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So our next case is a 53 year old woman with a recent

0:04

diagnosis of left breast cancer with a metastatic lymph node.

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And the treatment team is considering neoadjuvant

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chemotherapy and we've been asked

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to assess the extent of disease.

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So here's our MIP for this patient and we can see this

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large enhancing heterogeneous mass in the posterior left

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breast and I think we can see part

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of a lymph node here as well.

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There's not that much else going on in the left breast

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or the right breast. Maybe a few foci here.

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And we'll take a closer look.

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So we'll pull in our T1 non-fat sat,

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and our first subtraction series.

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And just to show you,

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we can see that large lymph node in the axilla

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here on the T1 and post contrast series.

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And there's a second smaller,

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but still abnormal lymph node posteriorly,

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and then as we scroll down, we start to get into this large

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heterogeneous mass and there's a susceptibility artifact

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from a biopsy clip and it's in the center of the mass.

1:23

And she does have some background parenchymal enhancement, which is moderate.

1:30

There's not very much else going on, I think.

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These sequences are not exactly lining up,

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but

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this little mass here, laterally, on the left,

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was evaluated with ultrasound and I

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believe represented a lymph node,

1:49

an intramammary lymph node.

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So just looking at source images.

1:57

Again, pre contrast on the left, post contrast on the right.

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Really just seeing a few little foci,

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but nothing very suspicious and nothing worrisome

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on the other side either, so that's good.

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and then,

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We looked at internal mammary lymph nodes here.

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Just ran through that and there was nothing suspicious there.

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So really, her abnormal lymph node and known

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cancer have already been biopsied.

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This is a known cancer.

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There was no other suspicious finding in either breast

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so that we consider this to be a BI-RADS 6,

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known biopsy-proven malignancy.

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And the treatment team decided that the patient should have

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a neoadjuvant chemotherapy.

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So,

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in keeping with guidelines.

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We often will do an MRI after the neoadjuvant chemotherapy

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so I'm going to try and pull that up here and next.

3:09

So this is post chemotherapy for this patient.

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Here on the right side, pre chemotherapy on the left.

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You can see that

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she has some axillary lymph nodes.

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But they're all much smaller.

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I think this is the one that had previously been biopsied.

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Considerably smaller, although still a little bit prominent.

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And then in the left lateral breast,

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we can see this kind of line of non mass enhancement

3:56

with a susceptibility artifact from the biopsy clip, centrally.

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But that's all that's left of her

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large enhancing mass that we saw previously.

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So, not very much.

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And she went on to have a successful lumpectomy

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and axillary nodes surgery and is doing well.

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So that's another case of BI-RADS 6.

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So we would code this as BI-RADS 6 for

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the pre neoadjuvant chemotherapy

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situation and also in the post neoadjuvant chemotherapy

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situation, even though her mass has gone down to a very

4:38

small size or there's no evidence left of her mass,

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we would still code this as BI-RADS 6, unless

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she's had her definitive surgery.

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So, BI-RADS 6, pre and post neoadjuvant chemotherapy.