0:00

65-year-old female recently diagnosed

0:03

left breast invasive lobular carcinoma.

0:06

Just looking quickly here, um, you know,

0:09

we can see some areas of asymmetry, um,

0:12

you know, probably some distortion in

0:14

there and a few associated either coarse

0:16

heterogeneous or morphic calcifications.

0:19

Um, she did go on to ultrasound, um, to

0:24

better define that and say two o'clock looks

0:28

like we see kind of these heterogeneous

0:31

areas maybe this is a bit more focal

0:33

mass here, uh, these hypoechoic areas

0:36

multiple, multiple of them at that location.

0:42

You know, this, of course, we know

0:44

it's invasive lobular based on

0:46

the, um, history of our MRI exam.

0:50

But, you know, this would be a very

0:51

good look for that, uh, even in terms

0:54

of the mammogram and ultrasound, right?

0:55

These sort of big hypoechoic

0:56

areas, multiple of them.

0:58

Um, um, and, you know, not

1:05

more liberal with the use of MR, uh, in

1:08

cases of lobular carcinomas.

1:11

So that's what we got.

1:14

And so, um, you know, despite the fact

1:19

30 00:01:21,620 --> 00:01:24,550 that we biopsied only, I think, uh,

1:24

this site, I think it was a single site.

1:26

Um, this was my case from a number of years

1:27

ago, but I can't remember exactly what we did.

1:30

Um, uh, that, um, That we see quite an

1:35

area larger area of non-mass enhancement

1:38

in the left breast looks like extending

1:40

from anterior to posterior depth.

1:42

And of course, we've got a better

1:42

sense of, you know, where that is.

1:44

Cranial caudal just a moment but it

1:46

looks like, you know, pretty extensive

1:48

in that direction as well too.

1:52

I don't see any nodes right away

1:53

here that look too worrisome.

1:56

So we'll go on to that Excel.

1:57

So again, multiple areas

1:59

of non-mass enhancement.

2:02

That's always hard to tell clips on this one but

2:14

I think it would be reasonable to

2:15

either call these multiple masses,

2:16

multiple areas of non-mass enhancement.

2:18

Probably doesn't really matter in the end.

2:19

Or you could say one primary mass, if

2:20

that was about your biopsy, then there's

2:22

some surrounding non-mass enhancement.

2:24

Those are all typical ways of doing that.

2:26

Um, looks like we're in the mostly upper

2:30

and upper outer left breast, kind of

2:32

extending down to the level of the nipple.

2:34

There's some enhancement here extending

2:35

towards the base of the nipple.

2:37

Um, doesn't look like to me that

2:39

really gets into the nipple, although

2:40

maybe it gets really close there.

2:44

Um, and so that's probably how I'd describe that.

2:48

67 00:02:51,339 --> 00:02:53,820 Um, almost looks like some clustered

2:53

ring kind of stuff too on this one.

2:55

Um, but you would measure something

3:04

a couple normal-looking nodes there, level one.

3:09

The reason that we brought this case, I

3:12

think, is interesting is that especially in

3:14

these invasive lobular carcinomas, it's not

3:16

uncommon for us to provide an extent, an

3:20

estimated extent of disease or measurement

3:22

based on the mammogram and ultrasound.

3:24

Um, but then we therefore go on to

3:27

MR, and we see the extent of these

3:29

much greater, uh, based on the MRI.

3:31

Um, and I think this is an important point, um,

3:40

know, you have biopsy-proven, uh, malignancy in

3:44

the left breast at this position, um, measuring

3:47

up to whatever, um, centimeters or millimeters.

3:52

Um, and I usually include a phrase,

3:54

something like, you know, much larger

3:56

than the extent appreciated on

3:59

mammography and ultrasound.

4:00

And I think that's helpful, um, for

4:02

your surgeons to know, look, this

4:04

is not just this one area, right?

4:06

This is not just two centimeters of the

4:08

disease, this is six centimeters of disease.

4:11

Um, and that's a very important force for them

4:14

planning their surgical approach and considering

4:16

a question of neoadjuvant chemotherapy.

4:18

Um, and so I think it is very helpful.

4:21

To specifically mention that kind of thing.

4:25

Um, so anyway, this case was just,

4:26

um, a good demonstration of that.

4:28

Um, and of course we see this as you

4:30

all probably know, um, not uncommonly

4:32

in the invasive lobular carcinomas.

4:38

So any questions either about that case or other

4:41

general things coming up that are things you've

4:44

seen in practice and you're wondering about.

4:45

Can I just ask a general question, please.

4:50

Um, so, and when we interpret, um, um.

4:56

Again, a little tiny foresight

4:59

that may or may not be significant.

5:00

One of the points that we discussed last

5:02

time was to see if they are bright on the T2.

5:06

Um, but if they're bright on the T2 and you

5:11

tend to not give them that much importance,

5:13

but if they're showing up on the subtraction

5:15

images as um, even though they're bright and

5:18

teeter, they are enhancing as well.

5:21

Um, would you, um, then again, as you

5:25

mentioned, go by instinct and morphology and,

5:28

uh, relevance to the case, uh, to interpret?

5:31

Yes.

5:32

And I think multiplicity, right?

5:34

So the other thing that I always tell our

5:36

trainees is that if you're looking at areas,

5:39

uh, let's say that you think it's a small

5:41

mass or some area focal non-mass enhancement

5:43

and you're thinking about, you know, making

5:45

this decision to biopsy or not, right?

5:47

But you're suspicious that it

5:48

might be background enhancement.

5:50

As you're looking through that case, if

5:51

you are finding, you know, multiple things

5:55

that are starting to look like that.

5:56

So all of a sudden you're saying, well, if I'm

5:57

going to biopsy this one, then this other one

5:59

looks suspicious too, and that's more anterior.

6:01

Maybe I should biopsy that too.

6:02

If you're starting to get up into like two

6:04

or three or four things that would at least

6:05

be candidates for biopsy, I would say you

6:08

probably want to start thinking, okay, maybe

6:10

this is really just background enhancement

6:11

and do I really need to biopsy this or

6:14

maybe I'm going to choose just the one that I

6:15

think is the biggest one or has most suspicious

6:18

features or something like that, but I'd say,

6:21

I mean, I said before that, I think that is,

6:23

um, one of the most difficult things, right.

6:26

Is making that decision on

6:28

background and practical enhancement.

6:29

Um, it's, of course, something

6:30

that we all confront all the time.

6:33

And, um.

6:35

You know, it's not uncommon for us

6:37

to share cases of muscular and say,

6:39

look, I think this is just background.

6:41

What do you think?

6:42

I'm not sure it looks different from before.

6:43

It looks bigger, bigger from before.

6:45

What to do?

6:46

Um, you know, and I think that's when we

6:48

start to put other things into context, right?

6:50

So, uh, are you looking at

6:52

a case with known cancer?

6:53

Are you looking at a

6:54

patient who's BRCA positive?

6:56

Um, is there some other thing that

7:00

you're trying to consider, um, that

7:02

might raise your index of suspicion?

7:07

Um, the reason I asked is in this particular

7:09

case because of the higher percentage

7:12

of lobular cancers being bilateral.

7:15

Um, in this particular case, it just went

7:19

past one little area on the contralateral,

7:23

uh, yeah, there, and just posterior as

7:25

well, which are actually showing up on the,

7:28

yeah, that one, even though it's, yeah.

7:31

Uh, by morphology, it looks really insignificant.

7:33

Yes.

7:33

And they are bright on T2.

7:35

Right.

7:35

Uh, but they show up on this.

7:37

And on the subsequent set of images,

7:39

which show the CAD also, it shows up.

7:41

Mm-Hmm.

7:41

Mm-Hmm.

7:42

Um, when you have a higher index of suspicion

7:45

in a case of invasive lobular cancer.

7:47

Yeah.

7:47

Uh, would it be reasonable to

7:49

keep this on close follow-up?

7:51

Um, yes.

7:51

Since it's too, it may not be too significant.

7:54

Yes.

7:54

But you don't wanna miss something.

7:55

Right.

7:56

The, the only caveat to that I

7:57

would say is that, you know, in

7:59

general, when you're looking at

8:01

a case that is for extended disease.

8:03

Um, it is not, uh, appropriate, I would

8:08

say, to choose VIRADS3 and keep an eye on

8:11

something, um, because you sort of need to make

8:14

a decision about just calling it benign and

8:18

being done or going ahead and doing the biopsy.

8:20

And part of that is like

8:21

a logistical thing, right?

8:23

Because if you're, if you're considering

8:25

something and you think it warrants a

8:26

biopsy, then what you're saying is

8:29

that you believe there's a reasonable

8:32

chance that that's cancer.

8:34

And if that's true, then that moves the patient

8:38

from having one, you know, single-sided breast

8:41

cancer to then having a bilateral breast cancer.

8:44

And that may be really significantly

8:47

change, of course, their operative

8:50

plan, needing to excise both sides.

8:53

Um, but then also the patient may decide that

8:55

they're sort of done with, you know, um,

8:58

and they really want to have mastectomy.

9:00

So I feel like what we used to tell our

9:03

trainees is that when you're looking

9:05

at the ascending extent of disease,

9:06

you really need to come down on either

9:08

side of that and not choose by urgency.

9:10

The other problem that arises is

9:12

let's say you decide to call something

9:15

about VIRADS3 and follow it up.

9:17

Patient gets neoadjuvant chemotherapy.

9:19

The thing disappears.

9:20

Now you don't know really

9:22

if it's disappeared because

9:23

it responded to chemotherapy or does

9:26

happen to be a different phase of their

9:28

menstrual cycle or something, and it

9:29

disappeared because of that, right?

9:30

And then you're kind of, there's

9:32

always this question of whether that

9:34

was something real or not, and whether

9:35

it's something you need to address.

9:37

So we tend to suggest that in the setting

9:39

of a synchronous disease, we discourage

9:41

the use of VIRADS 3. Um, because

9:43

we need to be more definitive about

9:45

whether the disease is there or not.

9:46

So in this case, if you said,

9:48

look, I think that that

9:50

this little area here warrants a 5c, I would

9:53

just call it a 4, and I wouldn't follow it.