is very different whether it's unilateral bilateral for

43:03

unilateral you're thinking inflammatory breast

43:06

cancer prior radiation treatment. Obviously me that

43:09

that history Mass scientists. It can be hard to

43:12

Affected from inflammatory breast cancer, but with Methodist, it

43:15

gets better inflammatory breast cancer does not get better with antibiotics. That's

43:18

a big Discerning Factor lymphatic obstructions

43:21

CHF usually bilateral

43:24

like we said and SEC obstruction again, usually bilateral

43:27

so for bilateral very specific,

43:30

you know, usually congestive heart failure or some

43:33

kind of fluid overload or lymphatic obstruction very unlikely

43:36

to have inflammatory breast cancer, but I have seen cases of

43:39

inflammatory breast cancer that kind of cross over from one breast

43:42

to the next through the midline.

43:44

Oh, we got through it all in time. So thank you

43:47

so much. I hope you learned a lot. I'm plugging

43:50

in all my social media here.

43:53

And then I also run a podcast called the girlfriend's guide to

43:56

breast cancer breast health and Beyond where I talked it really

43:59

is designed to help people navigating a breast cancer diagnosis. I

44:02

talked to lots of doctors and yeah, follow me

44:05

everywhere. Thank you.

44:10

Dr. Ross, um, there's a bunch of questions in the Q&A box. Do

44:13

you want to pop that open or do you want us to read them to? Where

44:16

do you prefer?

44:17

I'll do it. So when you use vacuum assisted biopsy,

44:20

when do you use vacuum assisted biopsy versus

44:23

the conventional biopsycon? I actually have a great answer to this. So I typically

44:26

use the spring loaded.

44:30

Back, I usually do a spring-loaded for

44:33

everything because it's a lot cheaper like we don't

44:36

get reimbursed the way we used to a vacuum. However, if I have

44:39

a very small lesion that I'm only going

44:42

to get one really good pass on like let's say

44:45

it's a three millimeter mass and I know the second I take a sample. I'm

44:48

gonna lose my Target and get bleeding and you know

44:51

lidocaine obscuring it then I go in with a vacuum. So

44:54

a vacuum you can go in one time kind of turn it around so

44:57

that you know, you're in the right spot all so if I'm trying

45:00

to get calcs calcifications, I'll use the

45:03

vacuum. So let's say I'm doing an ultrasound Guided by it. So you have a mask that has

45:06

calcs. Sometimes they'll go in with the vacuum and image that

45:09

tissue under you know, get a specimen redo grasp

45:12

to make sure that I also got the calcifications that we saw on the

45:15

mammogram.

45:18

How do you use contrast mammogram? Okay, that's a great

45:21

question. It's a complicated answer. We right now.

45:24

We're pretty much using in the diagnostic setting if we are working

45:27

up somebody with dense breast tissue

45:30

and kind of findings in both breasts.

45:32

I think it's a great more and more people are getting it for

45:35

you know, they have dense breast tissue and kind of that intermediate

45:38

risk for breast cancer. So more and more surgeons

45:41

are offering that you know, instead of MRI, you

45:44

know, which they don't really qualify for and ultrasound. They

45:47

want something better than that contrast mammogram.

45:50

I like using it there. I hope to see it. Like I

45:53

said in a in their intermediate risk of breast cancer

45:56

population with dense breast tissue, but

45:59

They're we're going to see lots about contrast mammography right

46:02

now. The thing that I find the biggest struggle is being

46:05

overcome, which is we can't biopsy a contrast

46:08

mammogram finding currently. So it's in

46:11

in those cases. We have the recommend an MRI and MRI biops. You

46:14

can't go straight to an MRI biopsy off of contrast the Immigrant even though it

46:17

makes sense insurance won't pay for it like that. So but there

46:20

are newer technologies that allow you to buy and see a contrast Mamo

46:23

finding so with that like the world doesn't really sorry. I think we're going

46:26

to do lots of things with that. Oh, how do

46:29

you do a contrast immigragram? I have a great there's some really great articles,

46:32

but it's almost like you've given injection wait two

46:35

minutes and then it uses dual energy and subtraction Imaging

46:38

that's all I'll say about that but it's

46:41

a great great test in case

46:45

of the bench press tissue. Can we skip regular mammography instead you

46:48

Como or contrast name an ultrasound? So we

46:51

don't miss Allegiance. So to me regular mammography is 3D mammography,

46:54

like that's the standard of care now here in the US

46:57

I would love

47:00

People to get contrast mammograms. The only issue is like

47:03

it requires an IB and an injection of contrast,

47:06

which is not without it, you know limitations, but you

47:10

know, we give contrast all the time for CTE and

47:13

so I think we're going to get there eventually unless

47:16

like breast CT really proves itself to be a great Imaging modality.

47:19

But yeah, I'm Pro contrast

47:22

mammogram. It's not FDA approved as

47:25

a screening test yet. So I think we have to get there last time

47:28

I checked.

47:29

Case number thickening has a side. I'll have to

47:32

go back to that.

47:34

Do you need to classify gynecomastia into nodular

47:37

or dendritic? I don't I you know,

47:40

you're just saying I think that's more of like a pathology and

47:43

textbook type of thing. I just say that there's benefit and leave

47:46

it at that.

47:49

If a young patient in her 20s have Micro calcification

47:52

on her mammogram, which we do next. Well, why is

47:55

she having a mammogram number one because we usually start with mammography

47:58

at age 30 ultrasound. I mean

48:01

MRI is early as age 25. So I need to

48:04

know more about the calcifications. Are they plea amorphic or are they

48:07

classic of a fiberatinoma? And you know why we were

48:10

doing the mammogram in the first place is she high risk. Those are all things. I would

48:13

take into consideration before deciding if I should buy it to them. So need

48:16

more information asymmetry versus non-mass enhancement.

48:19

So non-ass enhancement is like more

48:22

of something you see after contrast. When a symmetry you

48:25

see on the mammogram on one view. It's a one view finding a dense tissue

48:28

on one of you finding linear and

48:31

non-mats enhancement is something that you'll see on ultrasound. I mean on MRI

48:34

or contrast me. I'm a Graham you need

48:37

that contrast to have non-math and enhancement. It could be a number of things but

48:40

you know, it is concerning.

48:44

so hopefully that helps I think that

48:47

We're going to stop here in that setting and then

48:50

there's some chats. Thank you so much. Okay, I think that was the

48:53

big one.

48:56

Any other questions, please feel free. Feel free to you

48:59

know, email me message me at the booby docs.

49:02

I'm very responses to messages there.

49:05

Yeah, I always say follow me for the breast information Rod. Thank

49:09

you so much for this amazing lecture and all the cases you covered appreciate it.

49:12

And thanks for everybody else for participating in the new conference.

49:15

You can access the recording of today's conference and

49:18

all our previous new conferences by creating a free MRI online

49:21

account.

49:22

Be sure to join us next week on Thursday, April 27th

49:25

at 12 pm Eastern. We're featuring Dr. Brian

49:28

Smiley for a lecture on pulmonary adenocarcinoma atypical

49:31

pulmonary cyst and lung RADS. You

49:34

can register for this free lecture at MRI online.com and

49:37

follow us on social media for updates on future new conferences.

49:40

Thanks again, and have a great day.