0:00

So in this case, we have a biopsy-proven

0:02

cancer in the left breast, right?

0:04

Let me pull up our MRI first.

0:07

And of course, right away we see our mass here,

0:10

and we can probably see our little clip located

0:12

almost centrally. But immediately, we see this

0:15

surrounding area of non-mass enhancement, right?

0:18

You could describe that as multiple

0:20

regions, maybe clumped, um, but certainly

0:23

looks suspicious and definitely

0:24

stands out from the other breast.

0:27

Um, this stuff here is just some

0:29

of the breast up against the

0:31

plate there.

0:32

So don't worry about that.

0:33

And then we do want to make a quick look

0:34

at some of the nodes, and they look sort

0:36

of okay so far, at least on this image.

0:40

So we'll pull up our post-contrast.

0:41

So, um, right.

0:45

So we've got a mass.

0:46

Um, probably some speculated

0:48

margins here, at least angular margins.

0:50

Um, so, irregular, say, uh, so this would

0:53

be an irregular mass with irregular margins.

0:56

Uh, But as we scroll through, we can

0:59

see additional areas of enhancement

1:00

that are extending anterior from the

1:02

mass, um, and also inferiorly, right?

1:05

So, and it goes quite a ways.

1:07

So when you're describing this, what I

1:09

would do is describe the mass and then

1:11

say there's additional areas of non-mass

1:13

enhancement, which extend whichever direction,

1:15

um, for the mass that you have.

1:17

Um, and then I think it's important

1:19

to give, um, if you either to give the

1:22

dimensions of the mass that you know is

1:23

already proven and then say, Additionally,

1:26

there's this area of mass enhancement,

1:27

which extends X, you know, millimeters in

1:31

whatever direction from your index lesion.

1:33

And I think this really helps your

1:34

surgeon identify the additional areas

1:37

that need to be addressed and whether

1:39

they need to consider additional biopsy

1:41

to be able to fully excise that area.

1:44

Looks like at this institution.

1:46

This is not mine, but they put a

1:47

little palpable marker, probably over

1:49

the primary palpable abnormality.

1:52

So we know that's nearby. If

1:54

you're wondering what that was.

1:58

Yeah.

1:58

So this is a sort of a good case of, um,

2:01

you know, extended disease, uh, larger than

2:03

you anticipated based on your prior imaging.

2:06

Um, and I like to say that in the impression,

2:08

I think it's important to say to your

2:10

referring providers that, uh, you have

2:12

this, you know, primary lesion, which was

2:14

measured at, let's say, two centimeters.

2:16

But now, based on the MRI, you believe

2:18

the extent of these is two centimeters.

2:19

You know, much larger than anticipated now,

2:21

measuring up to four centimeters or five

2:23

centimeters, whatever it is, so that they can

2:25

make a decision about what the best surgical

2:27

approach is or whether chemotherapy is needed.

2:31

I'm sorry, just just a

2:33

short, I mean quick question.

2:34

If you're going to biopsy that area,

2:38

the non-mass enhancement, would

2:39

you go for a part that's furthest

2:41

away from the index lesion, or yes?

2:45

Yes.

2:46

So you're always trying to balance:

2:48

Do you want to get the area that's furthest

2:50

away, right, to most accurately define

2:52

the extent of disease, right, to give the

2:54

greatest extent? But you also need to balance

2:58

that with: How likely can I get it right?

3:01

Uh, how confident am I going to be that that is

3:04

truly abnormal enhancement and not background?

3:07

And so I think in this case, it's pretty clear.

3:09

So I would choose, um, you know, if I

3:10

was going to do this by MRI, I might

3:12

try to choose this little focus

3:14

of enhancement here, right?

3:15

We know it's almost contiguous

3:17

with this non-mass enhancement as well.

3:19

And, um, you know, that would be

3:22

the most anterior, inferior extent.

3:26

Maybe you might go for these ones.

3:27

This is also a really nice one, right?

3:29

So somewhere in that region, that's where

3:30

I would be targeting for a MR biopsy.

3:33

I was going to do one.

3:35

Thank you.

3:36

I think this case, you could also

3:39

I know we talked about, um, you know,

3:41

masses being easier to see and larger

3:43

size, uh, in terms of targeted ultrasound.

3:46

This one you might consider it.

3:48

I mean, you have a nice, um, anatomic

3:50

marker in the biopsy-proven cancer.

3:52

And then you could say, okay, I'm going to

3:53

scan, you know, inferior and interior

3:56

from there and see if I could see this.

3:57

You might consider it.

3:59

I still think this would probably be

4:00

one that would be easier done by M.R.

4:03

R.

4:03

Um, but but I wouldn't fault anybody

4:06

if they said let's give it a shot with

4:07

ultrasound and see if we can find something.

4:11

Sometimes the question does arise of, let's

4:14

say you do an MR biopsy, um, or let's say, no,

4:18

sorry, let's say you do a targeted ultrasound,

4:20

you think you see something and you biopsy it,

4:23

but you're not real confident. You know, do

4:25

you ever go back and check? Um, there are, uh,

4:29

at our institution, we tend not to, right?

4:31

We tend to say, let's have a lower

4:34

threshold for doing an MRI-guided biopsy.

4:37

At our institution, MRIs and biopsies

4:40

are readily available, so that's

4:41

the easiest thing for us to do.

4:43

There are some institutions that do go

4:46

back and do a limited MRI exam to see

4:49

if you have indeed, um, biopsied the

4:53

area that you intended to on the MRI.

4:55

Um, you could look where the clip is

4:59

in relation to the non-mass enhancement

5:00

and check that out and check that out.

5:03

Those are sort of two approaches to doing that.