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We are looking at our 47-year-old patient

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who had a recent diagnosis of right breast

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cancer, and it's, um, rapidly enlarging.

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It's, um, terrible looking, um, and, um,

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I'm going to switch over and just do the,

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I'm going to do the, um, dynamic sequences.

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So we'll start in this case.

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We're just going to start at the top.

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Um, in this case, we're going to talk

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about, uh, we're going to, we're going to

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emphasize local, regional, and venopathy.

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I know I've already said that already,

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but, um, and then this is an example

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where it would be really hard.

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It's just the way the, the way the

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MR, um, anatomically, and the patient

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has been positioned, but it would be

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hard to get above the pec minor here.

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To see these lymph nodes, so this

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is a nice example, it would be really

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difficult to see level 3 lymph nodes.

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Um, we do see, um, large, even though they're

0:54

enormous, they're all level 1 lymph nodes, which

0:57

is really surprising because this is her pec

0:59

minor and her pec major on the right side.

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She has a very large again, heterogeneous,

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irregular enhancing lymph node with

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actually, there is a susceptibility

1:12

artifact in it, and it's just they're huge.

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And there are a lot of them.

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And they're probably actually several

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lymph nodes that are matted as to whether

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we could distinguish for the surgeon.

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If there's,

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if there's 3 or less, or 4 to 9, or greater

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than 9, it's impossible in this patient.

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But as we come down, we're seeing

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that we're seeing a long string of

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matted, presumably matted lymph nodes,

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and then we're getting into this.

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Really, um, graphic example of

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rim enhancement, heterogeneous

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enhancement, and a really large tumor.

1:47

Um, she only has interestingly

1:50

level 1 lymphadenopathy.

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Uh, they're large and

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impressive, but it's only level 1 and

1:57

then the other thing that we wanted

1:58

to make sure that you knew about this.

2:00

This case is this direct extension.

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So she has direct extension to the skin.

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She has direct extension

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into the pectoral muscle.

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So there's no question.

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Um, this is her pectoral muscle, uh, here and,

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um, in, in terms of the chest, you can see

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the mass actually dipping into it and with

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some concomitant enhancement of the pec.

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Um, and then one final thing on the axial

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images, you can tell that there is diffuse

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skin thickening and skin enhancement that is

2:31

really nicely seen on the subtracted images.

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So altogether and rapidly enlarging

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again with erythematous breast as well.

2:39

So you put all those together and she

2:40

likely even has an inflammatory breast

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cancer component to her breast cancer.

2:46

Um, which is a certain type of breast cancer.

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Let me show you in the sagittal plane as well.

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I'm going to show you the normal breast

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sagittal plane, and you can see how nicely

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maintained the fascial plane is between the

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parenchyma and she's small, or at least her

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breasts are not necessarily small relative

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to her body habits, but she's a small person

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and you, you can see quite nicely that, um,

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that even though she is extremely dense, and

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there is a lot of enhancing parenchyma, that

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the, um, that the pec is, um, uh, remains,

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um, pristine, uh, with its striated muscle.

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And even though the parenchyma is sitting on

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it, there's no enhancement of the pec.

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And so that's the normal side.

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And in contrast, um, the, um,

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abnormal side shows very graphically.

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Um, the, um, extension and involvement

3:42

of the pectoral muscle and enhancement

3:45

of the pectoral muscle as well.

3:47

So this is pectoral invasion.

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This is not chest wall invasion.

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Remember, chest wall invasion

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requires involvement of the

3:56

musculature of the chest wall,

4:00

not the pectoral muscle. The pectoral muscle

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is considered part of the breast, part of

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the superficial chest structures, whereas

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the chest wall and specifically

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the intercostal muscles, the transversus

4:15

muscle... we're going to see an example of

4:17

that in just a moment. But that is this.

4:20

And then you can see again, the similarity

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between the lymph node enhancement

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and enlargement of her axillary lymph

4:29

nodes and her primary tumor.

4:33

Let's go back and look at her internal mammary.

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Let's just practice this.

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And I think this is a lovely example.

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And then I always, as,

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you know, apologize about.

4:45

Calling this, um, this patient a

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lovely or great example of anything,

4:51

because, of course, it's awful.

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But, um, of the recruitment of the lateral

4:57

internal mammary vessels, artery in

5:02

particular, and the vein that tumor is

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commanding and demanding, um, blood supply.

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So, but this is what a vessel looks like.

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And remember, this looks very different than the

5:13

internal mammary lymph nodes that we just saw.

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I mean, I, there, there was some method to how

5:17

we, to the madness of how we organized week 5,

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and even how I've organized our office hours.

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But so I just want to, this

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is, um, a continuous vessel.

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You're just tracing it down.

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You're tracing the artery down,

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asymmetric in size, right versus

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left, but that's because this.

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This, um, triple negative breast cancer, um, is,

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um, has recruited, has recruited vascularity.

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And then I, I know I spoke earlier

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about not being, um, not being misled

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by, uh, by a vessel that was exiting

5:49

and going, um, going into the breast.

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And this would be an example of

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one of those vessels where you can actually

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see the vessel going into the breast, internal

5:58

mammary artery branch going into the breast.

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So, but her internal mammary,

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um, uh, parasternal.

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Parasternal sites are normal,

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so there's no lymphadenopathy.

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So I just wanted to illustrate that and you've

6:14

got to go all the way up and all the way down.

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Remember we had that last case where

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I think probably some people just

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didn't see the inferior 1 because

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you just didn't go low enough.

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Truth be told.

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Um, so we're just continuing to scroll down.

6:26

Okay.

6:26

Any questions about any questions about that?

6:31

Um, so let's see, let me just make sure I

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made all the teaching points I wanted to.

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So case 3, uh, was locoregional lymph nodes.

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In this case, it was axillary.

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They weren't subtle, but

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they're all level 1 axillary.

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Um, the pectoral, um, muscle,

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um, enhancement slash invasion.

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And the inflammatory breast cancer component.

6:54

All of those things are, um, all of those

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things are, um, are stage three cancers,

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you know, once the patient has had, um,

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systemic staging and just negative, which

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hers was, um, then, uh, all of this backs

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back down to stage three cancer while the

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survival statistics are considerably lower.

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Uh, then stage 2 tumors, certainly, um, stage 3

7:19

cancer, um, survivors exist all over the world.

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And, um, certainly we have a, a large

7:26

cohort of them in, in my practice.