Interactive Transcript
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So we often see patients for a follow-up
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of probably benign findings.
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So these are the BI-RADS 3 patients.
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And the rationale for BI-RADS 3 is that
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some findings are known to have a less
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than 2 percent likelihood of malignancy.
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So using BI-RADS 3 should decrease the number
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of biopsies for false-positive findings,
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while also maintaining sensitivity for
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detection of breast cancer, because we're
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following these patients more closely.
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The protocol for BI-RADS 3 follow-up is
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that we will perform a full diagnostic
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workup before assigning a BI-RADS 3 assessment.
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16 00:00:40,785 --> 00:00:43,785 So we don't do this from a screening mammogram.
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We have the patient come back,
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have the finding evaluated, and then
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assigned the BI-RADS 3 category.
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Then we follow up with diagnostic imaging
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at six months, 12 months, and 24 months,
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and the finding is categorized as
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BI-RADS 3 until it's stable for treatment,
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at least two years.
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If the finding is stable at that final
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24-month follow-up, then we'll change
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the assessment to BI-RADS 2 and then
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perform routine follow-up going forward.
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We want to be sure that we're reassessing
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the finding and the rest of the breast
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tissue at each of the follow-up exams.
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And it's important to try and figure out
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whether it's possible to downgrade this finding
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to BI-RADS 2 if it truly is benign or has
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resolved or whether it's necessary to upgrade
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to BI-RADS 4 and actually biopsy the area.
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So for follow-up at six months,
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this is the Hopkins protocol.
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If it's a mass, if it's well seen on
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ultrasound, then we'll do ultrasound
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only at the six-month follow-up.
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There's no need to do the mammogram.
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If the mass was only seen on mammography, then we
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would do a unilateral full CC and MLO views,
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and we wouldn't necessarily repeat an ultrasound if
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it didn't show anything on the previous workup.
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For asymmetries, we'll do a unilateral
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mammogram, full CC and MLO views, and for
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calcifications, we'll do full CC and MLO views,
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unilateral, and then magnification views of the
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calcifications in the CC and lateral projection.
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If we're coming up to the 12 or 24
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month follow-up, if it's a young person,
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where we're following a mass seen on
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ultrasound, we'll only do ultrasound.
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Um, so we'll do ultrasound
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at six, 12, and 24 months.
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If the patient is age-appropriate for
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screening, then we'll do a bilateral
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mammogram at the 12 and 24-month follow-up
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because they would need to have that anyway.
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So CC and MLO views of both breasts and then
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ultrasound of the mass or the ultrasound finding.
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For asymmetry, we would do
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bilateral CC and MLO views.
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Um, so we're following the asymmetry and
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screening the rest of the breast tissue.
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And then for follow-up of calcifications,
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we would do the bilateral CC and MLO views
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as well as magnification views of the
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area of calcifications in CC and lateral.
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So there are only a few findings on
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mammography that are eligible for BI-RADS
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Category 3, and that is a solitary group
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of round or punctate calcifications.
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Non-calcified circumscribed solitary
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mass and a focal asymmetry without
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calcification or distortion.
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And really those things should be areas that
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we're seeing on a baseline screening mammogram.
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And there is room, you know, the BI-RADS atlas
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does give room for radiologist discretion,
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if there's something that you feel in
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your estimation is, um, a probably benign
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finding and could be categorized as such.
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You could use BI-RADS 3 for that finding as well.
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And some of the things that I think really
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fit nicely into that are calcifications
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that are likely to be early fat necrosis
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and calcifications that are likely
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to be early vascular calcifications.
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So some things we, we have an idea
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that these are going to be benign.
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And we don't need to biopsy
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them or in the case of
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early arterial calcifications,
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we really don't want to biopsy them.
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On ultrasound, um, BI-RADS 3 findings include
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masses with an oval shape, circumscribed
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margin, parallel orientation, hypoechoic
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echo texture, and no posterior features
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or posterior acoustic enhancement.
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And examples of this would be a classic
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fibroadenoma, a solitary complicated
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cyst, or clustered microcysts.
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And there has been some evolution in
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thinking about clustered microcysts.
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Um, these probably will be
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considered by Red's team
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to in the future.
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I mean, certainly if there are multiple
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groups, we would consider them by reds too.
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But particularly in an older woman, post-
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menopausal woman not on hormone therapy.
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If we have a solitary clustered microcysts,
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we would probably still give that a BI-RADS 3
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follow-up designation.
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And then, um, suspected fat necrosis or hematoma
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may be followed in a shorter time interval because
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evolution of the finding or resolution is likely.
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So we might follow that at four to eight
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weeks, or maybe even three months, um,
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something shorter than the six-month follow-up.
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So when would we downgrade to BI-RADS 2?
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So if we have a mass or complicated
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cyst and it goes away completely,
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You know, we can't find it anymore.
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That's it.
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That should be a BI-RADS 2.
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And I think also if a mass or complicated cyst
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really decreases a lot in size, it's unlikely
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to be a breast cancer calcifications that are
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clearly milk of calcium on magnification views.
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Maybe it wasn't so obvious on the on the previous
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exam, but now it is, that could be downgraded.
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Um, if the calcifications are definitely
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vascular, or the grouped calcifications form
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a circle consistent with calcification in
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the wall of an oil cyst, those could all be
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things that could be downgraded to BI-RADS 2.
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When do we upgrade to BI-RADS 4?
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Well, you know, if we're following a
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mass and there's a significant increase
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in size, I'd say more than a percentage.
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You know, more than a few millimeters,
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we would upgrade to BI-RADS 4 if there's
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development of a more suspicious feature.
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For example, if we're following a circumscribed
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mass, and then, um, you know, when we follow
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up one part of the mass looks more irregular
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or has irregular margins, we might, uh, upgrade
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to BI-RADS 4 in that situation, or following
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a group of calcifications, but the number of
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calcifications increases significantly as we're
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following, um, We may recommend biopsy of that.
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Um, and then there's also the issue that
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the rest of the breast tissue, um, is also
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being evaluated when we do these follow-ups.
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So a different suspicious finding may be noted.
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And that might require a BI-RADS 4 designation.
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