0:00

65-year-old presented from outside facility,

0:03

recently biopsied left axillary mass, and no

0:06

demonstrating grade 3 invasive ductal carcinoma,

0:08

and this is for evaluating extended disease.

0:12

Of course, in this case, if we have

0:13

something with biopsy-proven axillary

0:16

whatever, either node or mass.

0:19

Oops.

0:19

Oh, sorry about that.

0:21

Oops.

0:22

That's not going to help.

0:23

Um, let me pull that up again.

0:26

Um, so if you do have something that

0:28

is, uh, an axillary node, you do

0:33

want to, of course, go looking for that,

0:35

um, for something in the breast, right?

0:37

And the typical pathway, of course,

0:39

is to do a mammogram first, right?

0:40

If you can see something by mammogram

0:42

and you can do an ultrasound and biopsy

0:43

that way, that would be one approach.

0:45

That'd be great.

0:46

Um, but of course, if that imaging is negative,

0:49

then the recommendation typically would

0:52

be to go onto an MRI exam to try to

0:55

discover, um, you know, smaller areas that

0:58

were mammographically or sonographically cold.

1:02

Um, so let's see.

1:03

So in this case, this was left side.

1:06

So, you know, already in our MRI here

1:09

again, we can see this large, um,

1:11

axillary mass or large axillary node.

1:14

Um, you know, maybe something here as

1:16

well, and we'll have to determine whether

1:18

that's just, you know, benign-looking,

1:20

um, intramammary node or something else.

1:23

Um, and then if we rotate this just a

1:25

little bit to get this vessel out of the

1:26

way, we can see two little small areas

1:28

here in the left breast, which we'd want

1:32

to make sure that we interrogate further.

1:35

So let me pull down our seal again here.

1:42

So let's first go look up that,

1:44

uh, nodal area or direction.

1:48

Okay.

1:48

So that's sort of coming into view here.

1:50

It looks like a large, um, you know, level

1:52

one, uh, or, you know, maybe one slash two,

1:56

uh, node or conglomeration of nodes, um, uh,

2:01

any way to describe that is probably okay.

2:03

It looks like we're getting relatively

2:05

high here up into maybe level two as well.

2:07

Some of them look like they.

2:09

You know, either have potentially

2:11

some necrosis in there.

2:13

Um, but the other, um, important piece on

2:17

this case, um, is that we want to evaluate,

2:20

um, whether this thing is attached to the

2:23

pectoralis muscles or not, and that can be

2:25

difficult to do, especially in an area like

2:27

right here, where, um, there's, there's

2:30

you know, maybe not a definite fat plane.

2:33

Um, I think in this case, for the most

2:36

part, there is, there does maintain

2:38

a fat plane between the pectoralis

2:40

musculature and the nodal conglomeration.

2:43

Um, it can sometimes be helpful to

2:45

look at the sagittal, see if I can go

2:48

the right way here, um, to do that.

2:51

So, whoops, uh, so in this case,

2:53

here, we see a nice fat plane here

2:55

between, uh, pectoralis major.

2:58

Posteriorly, it's a little bit more difficult

3:00

to see, but, you know, maybe something in here.

3:03

It's a little hard to see where pec minor

3:05

is in this, in this satchel, but it is

3:10

something that you'd want to mention and, you

3:12

know, it's, it's not like it's gonna change

3:14

anything too much, but I think your surgical

3:17

providers would, um, really want to know

3:20

that information, whether they're going to be

3:22

having to dig into the pec a little bit, uh,

3:24

to get this thing out or whether it's something

3:25

that might come out a little more easily.

3:28

Um, so back to the breast, um, we do see these

3:33

tiny little irregular, uh, irregular masses

3:38

right next to each other, um, which are likely

3:40

the cause of, um, this nodal englaboration.

3:43

Of course, we'd want to verify that and, um,

3:45

Um, biopsy these things, so we could either

3:48

go to targeted ultrasound, look for it in

3:51

the breast, uh, that way, um, and if not seen

3:53

there, then move on to MRI-guided biopsy

3:56

to verify that that was truly the case or not.

4:00

Um, this node is difficult, um, you know,

4:03

there's perhaps a little fatty hilum there

4:05

that we can see if you look closely, probably

4:06

doesn't project real well on our shared screen,

4:09

but, um, But you would want to try to kind of

4:13

look like that, look at that a little closer.

4:15

You could also do an ultrasound there if

4:17

you wanted to get your best attempt at

4:19

imaging that and really look at the, uh,

4:22

the cortex that, uh, that would be a very

4:24

reasonable, uh, reasonable approach too.

4:26

Um, of course, if you are wondering about

4:29

that and you think that these masses look

4:30

pretty suspicious, which they do, um,

4:33

you know, whether that, um, node

4:35

is involved or not is a little bit, um,

4:38

it's not as important to figure that out.

4:40

If you prove there's something in the breast

4:42

and you already know that there's metastatic

4:44

axillary disease, then, you know, if there's

4:46

a kind of like an in-transit node, then

4:48

that's a little bit less important unless,

4:50

unless your surgical providers are going to

4:51

try to, you know, remove each of those things

4:54

separately, but that would be a bit difficult.

4:56

This was a case from my institution, and

4:58

I think it was a little bit surprising

5:00

to think that these tiny little things or

5:02

thing could cause that, I know, but that

5:04

was exactly how this patient presented.

5:07

And those were biopsy-proven.

5:10

Um, could I please ask about the

5:12

you did mention about the um, How

5:16

to interpret chest wall invasion?

5:18

Um, um, in this case, yes, it

5:22

did show a bit of a fat plane.

5:23

Is there something like, uh, this

5:26

much contact or these many centimeters

5:29

of contact that would increase the

5:30

chances of a possible invasion?

5:32

Or do we just have to go by whether the

5:34

enhancement is extending into that, um,

5:38

That either the chest wall or the pec.

5:40

Yeah.

5:40

Yeah.

5:41

I don't know of anything that

5:43

describes like, you know, how much

5:46

kind of potential contact there would

5:48

raise your risk of actual invasion.

5:51

Interesting idea, though.

5:53

So I would say that what most people do

5:55

is look at trying to identify, you know,

5:59

that fat plane between, excuse me, um,

6:03

the mass and the pectoralis or chest wall,

6:06

either way, it's sort of the same idea.

6:08

And in my mind, I put it into

6:09

three categories where either it's...

6:12

There's no evidence of invasion.

6:14

So like in this case, or in this image

6:16

here, right, we have a very nice fat plane.

6:18

You could say, yep, no evidence of invasion.

6:20

It's close by, but whatever, no invasion.

6:23

One, uh, the next level for

6:25

me is sort of, it abuts.

6:27

And then you could say, well, it possibly

6:29

invades or probably doesn't invade.

6:31

Um, if you think that it just happens to be that

6:33

the two areas are coming pretty close together.

6:36

Um, and then the other one is

6:39

definite invasion, right?

6:40

You can see that abnormal enhancement

6:42

within the muscle fibers in some way.

6:44

Um, then you can say, yes, um, there's this,

6:47

you know, nodal mass level one nodal mass that looks

6:50

like, or that has abnormal enhancement within

6:52

the musculature compatible with, you know,

6:54

pectoralis invasion or something like that.

6:56

Um, that's kind of how

6:59

I break it apart in my mind.

7:00

We do occasionally see cases where

7:01

that invasion or abutting, um, the

7:05

musculature can be quite focal.

7:07

Um, so, uh, I think it is worth mentioning and

7:12

not, um, even if the rest of it is definitely

7:16

not invading, it would be good to say, oh,

7:18

it's, you know, focally abuts it here at this

7:21

location or focally invades the muscle at

7:23

this, at this site, and that would be useful.

7:27

Were you able to see those

7:28

little masses on ultrasound?

7:31

Yes, I believe we were.

7:33

I believe we were.

7:34

It's been a while.

7:36

Thank you.

7:39

Yeah, in this case, you know I mentioned last

7:41

week I think camera if you're on or not but

7:43

you know the couple of couple sort of basic

7:45

sort of criteria that we use for determining

7:48

whether we should do targeted ultrasound, or

7:52

not, would be you're more likely to see it.

7:55

If, uh, it is a mass you're describing

7:57

rather than non-mass enhancement,

7:59

and usually 10, 10 millimeters.

8:00

So this would be a little bit less than

8:01

that, but, um, but given its location, you

8:04

know, relatively superficial, um, I think it

8:07

would be a good chance of, of seeing this on

8:08

ultrasound and would probably recommend that.

8:11

Of course, this is our particular institution.

8:14

We do have, um, pretty good availability

8:16

for doing, um, MRI guided biopsies.

8:19

Uh, and so we do leave it up to our interpreting

8:22

radiologist to determine whether they want

8:24

to go just straight to, uh, biopsy or not,

8:27

based on their assessment of how likely it

8:29

is that they're going to see it on ultrasound.

8:32

That may be very different

8:33

at other institutions.