0:04

I've specifically shown you the pre-therapy.

0:08

I think the case itself had wanted you to look

0:11

at the post-therapy first, but let's look at

0:14

the pre-therapy just in terms of the sheer

0:17

amount of tumor that the patient has.

0:22

Okay, so.

0:23

I'm going to do the subtracted in this case, and

0:26

this is already rotated for us, which is good.

0:29

And I'm just going to window

0:30

and level it a little bit.

0:32

And this would be classic.

0:33

Now, this is the patient, unlike all of

0:35

our other patients, except for the first

0:36

patient, which was a high-risk screening.

0:39

All the other patients have been

0:41

successfully treated cancer patients

0:43

that we're trying to avoid doing too many

0:46

things on because they're all benign post-

0:49

therapy. This is a newly

0:53

diagnosed breast cancer, and I'm just

0:55

going to show you what we're seeing.

0:57

So we're going to start at the top

0:59

in her think, and then scroll down.

1:03

And this is a patient in whom there is.

1:07

Oh, I'm showing you the post-neoadjuvant.

1:10

So let's, I'll go back and

1:11

pull the pre-neoadjuvant.

1:12

But this is a really nice example

1:14

of a young woman who had a dramatic,

1:16

only 39 years old, who had a dramatic

1:19

response to neoadjuvant chemotherapy.

1:22

And I just want to alert you

1:23

to her negative, right, axilla.

1:26

Here, nice, normal, right?

1:28

Axilla.

1:28

These are normal lymph nodes.

1:30

Remember the lymph node-bearing chains.

1:32

I'm sure one of the other doctors has already

1:34

gone over it, but we look at both the axilla.

1:37

We look at the interpectoral region

1:41

and we look at the subpectoral region.

1:43

So, uh, uh, level levels 1 and 2.

1:48

Are here and here, and then the

1:51

intrapectoral and a retropectoral need

1:54

to be mentioned because of the surgeons.

1:57

And then, of course, we're looking at the

1:59

internal mammary lymph nodes, and they are the

2:02

ones paralleling the sternum on each side.

2:04

So, and then we just have a minor amount

2:07

of a minor amount of remaining non-mass

2:11

enhancement in the right breast laterally.

2:13

This right breast is.

2:14

Smaller than the left breast.

2:15

So this does hold true.

2:17

They hurt the affected

2:18

breast, the cancer breast.

2:19

This hasn't been certain.

2:21

This hasn't been surgically intervened on yet.

2:22

But even the therapy itself

2:24

has shrunken the breast.

2:27

So these are the after, and then let me go back.

2:29

Quickly and pull up the befores.

2:32

All right.

2:33

So, um, we're coming down.

2:35

Remember before you may recall that

2:37

the axilla on the right, um, looked

2:41

sort of like the, at most lymph nodes

2:42

looked about the size of this one.

2:44

But now I want to direct your attention to the

2:48

marked lymphadenopathy that is going that you're

2:51

going to be able that you're going to see.

2:52

And it's definitely asymmetric

2:54

with the contralateral breast.

2:56

Coming down, it is all axillary at

3:00

this point, the intrapectoral and the

3:03

retropectoral regions are negative.

3:05

I believe she did not have

3:07

internal mammary lymph nodes.

3:08

I'm going to look as I scroll down,

3:10

but I don't see these are just

3:11

vessels lining up and they stay.

3:13

They stay in the.

3:14

Clue to internal mammary versus a lymph

3:17

node versus vessel is the vessel just

3:19

continues to go down in the internal mammary.

3:21

Lymph node is a little lump tissue.

3:24

And then this is an obvious breast cancer in

3:28

the right breast that has the imaging features

3:31

that are very suggestive of breast cancer.

3:33

Namely, you have a regular

3:35

mass plus-minus spiculation.

3:38

You have a very thick rim.

3:41

Uh, of enhancement at very irregular.

3:44

And then recall that in week one,

3:47

we had, uh, those little, those

3:50

cysts that had very thin rims, barely

3:52

perceptible rims of enhancement.

3:54

Those are the inflammatory components.

3:57

And also, you can have a surgical

3:58

cavity, a lumpectomy cavity that

4:00

has a thin rim of enhancement.

4:02

But anytime the enhancement is thick

4:04

and irregular like this, there's

4:05

something, something definitely

4:06

going on, classically neoplasm.

4:09

Um, and then, um, we have actually have

4:12

direct skin extension, and I want to

4:15

remind you that this would be an example

4:17

of locally advanced breast cancer.

4:20

By definition, we, you may recall

4:23

that in week two, we had a locally

4:25

advanced breast cancer patient as well.

4:27

It was the contralateral breast,

4:29

and it wasn't quite, it wasn't.

4:32

It wasn't this dramatic by any stretch of

4:34

the imagination, but, um, they are both,

4:37

um, we used to call them neglected breast

4:40

cancers in the States, but we no longer

4:43

assign sort of pejorative, uh, term to

4:47

them, but it's called locally advanced.

4:49

They are the most curable.

4:51

They are the most advanced, but curable

4:53

tumors that we see, and we see them fairly

4:55

regularly, especially in the post-COVID era.

4:58

I'm anecdotally seeing them fairly frequently.

5:00

Um, they are relatively easily cured

5:04

actually, with a multimodality approach.

5:06

So this patient, um, is a

5:08

nice illustration of that.

5:10

She received her neoadjuvant chemotherapy.

5:12

It's not just chemotherapy anymore.

5:13

Have a tendency to call it neoadjuvant

5:15

chemotherapy, but remember,

5:16

they also receive neoadjuvant.

5:18

I'm sorry.

5:19

Yeah.

5:19

Neoadjuvant hormone therapy and immunotherapy.

5:22

If, um.

5:23

If, uh, the tumor, um, the tumor in

5:26

particular has a P53, um, uh, pathogenic

5:30

variant, uh, or is affected by that, or has

5:33

a patient that has it, those will often,

5:36

um, respond, uh, to, uh, immunotherapy.

5:39

Anyway.

5:39

So those are the three things in

5:41

the armamentarium of neoadjuvant

5:43

therapy, neoadjuvant therapy, and

5:45

then they are classically treated,

5:48

uh, with, um, mastectomy, although.

5:52

Occasionally, as in this case, the patient

5:55

is even a candidate for breast conserving

5:56

therapy, just because the tumor responded so

5:59

dramatically, it's just, you'd have to get

6:01

all that original skin and everything else.

6:02

So I'm assuming I don't know, but I'm

6:05

assuming that this patient would have

6:07

this patient would have definitely

6:10

gone to that section at our even now.

6:14

Um, but, uh, and one more point about

6:17

neoadjuvant chemotherapy, because that was

6:18

the teaching point for this case, um, you

6:21

do not localize where the tumor used to be

6:24

in a patient who is undergoing, um, breast

6:27

conserving therapy, uh, not necessarily in

6:29

the locally advanced breast cancer example,

6:32

such as this, where there's skin involvement

6:33

and multiple lymph nodes, but certainly in

6:35

the instance of the smaller breast cancer, uh,

6:38

that receives neoadjuvant chemotherapy, and

6:40

there's a whole, there's a certain list of,

6:44

folks that receive it in the states regularly,

6:47

you do not localize where the tumor used to be.

6:50

You merely localize where the tumor now

6:53

is, or the clip where the tumor was.

6:56

In other words, a 6 centimeter tumor

6:59

previously does not require a 6 centimeter

7:01

localization after successful neoadjuvant

7:04

chemotherapy that has evolved over time.

7:08

But that is well established now.

7:11

Oh, I've talked on and on.

7:12

That's way too much talking.

7:14

Okay.

7:14

I'm so sorry.

7:14

Why don't you feel free to ask questions?

7:17

And again, it's a privilege

7:19

to work with each of you.

7:20

I do feel like I know each of you.

7:23

I've even Googled some of you, which

7:24

I probably shouldn't even say that.

7:25

That sounds creepy.

7:26

But anyway,

7:30

any questions?

7:32

Dr.

7:32

Sherry.

7:34

Yes.

7:35

Going back to case two.

7:36

Can I just ask something?

7:38

Um, on the tram case?

7:40

Yes, please do.

7:41

Case of, I've just heard that that line,

7:44

you know, the, the, the line, uh, that

7:47

separates the tram from the native breast.

7:50

That's where most of the

7:51

recurrences come, comes in.

7:54

So when do you start worrying?

7:55

Because with the case that we had, um, there

7:58

was a bit of thickening and lobulation.

8:01

So, um, I thought there was

8:03

something there, but clearly not.

8:06

So when do you start worrying?

8:07

Um, Yes.

8:09

Yes.

8:09

I, I think that is a tough question.

8:13

Question I must say.

8:14

So, um, I think it's a case

8:17

where, um, um, not so much Mr.

8:20

Honestly, but mammogram and

8:21

ultrasound can be extremely helpful.

8:23

Um, I wouldn't necessarily pursue it with Mr.

8:26

Although I.

8:27

Admittedly, if MR is the modality you're

8:30

looking at first, because the patient is

8:31

being high-risk screened or something,

8:33

then you've got to sort it out.

8:34

So that would be one that I would go on to MR.

8:37

It's called MR-directed.

8:37

We just call it second-look ultrasound,

8:38

but now it's just called or

8:41

second-look mammogram or whatever.

8:42

But now it's called MR-directed.

8:43

So, uh, MR-directed

8:44

mammogram and or ultrasound and, um,

8:50

Interestingly, the breast cancer

8:53

recurrences look very much like the

8:55

originals and, uh, and the fat necrosis,

8:58

doesn't classically look like that.

8:59

The fat necrosis is hyperechoic.

9:02

Uh, the fat necrosis on mammogram

9:04

will in fact have low density.

9:06

I'm not saying that there aren't some fat

9:08

necrosis instances that are, of course,

9:10

speculated masses, and there aren't

9:12

some that are, of course, hypoecoic on

9:15

ultrasound, because both of those are true.

9:17

But, um, you can use.

9:19

Um, adjuvant, um, uh, you can use, um,

9:23

the, uh, the diagnostic mammogram and,

9:26

um, mam and ultrasound to your advantage.

9:29

Also, remember, counsel and assist

9:32

your technologist that entire breast.

9:35

Um, that trend does not need

9:37

to be imaged in its entirety.

9:38

You are going specific to a site of concern.

9:42

Hello, Dr.

9:43

Burns.

9:44

She has a question about enemy.

9:45

Does it affect your staging?

9:47

Actually, you know, the does not affect

9:50

our staging in the state because the

9:53

staging of breast cancer is determined.

9:58

By the invasive component, uh,

10:01

that being said, the non invasive

10:04

component does need to be removed.

10:06

So, uh, there, there in lies the rub, right?

10:09

You can have a quote stage 1

10:11

disease that has a lot of enemy.

10:14

And once you know that you have to, you do

10:16

have to sort of work through the NME because

10:19

the NME is DCIS then it needs to be removed.

10:21

So the answer is ironically, it does not

10:24

affect your staging, not the true staging

10:27

of the breast cancer, but it does affect

10:30

the surgical management and it does affect.

10:33

The in between maneuvers that you as the

10:35

interpreting physician need to make you a need

10:37

to alert the alert of those involved as to

10:41

the, as to the presence of enemy, it needs to

10:44

be pursued with the diagnostic is classically

10:47

a 2nd, the more directed slash 2nd, direct.

10:51

Second look diagnostic mammogram to see

10:54

if there's something that bugs everybody.

10:57

Also, the I'd look back at the

10:59

original tumor biopsy if the original

11:02

tumor biopsy has DC is in it.

11:04

Also, there are some new this is like an

11:06

answer that you weren't expecting all this

11:08

I'm sorry, Martha, but sorry about this.

11:10

But, uh, also there are some, uh, types of

11:14

DCIS no capillary that just scoot everywhere.

11:18

They just, it scoots everywhere.

11:20

So, um, the, some of the garden

11:22

variety papillary, uh, I'm sorry.

11:24

Some of the garden variety DCIS is, you

11:26

don't have to be as concerned about, but if

11:28

your original tumor biopsy has a papillary

11:30

DCIS in it, then your NME on Uh, M.

11:34

R.

11:35

Probably is.

11:35

So all to say occasionally, uh,

11:40

and now that we've all gotten

11:41

better and faster, honestly, at M.

11:43

R.

11:43

biopsies, I find that being requested

11:46

by the surgeons more frequently.

11:48

We are, in fact, going to M.

11:50

R.

11:50

directed biopsy, or I'm sorry, M.

11:52

R.

11:53

guided biopsy to.

11:55

Uh, confirm or, um, disprove that the NME is

11:59

malignant because it affects so how they manage

12:01

the patient in terms of their surgical size, i.

12:04

e.

12:04

the whole oncoplasty and good outcomes.

12:07

You know, surgeons are

12:08

very concerned about that.

12:09

It's no longer, it's no

12:11

longer a slash and burn case.

12:12

That's for sure.

12:13

Much more nuanced, um, surgical,

12:16

uh, interventions being pursued.