0:00

A 37-year-old.

0:02

History of recently

0:03

diagnosed left breast cancer.

0:04

Evaluation for extended disease.

0:08

So I don't remember if the case history,

0:10

if we gave any indication about how

0:12

large the left breast cancer was that

0:14

we've, uh, that has been biopsy-proven.

0:17

Um, uh, but, you know, we can tell right

0:21

away that this looks pretty extensive.

0:23

Right.

0:23

Um, again, a pretty large portion of the

0:26

breast, um, you might at least wonder about

0:29

these nodes and especially in relation to this

0:31

larger enhancement that we're seeing, but they

0:34

do look pretty symmetric with the other side.

0:36

So, um, you know, perhaps we'll let those go.

0:38

We'll have to see.

0:40

Um, The right side, I think, looks pretty good.

0:43

You maybe were wondering, might

0:45

wonder about this little area here.

0:47

Want to have a look at that specifically and

0:49

see, um, see how you feel about that one.

0:59

So let's get to the top here.

1:03

So again, already in this case,

1:04

um, you know, we can see some.

1:06

Uh, skin thickening again, right?

1:09

And I want to mention that as one

1:10

of our, um, acts, uh, not acts,

1:13

sorry, um, additional findings.

1:15

Um, and just focusing on the skin for the

1:18

moment, in this case, in comparison to

1:20

that other one, that was the inflammatory

1:22

cancer here, we do see some direct,

1:25

uh, enhancement within the skin, right?

1:27

That it looks like, uh, the area of enhancement

1:29

extends really to the skin surface here, maybe

1:31

a tiny, you know, mass within the skin here.

1:35

Um, and we can see that, uh, you know,

1:37

in multiple locations in reporting, I

1:40

would specifically mention that, that,

1:41

that there's some focal enhancement

1:43

within the skin at whatever clock face

1:45

position, 12 o'clock, if that's what it is.

1:47

Um, so within the breast, um, I would describe

1:52

this as multiple areas of non-mass enhancement.

1:56

I would.

1:57

Probably give this sort of the clock

1:59

face position and say multiple areas of

2:01

non-mass enhancement extending from,

2:04

you know, x location to x location, um,

2:08

uh, and then give a sense of the depth.

2:10

So from interior to middle depth,

2:12

and that should be pretty good

2:14

for your referring providers.

2:20

Generally, in all of these cases, too, I

2:23

think it's important to try to, um, determine

2:27

where you biopsied already and whether

2:31

you want to recommend additional biopsies.

2:34

Now, in this case, of course, with this

2:36

extensive area of enhancement, you would hope

2:39

that your surgical providers would be, um,

2:42

not considering, uh, breast conservation.

2:46

Uh, in our reporting, we will occasionally,

2:50

um, despite the fact that we really believe

2:53

that we wouldn't want a patient to have breast

2:55

conservation in this case, we might say,

2:57

you know, if there's consideration of breast

2:59

conservation, then here's what you need to do.

3:02

You know, you're going to have to

3:03

biopsy multiple additional areas

3:05

to define the extent of disease.

3:07

Now it's a little bit. You wouldn't

3:10

really expect that to be the case in this

3:12

particular case, but let's say you had a

3:14

larger area of non-mass enhancement and,

3:17

um, it would at least be theoretically

3:19

reasonable to do breast conservation.

3:21

You might want to guide your surgeons and

3:24

your other radiology colleagues for the next

3:26

step, saying, here's what I think would need

3:28

to be done in order to prove that there is,

3:31

uh, indeed disease in these other places.

3:34

And then that would help you

3:35

also plan your localization.

3:39

We do, I'm sure you get it too, um, have

3:42

patients that, um, you know, despite our

3:47

belief that they won't necessarily

3:49

be well served by breast conservation,

3:51

that they're highly motivated to do so.

3:53

And so we have, you know, sometimes been

3:56

in this business of, you know, defining,

4:00

definitively defining, um, the extent of disease

4:03

either for the patient or the surgical

4:06

provider to sort of prove that, you know,

4:08

even though based on the imaging, we think

4:10

it's highly likely this is additional disease.

4:13

Sometimes patients need that

4:14

verification that that is actually true.

4:17

Um, and we've also, um, done multiple

4:20

additional biopsies and sort of very

4:22

complex localizations to get this entire

4:24

area, um, because patients are very

4:27

motivated for, um, for breast conservation.

4:31

Um, that's, you know, a little bit of an aside,

4:33

but, um, it's all to say that, um, we will

4:37

occasionally put in that statement to report,

4:38

saying if it's being considered, then these

4:40

are the other things that you need to do.

4:42

Um, I don't think I would necessarily do it

4:43

in this case because it is quite extensive.

4:45

I think, you know, most surgeons could look

4:47

at this and say, "Oh, yes, this is not a

4:49

good idea to do breast conservation here."

4:51

Um, anyway, so multiple areas of non-mass

4:55

enhancement, um, extending into the looks like

4:59

periareolar skin, nipple, um, and of course

5:03

it's important to mention that, um, because if

5:06

the surgeon is considering mastectomy,

5:09

um, this patient would not be a good candidate

5:11

for nipple-sparing mastectomy, um, because

5:13

it looks like we have some direct invasion

5:16

into the nipple in this case.

5:19

Um, we would want to look up,

5:20

of course, into our nodes again.

5:22

Um, these are a little

5:23

bit harder to tell, right?

5:24

A bunch of smaller nodes.

5:27

Um, I'd say these probably, this

5:29

one's a little funny looking.

5:31

Looks like we did biopsy that one.

5:33

Um, uh, And so you'd want to at least mention

5:37

that you see a biopsy clip in that one.

5:39

I don't see any other nodes that

5:41

look particularly suspicious.

5:42

Of course, if you did see one, even if you'd

5:45

biopsied a node previously and you saw another

5:46

one that looked more suspicious,

5:49

maybe a rounded node without a hilum, you

5:51

could recommend repeat targeting of the

5:53

axilla, trying to find that one particular node

5:56

and potential subsequent biopsy from there.

6:00

Um, I think we had one area

6:02

in the other breast where we were

6:04

a bit curious. Um, looks like she

6:06

had something that I've seen

6:08

previously here on the right side.

6:11

Um, almost looks a little bit

6:13

like some of those dark

6:15

internal septations of a fibroadenoma.

6:18

Um, I don't remember or know if we have

6:20

pathology results from that side or not.

6:23

Um, it looks like she has some

6:26

ductal signal here.

6:28

I'm guessing that's probably also, um,

6:31

uh, true also on the non-contrast one.

6:34

So this would be proteinaceous debris

6:36

or something within the ducts.

6:38

Um, and we can confidently call that benign

6:40

if we see it on that pre-contrast series.

6:44

This little mass here, you could probably call

6:46

that, um, we'd have to look a little bit further

6:47

and perhaps look at something like kinetics

6:49

to help us determine whether we need to do

6:51

anything more about this, uh, this one here.

6:53

I had a quick question.

6:56

Just a quick question about the sternum.

6:58

Yeah.

6:58

Um, I think it was PA or

7:00

Image 90, that one there.

7:02

That little guy there?

7:03

Yeah, that guy there.

7:04

Yep.

7:06

So the sternal thing's, of course,

7:08

a little bit difficult, right?

7:10

Um, what I would do is try to look at RT two.

7:17

So let's pull that down.

7:19

Okay.

7:21

See if we can find that little thing.

7:24

A little bit has a little

7:25

bit of T2 signal there.

7:28

Um, the other thing we could do is

7:32

look at our, so it's a little easier

7:36

when you can actually link them together.

7:39

Um, you can, you can link them.

7:41

Oh, there we go.

7:41

There we go.

7:42

Um, right there.

7:44

So it does persist.

7:46

So, um, you know, of course it's always good

7:48

to think about, especially in a case like.

7:50

This about metastatic disease, right?

7:53

Um, we are a little bit limiting you in the

7:56

sense that we're giving you only the first

7:58

phase here, but this would be one that you

7:59

might want to look over multiple phases,

8:02

trying to show that that's like a angioma.

8:05

Um, and that would be my sort of primary guess.

8:08

If you had other prior studies,

8:09

you could try to figure it out.

8:10

Of course, if you had CT or

8:11

something, that would be helpful.

8:13

Um, in the absence of those things,

8:15

I think you could mention it.

8:17

Um, uh, you know, sometimes you could say,

8:21

well, I'm not really sure about it, but you

8:23

could get dedicated imaging, like a CT scan.

8:26

Uh, you could potentially look at if the

8:29

patient gets the subsequent bone scan.

8:31

Um, uh, Or if you were more worried about it,

8:38

you could say that it's, you know, possibly mets

8:40

and maybe you'll see those other things and,

8:41

um, they would have to deal with it

8:44

from, you know, either radiation perspective.

8:46

And of course, if you mentioned that, then

8:47

that I want to go looking for other moments to

8:49

make sure that that's not, um, not the case.

8:52

So I think it would be a

8:53

reasonable mention here.

8:54

Um, probably still hematoma, but, uh, yeah.

8:57

But it's a little bit difficult to tell.

9:00

Um, for ones that I have seen that are,

9:05

uh, true mets, I feel like they tend to

9:08

be more kind of rim enhancing, right?

9:11

Or like nodular sort of rim enhancing.

9:14

Um, not exactly looking like this,

9:18

um, with maybe even some enhancement

9:20

going out, you know, sort of beyond the

9:21

margins of the cortex or the bone.

9:24

Um, those are the kinds

9:25

of things that I look for.