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Hello and welcome to Noon Conference hosted by MRI Online. In response to

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the changes happening around the world right now and the shutting down of

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in person events, we have decided to provide free Noon Conferences to all

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radiologists worldwide. Today, we are joined by Dr. Michael Fishman. Dr.

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Fishman is a breast imaging radiologist at Boston Medical Center interested

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in artificial intelligence and social determinants of health. Also a trained

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health and wellness coach, he develop both a wellness/non clinical skills

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curriculum and a coaching program for residents. A reminder that there will

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be a Q&A session at the end of the lecture, so please use

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the Q&A feature to ask your questions and we will get to as

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many as we can before our time is up. That being said,

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thank you all for joining us today. Dr. Fishman, I will let you

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take it from here. Hopefully everyone can see my

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slide. Thank you so much for that introduction and welcome to everybody

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who is joining us today from near and far. I encourage you

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just so that I can get a sense of who our audience is,

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feel free to put into the Q&A where you are from and

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whether you are a resident or an attending and

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what specialty you are thinking about going into if you are a trainee or

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a fellow for that matter. So I wanted to talk a little bit

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about Rad Path correlation, which is something that we do in breast imaging

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all the time. Primarily at the time of the biopsy or when we

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get the pathology back, some institutions like our own have a specific Rad

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Path correlation conference that they hold at regular intervals to discuss

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either all biopsy cases or particularly challenging cases where there may

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be an interesting lesson learned. So we are going to just jump into

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it. The goal for today is to talk about

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concordance for benign and malignant diagnoses to identify when discordance

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might be suspected and when there may be additional sampling needed and

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to review management for some areas that are a little bit more controversial

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recently. So just in general, as you hopefully are all aware,

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there are lots of different ways to perform biopsies.

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What we do in radiology is minimally invasive relative to surgery and there

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are lots of different modalities that can guide our images and our procedures.

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Primarily in breast imaging, we use mammography with stereotactic biopsies

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and with ultrasound core biopsies. And there's lots of other procedures

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that have been developed, not specifically for diagnoses per se, but sometimes

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for presurgical planning. The advantages of the core biopsy relative to

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surgery is that they're very accurate in making the diagnosis and

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most importantly, they're able to differentiate invasive from in situ carcinoma,

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which is generally different than an FNA as well as receptor status for

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cancer diagnoses, which help guide treatment. In addition, it's very fast,

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we can do these sometimes as quickly as 10, 15 minutes.

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They're much less costly than surgery, there's less

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pain, there's minimal recovery time for most patients.

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And when we are able to make a diagnosis before surgery,

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it really optimizes oncologic management. And recently, at least at our

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institution, there's been a lot more neoadjuvant chemotherapy being performed.

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And so I'm curious to hear about whether that is happening at your

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institutions as well. So again, lots of different modalities to use,

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most commonly are ultrasound core biopsies. In general, they're more comfortable

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for patients and very fast to perform. So

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what we do is we perform the biopsy, send the tissues to the

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pathologist, and then coming back, we want to look at the diagnosis that

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the pathologist sends us and determine whether or not it is concordant,

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whether it sort of matches up with what we expected on the imaging

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findings. So when we're looking at the imaging, not only do we categorize

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it as suspicious with the BioEds 4 or 5, but we also have

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in our mind a differential diagnosis for whatever lesion it is,

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whether it's a mass or calcifications or an asymmetry, as to what that

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target lesion may or may not represent. So

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we may expect a cancer, and if the diagnosis is not a cancer,

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then it calls into question whether or not the results are concordant.

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So it's important to communicate these findings reliably both from the pathologist

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back to the radiologist and then both from the radiologist back to

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sometimes the referring physician, sometimes the patient, and to addend

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the report with management recommendations. And the documentation is really

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critical in this case. So we're not going to do this poll everywhere,

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but we're going to start looking at some of the cases.

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And the first case is a 41 year old woman who's having her

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baseline screening mammogram. As many of you may know, the American College

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of Radiology recommends screening to begin at age 40 for average risk women.

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In other countries, those recommendations may be different based on

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radiology societies and other medical societies in your countries.

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No other history for this patient. So this patient,

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just to give you a second to look at it, she has heterogeneously dense breast

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tissue. She has calcifications that are in the lower inner quadrant of the

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left breast. So she was called back for workup of those,

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and these are magnification views that were taken at that time.

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And some of these are loose and centered, suggesting that they're dermal

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calcifications, and other calcifications are more coarse heterogeneous.

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Coarse heterogeneous calcifications have a certain connotation. So the question

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is, what is the recommendation for those calcifications? Do we

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think that they're benign and return the patient to screening? Do we think

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they're probably benign and never come back in six months for follow up?