0:00

So this is a 40-year-old who presented

0:05

with palpable mass in her right

0:07

breast, 6 o'clock posterior depth.

0:11

It was really tucked in there.

0:13

And so we're going to start up high.

0:15

Actually, let's start down low in her

0:17

because you can see the mass more readily.

0:19

Unlike the last patient who had stage zero

0:22

disease DCIS and non-mass enhancement.

0:25

This is, remember these, this is the

0:27

source data here, but, and this is the

0:30

biopsy track. This got a lot of people

0:31

this just tripped up a lot of people.

0:34

But this is T2 bright.

0:35

So this is actually the biopsy tract here.

0:37

Just FYI.

0:38

Okay, so in the right breast coming up, and you

0:41

can see it just leads right into the index mass.

0:43

Um, we have our index mass, which is

0:46

an irregular. When you actually zoom it

0:48

as we did for the gold standard report,

0:51

you can tell that the edges are serrated.

0:53

So this is, and rather,

0:56

rather than being considered

0:57

round, oval, or circumscribed, we

0:59

would call this an irregular mass.

1:00

This is heterogeneous in enhancement.

1:03

It's not homogeneous like a light bulb.

1:06

It clearly does enhance, though

1:08

it sits posteriorly, but it does

1:11

not impact the pectoral muscle.

1:13

So I wanna make sure we make that point, that

1:16

pectoral muscle, uh, although there's a vessel

1:19

in it there, and that's just because this is

1:21

a, there's neovascular and this is, uh, this.

1:24

Um, cancer is begging and is commanding, um,

1:28

enhancement, um, because of its neovascularity.

1:32

There is no abutment or invasion

1:35

of the pectoral muscles.

1:36

I want to make sure that you see that.

1:38

But as we come up, in addition

1:40

to seeing the, seeing the mass,

1:43

we've already begun to notice that.

1:46

There is a symmetry of the local

1:50

regional lymph node 1 bearing site,

1:53

which is the internal mammary site.

1:55

So I just want to direct your attention.

1:58

Many of you were successful in

2:02

seeing 1 internal mammary lymph node.

2:05

Uh, but didn't mention the fact

2:07

that there are at least two of them.

2:08

So this is at least, uh, at least one other.

2:11

And these are large internal, this is a

2:13

large lymph node, not so much this one.

2:15

The other one's huge though.

2:16

So I'm going to just keep scrolling up.

2:19

And you're going to see a very large,

2:22

um, enhancing lymph node on the right.

2:25

The interesting thing here, I think,

2:26

is how much like the index mass.

2:29

And I have noticed that anecdotally after

2:31

a while, as the mammary lymph nodes get

2:33

larger, they just start to look and many

2:36

actually lymph nodes. They really do look

2:38

like the, they look like the index of

2:40

breast mass and I would, I would submit

2:42

to you that this is very similar to that.

2:45

Um, At the other, uh, let's pause

2:49

for just a moment and talk about

2:50

local regional lymphadenopathy.

2:51

Remember, we're always, we know about the

2:53

axillary lymph nodes one, two, and three.

2:56

We've discussed them before, um, with one

2:59

being lateral and inferior to the PEC minor.

3:03

This is the PEC minor.

3:05

This is the PEC major.

3:06

I'm gonna go, I'm gonna scroll down a

3:07

little bit here so that you can see it.

3:09

There we go.

3:10

And as we're just coming down,

3:12

there's the minor again and the major.

3:14

So we're looking out here and under this for

3:20

level 1, and there are, of course, the most

3:22

common limits, and they are typically the

3:23

lymph nodes that are the draining lymph nodes.

3:25

They're the so-called sentinel lymph nodes.

3:27

So those are the ones that will be involved.

3:29

It is unusual.

3:30

To go exclusively to the internal mammary nodes,

3:33

but that's exactly what this patient did.

3:35

And then the level 2 axillary lymph

3:37

nodes are the ones that are, um, that are

3:41

posterior to the, um, so they would be

3:43

back here, posterior to the minor muscle.

3:47

Um, the, um, Rotter's nodes are between

3:51

the PEC major and the PEC minor.

3:53

So they would be sitting in here if.

3:55

She had any, which I'm glad she doesn't.

3:58

They count as level two lymph

4:00

nodes as well, believe it or not.

4:01

And then, um, subpectoral lymph nodes, the ones

4:05

that are the ones that, um, a lot of surgeons

4:08

and medical oncologists call them subpectoral.

4:12

We still just call them level two lymph

4:13

nodes, but those, the so-called subpectoral

4:16

lymph nodes are largely level two lymph

4:19

nodes, and then level three lymph nodes are

4:21

tough for us or can be tough for us on MR.

4:23

Those are the ones that are.

4:24

Um, either medial to the PEC, so they'd

4:27

be sitting over here PEC minor or superior

4:30

to the, um, to the, um, PEC minor.

4:33

So, they're above it, and very frequently,

4:34

they're just not included because

4:36

they're in the superior mediastinum.

4:37

Sometimes they are, but you would more

4:39

frequently see them on PET or some sort of

4:42

axial imaging that goes through the neck.

4:45

All right, so we've talked about

4:46

local regional lymph nodes, and

4:49

all of them are in our must-check.

4:54

Uh, purview.

4:55

These are our responsibilities,

4:57

so we wanna get these right.

4:58

And that's the reason that we focused on

5:00

them as much as we did in week five.

5:02

So we've reviewed axillary one, two,

5:04

and three, or level one, two, and three.

5:07

We've reviewed all the weird ones like Rotter's

5:10

and subpectoral or the alternate type names.

5:12

They're all, they're all,

5:14

uh, level two lymph nodes.

5:15

Um, and then the point of this case

5:18

is, um, internal mammary lymph nodes.

5:20

I do wanna just.

5:22

Uh, let you know, I want to direct your

5:23

attention to the gift that we have

5:26

been given, which is the gift of the other

5:28

half of these patients' bodies.

5:31

So just remember to look to the other side.

5:34

So that really helps these internal

5:37

mammary lymph nodes stand out.

5:39

This is a really nice example.

5:41

So these are the internal mammary

5:43

vessels all sort of lined up in a row.

5:46

Um, there's a vein, there's an artery.

5:48

There are even some lymphatics.

5:49

There are certainly some branches, but there

5:51

should not be an additional mass.

5:55

Be careful not to overcall a vessel that is

5:57

branching from a normal vessel, which is branching

6:00

and going anterior just to get to the breast.

6:04

But again, there's typically a hint that there's

6:07

something different and wrong about these.

6:11

I also want to, we have a lot of.

6:13

Several of you actually, probably the majority

6:15

of you, um, were concerned about these lymph

6:19

nodes in part, I think, because we may have, um,

6:22

uh, given you a red herring by actually having,

6:25

uh, indicated indicating to you that somebody

6:28

had a clip, uh, or indicating to you that she'd

6:30

been biopsied because there's susceptibility

6:32

artifact. But I want you to also use the

6:35

technique that it was a benign lymph node, by the

6:37

way, but I also want you to use the technique

6:39

of comparison one side to the other.

6:42

So it's unlikely that we're going

6:44

to have patients who have symmetric

6:46

bilateral axillary metastases in the

6:49

setting of the usual breast cancer.

6:52

And so, when you see prominent lymph nodes on one

6:54

side, if they're not really much different than

6:57

the other side, and I would submit to you that

6:59

there are a lot of prominent "quote, prominent

7:01

lymph nodes in the left breast as well, have

7:04

a higher threshold to call them abnormal.

7:07

Okay, so, uh, spot her some, um, uh, spot her

7:12

some, um, uh, some enlargement of the lymph

7:16

nodes as non-pathologic if they're bilateral.

7:20

All right, so that's case, uh, case.

7:23

That's our, well, that's

7:25

already our third case, man.

7:26

Uh, okay.

7:27

Good.

7:27

Good.

7:28

Everybody.

7:28

Let me check the chat.

7:29

I see that there's a question in there.

7:31

Let me just check it real fast.

7:32

And we're not sure with enemy versus

7:36

fibrocystic disease, is it better to over

7:38

call your experience so that it gets biopsy?

7:40

I think, Dr.

7:42

John, and I've really enjoyed

7:45

doing your reports. By the way, I

7:46

did more of them last night.

7:48

As a matter of fact, I think

7:50

you're a terrific radiologist.

7:51

Actually, I think all of you are.

7:52

Let me check to see who

7:53

the participants are today.

7:54

But I think that's a really good question.

7:56

Rely very heavily on the symmetry

8:01

bilaterally and rely heavily

8:05

on any priors that you may have.

8:08

Also, the intrinsic breast density

8:12

and the intrinsic risk, which is really

8:14

frustrating for me to tell you all of that.