Hello, everyone. Thank you for being here at this time. Well, I'm going to start introducing myself for this lecture. I'm Silvia Pereira-Rodrigo. I'm the head of breast imaging department in MD Anderson Cancer Center in Madrid, and I'm going to talk about challenging cases in the screening setting in this session. So first of all, for me, the most challenging aspect was to find consensus in the different guidelines in the different areas of the world. So I have tried to summarize the different guidelines and some of them in different areas, and I'm going to start talking about the average risk because there is pretty much consensus in this area. And I'm going to start with this group of patients that is about 75% from 80% of the population. And it has been established that mammography is the test of choice in these patients because it's able to decrease the mortality rate up to 50% in some papers. So it's able to detect earliest stages and no negative cancers. And it's not only a matter of living more, but also of living better with improvement of the quality of life, detecting earliest the cancers and improving the comorbidity and having less aggressive treatments. It's true that it has some limitations also, like for example, the false positive results with record rates or benign biopsies. And in some cases, in some group of populations, especially in the cases of dense breast or other patients with personal history of breast cancer, the mammography has some limitations regarding the sensitivity that can be reduced by half percent of the cases or up to 60% of the cases. So in general, we can summarize in this paper also that the screening guidelines around the world can be a consensus in this setting of the group of age in patients that are from 50 to 75 years old. The recommended screening is mammography with a biannual interval year. But in the group of 40 to 49 years old, there is no pretty much consensus in this group. And some papers recommend and some guidelines recommend the use of mammography annual or biannual interval. The exception is China, where the ultrasound is the test of choice for doing this screening. What to say, I want to mention about the AI, that it's very important because it's not only able. There are some papers that compare the accuracy of the double reading versus triple reading versus AI alone and AI with one reader. And they conclude that the sensitivity of all of them can be similar with better cancer detection rates in the case of the combination of one reader and AI. But it's not only useful because of the ability of detection of their findings, but also because mammograms can be sorted and categorized based on the level of suspicion, decreasing the time of reading up to 75%. This is a case courtesy of Dr. Sara Romero from Hospital Universitario de la Sofía from Cordoba, Spain, that they are using the AI as supplement or complement to the mammography. And in this case, all the mammograms are sent to the AI and are classified according to the suspicious level. So in this case, this corresponded to a dense breast, a young patient. And if I ask you, what can you observe or what images can you see in the mammogram, most of them would conclude that it's a bi-race 2. But the truth is that the system categorized this patient as with an elevated risk and marked two areas of suspicious that in the diagnostic setting corresponded to three, in this case, two or three nodules with contrast-enhanced mammography that was performed later. And the correlation with the MRI findings was perfect. So there was a multifocal invasive ductal carcinoma luminal A. So it's very important to know and to trust in the AI in this process because it can decrease the time of reading. And for example, in our countries, it's a very important problem because we don't have enough breast specialized radiologists. So now I'm going to move to the next group right in the opposite side of the spectrum, that is patients with high risk of breast carcinoma. It's considered that about 5% to 10% of the population can be included in this group. And their lifetime risk of having a breast carcinoma is higher than 20%. It's pretty much consensus in this group also. And then it's also been shown that the mammogram is not enough alone. So in these cases, most of guidelines recommend another supplemental screening. And some different tests have been highlighted for its utility as, for example, tomosynthesis that has been shown that increase the cancer detection rates and decrease the record rates with a recommendation of grade 1 in CCM guidance, especially the synthetic view. Also, the ultrasound and automated breast ultrasound that is able to detect early stages of invasive breast cancers. But however, it has false positive findings also, false positive results. It's very important to highlight also the functional tests like, for example, MRI and contrast-enhanced mammography and molecular breast imaging with the problem of the radiation exposure to the whole body. But it has been mentioned also in some guidelines. So it's important to determine who may be considered in this group. In general, we can identify three groups of patients inside this group of high risk. All of them are going to have a lifetime risk higher than 20%. And there is pretty much consensus that the best option is to combine or combination the mammography with another functional test. Many of the guidelines talk about the combination with MRI and then with an interval test that is going to be performed annually. I have to say that the family history, the initiation age, is going to vary depending on the group. And in the case of family history, they're going to recommend to start at the age of 40 or 5 to 10 years prior to when the youngest family member was diagnosed. In the case of radiotherapy over the breast before 30 years old, it's recommended to start eight years after radiotherapy exposure, radiation exposure. In the case of genetic predisposition, it's recommended to start at the age of 30. So in general, mammogram together with MRI with annual interval. The difference, as I have told you, is that they don't recommend to start this test before age 30, usually for mammogram or 25. And in the case of MRI, 25 or 20 years old. And inside the group of genetic predisposition, there are some differences depending on the genetic mutation. Because most of us know very well, pretty well, the mutations BRCA1 and BRCA2, and that there implies a very high risk of having a breast carcinoma. But it's also there are other conditions, as for example, lymphomaniac syndrome, where the risk is very high. And then the initiation age in these cases for MRI is 25 or even 20 years old for lymphomaniac syndrome. In other conditions, in other genetic mutations, the interval test is also annual, combination with MRI and mammogram. But you can delay the initiation of mammogram if you combine the MRI, and then you can delay the initiation of mammogram starting at 40 in some cases. So this is the summarize of all this group of patients, family history, genetic predisposition, and history of radiation therapy. And then I wanted to show you one case of a patient with 35 years old and family history of breast and thyroid cancer. Additionally, this patient had a very tense breast, and she was performing mammogram and follow-up also with MRI. And in this year, the MRI showed what at that moment was interpreted as an asymmetrical parenchymal background, parenchymal enhancement. And then a virus tree was concluded. The truth is that this patient was living in another city, and then she didn't came from the follow-up at six months. And then the next year, when we performed the follow-up, there were some pleomorphic group calcifications, virus 4C, in upper outer quadrant of that breast that were not present in the prior mammogram. And then when we performed the MRI at that time, there was a non-mass enhancement with segmental distribution in upper outer quadrant, but also involved the lower outer quadrant. So in this case, one year later, the involvement was very extensive, and then this area was present the prior year. And it was not an asymmetrical background parenchymal enhancement. It was a non-mass enhancement that was pathological. So in this case, we performed the targeted ultrasound. And finally, the diagnosis was invasive ductal carcinoma, HER2 positive with multifocal and multicentric involvement, and also axillary and internal mammary lymph node positives. So then the conclusion is that we don't have to perform only MRI or mammogram. It's very important to combine all the techniques we are performing. And for that reason, we are combining mammogram and MRI in this group of patients. After that, the patient was diagnosed with BRCA1 mutation. Now I'm going to move on then intermediate group, the group that is in the middle of nowhere, because in this group, it's true that the consensus is very low, and the different guidelines are not, there is no agreement in the recommendations. It's true that they are considered a group with a risk that goes from 15% to 20% lifetime risk of having a BRCA sinoma. And we can include personal history of BRCA sinoma, high-risk lesions, and dense breast patients. The truth is that most of the guidelines recommend mammography and consider another option, like for example, functional tests like MRI or contrast health mammography and ultrasound, but with a shared decision making. And there is pretty consensus about interval tests that should be annual. The truth is that if we consider every condition, the personal history of breast cancer when there are other conditions, like for example, having the breast cancer before 50 years old or dense breast, it says that the real risk is higher than 20%. So in these cases, additional MRI increases the sensitivity of mammogram because the mammogram can decrease the sensitivity up to 50%. So when you diagnose a BRCA2 on a mammogram in a patient operated of breast cancer sinoma, the probability of being right is about one of every two cases because of the scarring, the distortion, and the fat necrosis. So it's very important to combine with other tests. In the cases of high-risk lesions, it has been shown that we are going to be able to increase the interval detection rates in these patients and also higher grades invasive cancers. So it's very important to associate the mammography with other tests, especially in the cases of atypical epithelial atypia, lobular carcinoma in situ, or atypical hyperplasia, typical lobular hyperplasia. So in all those patients, the sensitivity of mammography is pretty much lower than combination of mammography with another test. And in the case of dense breast, it has been shown that the dense breast is about 50% of the population, and the risk of having a breast carcinoma can be up to six times higher in this group of patients, being also higher in the contrateral breast. And it has been determined that the risk of having an interval cancer is also higher. So there are multiple studies, like for example, dense trial or a green trial, that has been shown that the combination of mammography with MRI can be very useful. So this is a patient with 40 years old that on a screen mammography, there was a distortion and the corneal biopsy came back with a result of B3 lesion. In our hospital, we are performing the follow-up of these patients with MRI and also with excision of this lesion with vacuum-assisted excision, and we are not sending to the surgery room. So this patient here, there was the distortion in the superior quadrants of the left breast. And then with ABUS and ultrasound, there was a very well-depicted distortion in this area, and we performed the MRI. With this MRI, previous to the vacuum-assisted excision, we could rule out also other pathologies, other areas of enhancement, and then a not well-defined nodule, a little bit speculated, was determined in this area and even the distortion. So then we performed the vacuum-assisted excision, and the result came back again with lesion. We always deploy the marker, and then we perform a mammogram after the procedure, showing that the distortion had disappeared and the marker is in the right position. In this case, we usually deploy a hydrogen marker because the correlation with the other test is much better. Then after that, this patient has been followed up with an MRI with annual interval, and the patient is perfect. This is another patient with 45 years old with a personal history of breast carcinoma with surgery in 2018. This is one of the most complex cases I have found because the truth is that in one of the MRI, in the follow-up, there was a small nodule in the post-surgical area, but the problem is the targeted ultrasound only showed a scar tissue and bad transmission area and was completely negative for this nodule. So we tried to perform an MRI-guided biopsy with a benign result. The problem is that the area was very close to the pectoralis muscle, to the chest wall, and then it was a little bit complicated, and we had to deploy two markers, with trial marker and X-shaped marker, because we had some problems during the biopsy, in the delivery of the marker. So, in fact, we performed after that the biopsy, the mammogram, and then here was the X-shaped coil, and here was the trial marker that was displaced to the lateral area, and this was the MRI of the follow-up, and it seemed that there was a void signal in this area, and the enhancement was even smaller than the previous MRI. In the next follow-up, the problem was the nodule seemed to be a little bit higher. We continued with a mammogram that was negative, ultrasound negative, but on MRI it seemed a little bit bigger, and then a virus 4 was determined. We tried to do the corneal biopsy under ultrasound guidance, but the result was only fibrosis, and we didn't deploy this time a marker, because we considered that the first marker with X-shape was in the right position. The problem is that in the next follow-up, again, virus 4, because the lesion seemed to be even a little bit bigger, and then we decided to do a correlation with the tool clip that was displaced, but going medially, we tried to identify a different area, and then we deployed a hydrogel clip. We did again perform an MRI, and then this time the marker was exactly in this area, because the X-shape marker was not visible on MRI, and the tool marker was displaced, so this was the only marker that was completely visible on MRI and was right in the upper side of the lesion, as you can see here. Then we went again to the ultrasound, I performed a corneal biopsy, this time under ultrasound guidance, and the result was invasive ductal carcinoma. So we have to combine the three techniques. The MRI, for us, is much better than the other techniques, especially in the follow-up of the operated patients, but the problem is that when you see a finding, you have to be able to biopsy that finding, and sometimes it's not easy because the MRI can see much more, but it's not always easy to do the biopsy. So in this case, the curious part is that the hydrogen marker was right beside of the X-shaped coil that was deployed at the beginning, so both biopsies were very close, but the MRI continued being suspicious, and for that reason we continued and insisted on that. So in summary, it's very important to know who patients may be considered in every group, because we have to be able to determine the risk group of patients, because the follow-up has to be different. Additionally, it's very important to know when to continue, like in the last case I showed to you. It's very important to know when a test is suspicious or a finding is suspicious in one test, and when you have to continue and to do the diagnostic process in a short time after the screening test. And for last, it's very important to do a good correlation between the different techniques. We are working in a multimodality and multidisciplinary setting, so all of these considerations have to be kept in mind. So thank you. Good afternoon. I'm Beatriz Adrada. I'm a professor of radiology at MD Anderson Cancer Center in Houston, Texas, and my topic is diagnostic patients and challenging evaluations. So the first case is a 67-year-old woman with history of lymphoma presenting with an abnormal finding on chest CT. We have a 0.9-centimeter mass in the left breast. A diagnostic mammogram and ultrasound was recommended, and we can see that there is an irregular mass in the upper inner quadrant. An ultrasound is a hyperechoic mass with angular margins and internal vascularity. The ultrasound got a corneal biopsy was performed, and it shows invasive total carcinoma luminal B. The patient underwent some mental mastectomy. The invasive component measures one centimeter. There was no definitive lymphovascular invasion identified, and there was no metastasis to the lymph nodes. The patient was treated only with endocrine therapy. No radiation was recommended due to the small size of the cancer. With this patient, they tried several lines of endocrine therapy, but she couldn't tolerate any of them due to the side effects. So we have 2019-2020 CC and MLO views, and you can see in 2020, she feels a pulpal abnormality. And at the area of our marker, which is our marker is a triangle, we can see that there is an irregular mass. Here we have it. This is 2019-2020, and you can have, you can see here, a mass which is irregular. Ultrasound was recommended, and we can see a hyperechoic irregular mass at the superficial aspect of the 12 o'clock region. There was not only one mass, but there was another smaller mass in the hypodermis that is extending into the dermis. We did an ultrasound, got a core biopsy. We placed two marker clips, and the pathology was invasive daughter carcinoma luminal B. At this time, the patient was treated with cemental mastectomy and radiation. So that was 2020-2021, and then let's go to 2022 in the right breast. So we have 2019-2022, and in 2022, she has a focal asymmetry. Ultrasound was negative, and we decided to do tomogyrid biopsy, came back as a DCIS. The patient underwent cemental mastectomy followed by radiation. Okay, let's go to the following year, December 2023. Patient is reporting low breast swelling for more than a month. We have here 2022. Here is the surgical scar with a second cemental mastectomy, March 2023 and December 2023. I don't know if you see, but there is a kind of subtle increased density of the surgical scar. Ultrasound was performed, and we only see post-surgical changes. An MRI was recommended, and this is the axial T1 post-contrast. And then I'm showing you the axial T1 without contrast. This is the axial T1 post-contrast at the surgical scar and a little bit immediately inferior. This is the MIB reconstruction. So the differential diagnosis is between fat necrosis and recurring scar, recurring cancer. So can you show your hands and to see who thinks it's fat necrosis? How about recurring cancer? Okay, so I guess we have like a kind of half and a half. And given her history of multiple contralateral breast cancer and second recurrence, we decided to do an MRI-guided biopsy, and we target the kind of clump enhancement that was here at the posterior region of the scar and came back as a recurring invasive ductal carcinoma. So let's talk about breast cancer recurrence. The risk for local regional recurrence is between 5 to 15 percent of the cases treated with breast conservation surgery and radiotherapy. The risk for contralateral cancer is between 5 to 10 percent. The big incident for recurrence is between two to six years after treatment. Luminal cancer, we know that they have better prognosis and survival than the triple negative and HER2 positive, and the endocrine therapy plays a big role in the treatment of this patient because it decreased the risk of local regional recurrence, distant recurrence, and contralateral cancer. We have to carefully look for this at the surgical side for any sort of changes like asymmetries, new or increasing calcifications. The post-surgical scar should be stable or become less conspicuous and less dense over time, and as in this case, occasionally tumor may engulf the surrounding fat as they grow. To be honest with you, I was thinking that it was fine necrosis, but it was a little bit nodular, so that's where we decided to do an MRR-guided biopsy. Let's go with our second case, unknown primary. 84-year-old woman with recent skin biopsy that showed malignancy, febrile breast origin. That's the CC, MLO view. I'm very generous. I'm gonna give you the tomosynthesis view. Where is the abnormality? In the right breast or in the left breast? Who says right breast? No one? Left breast? Oh, there are a few people who say right breast. Okay. So the abnormality was in the right breast. I'm bringing the previous mammograms dating back to 2015, and if you notice, there is kind of subtle increased density, like there is an asymmetry here in the superior region of the right breast. Ultrasound was negative, so we recommend a breast MRI, and there is some skin thickening with a mild non-mass enhancement. The question is, which modality should be selected to perform the biopsy? We usually choose the modality that we see the abnormality better. In this case, it could be either mammography or MRI-guided biopsy, but given the age, the patient age, which was 84 years old, we decided that tomo-guided biopsy was easier, so the pathology came back invasive lowland carcinoma. I just want to point out about this pattern of invasive lowland carcinoma, like a scan or a spiderweb pattern, which is kind of very difficult to identify. So let's review a little bit of imagined patterns of invasive lowland carcinoma. We know that the most common finding is a mass or architectural distortion. We can see asymmetries. This pattern, like it's a spiderweb, they can be bilateral, and we can see that there's shrinking breasts. This spiderweb pattern is difficult to perceive, even when it is extensive, and even when you have fatty breasts. Like in this case, it was not too dense, but the size of this abnormality was approximately 7 centimeters. There is an irregular thickening of the fibrous connective tissue, and that's why we see this kind of pattern. It mimics the appearance of normal granular tissue, and they have a tendency at the end to shrink the breast volume. Let's see our next case, man with palpable anormality. This is a 37-year-old male who presents for evaluation of a palpable lump in the retrorheolar region of the right breast. We have CC and MLO views, and we have a tangential view. Let's see it again. Let's see it again. Who gives a BRAS-2? How about BRAS-0? Okay, a few people. And BRAS-4? No one. Okay, so we gave a BRAS-0 and recommended ultrasound. And as you can see, this is the retrorheolar region, and there is an isochoid tissue that is very typical of gynecomastia. This is a longitudinal view, but if you see here, there is like a mass-like area here with increased vascularity. So, it was kind of, we were like looking if this is a mass or it was a gynecomastia. So, at the end, we decided to do a core biopsy and came back as an invested doctor carcinoma arising in a background of gynecomastia. So, even though the most common breast pathology encountered in male patient is gynecomastia, we have to carefully look for the patient palpable area concerned with ultrasound. Two processes can be occurring in the same breast. In this case, gynecomastia and breast cancer. And if you have a doubt, it's better to biopsy. So, gynecomastia, we think that can be an easy diagnosis, but sometimes it's very difficult to differentiate to see if there is any breast cancer or it's only gynecomastia. And many times, I can ask a colleague to have a second look just to make sure that it's gynecomastia. Let's go with our next case. It's a BRAS 3 case. This is a 72-year-old female who presents for six months follow-up of a BRAS 3 lesion. This is a second follow-up. At the second follow-up, the provider felt a palpable anormality. And the anormality is here in the lower inner quadrant of the right breast. This is the 2023-2022, which was the first diagnostic, 2023-2022. We have the spot compression views. And we have the ultrasound, 2022 and 2023. So what would you do? Who said BRAS 2? How about to continue with BRAS 3? How about to recommend a biopsy? I think most of us agree with that. And the radiologist who did the follow-up described the anormality as a solitary dilated duct. That was how I described in 2022, like a duct filled with debris and a focal area of autoassisted changes. But in 2023, it was described as a heterogeneous non-mass lesion in a linear distribution. And that's what it was decided to do. Ultrasound got a corneal biopsy and came back as a DCIS. So be very careful with new findings in patients older than 50 years. This was a new finding in the screening mammogram. Slow-growing cancer can be stable on follow-up imaging. Keep an open mind when you are doing follow-up of BRAS 3. Always ask yourself if the lesion meets the criteria for a BRAS 3 lesion. Regarding solitary dilated duct, it's a rare screening finding. It's defined as a tubular or branch structure. Solitary dilated duct is currently classified as a BRAS 4. But our recent studies have found the rate of malignancy is low. So we are going to have an update in the upcoming BRAS regarding solitary dilated duct. Let's go with the next case. Pulpular normality. 47-year-old woman presenting with a pulpular normality in the breast for more than one year. It has become larger. That's why she came to our institution. She came in 2022. The imaging in 2021, six months before, was reported as negative. 2020, 2021 CC, 2020 MLO, and 2021. And this is the ultrasound. And then pay attention to the palpable area, which is here. What do you think? Is normal or abnormal ultrasound? Who said normal? Abnormal? OK, most of the people say abnormal. I think it was abnormal. But it's kind of a subtle finding. There was something there that we don't know what it was. Six months later, the patient had this mass. This is a 5 centimeter irregular mass with a heterogeneous mass on ultrasound, predominantly hyperechoic. The diagnosis. OK, I'm giving you four possible diagnoses. Who said breast cancer? Hematoma? Phynecrosis? Angiosarcoma? So I guess most people think it's angiosarcoma. You are very good radiologists. It was an angiosarcoma. And this was the MRI of the patient. The angiosarcoma are usually bright on XLT2. And on post-contrast, demonstrates heterogeneous enhancement. So regarding angiosarcoma, it's a rare malignancy. Breast angiosarcoma, as we know, can be classified as primary or secondary. Secondary is when you usually see a patient after breast cancer treatment or lymphedema. Primary angiosarcoma is often in young women. And primary angiosarcoma is often seen as a fast-growing mass. The imaging features, they can be round or oval masses, or called, in 30% of the cases, can present as diffuse breast enlargement. On ultrasound, it can be seen as circumscribed or not circumscribed masses. And can be hypo or hyperechoic. And I have seen a couple of cases of hyperechoic angiosarcomas who have been missed. Because the radiologist is not thinking that in a young patient, something echogenic can be an angiosarcoma. MRI, they are characteristically bright on T2 images. They can have heterogeneous enhancement and variable kinetics. And my last case, this is a 71-year-old woman who complains of left breast changes. The last mammogram was five years ago. This was the left breast changes that the patient came. We at MD Anderson, we were very optimistic. And we would try to do a mammogram. So that was our mammogram. Of course, we didn't see anything. But we tried. I just want to show you the chest CT, how big the mass was. So the mass was all of that. Ultrasound shows a complex cystic and solid mass. And the solid portion has increased internal vascularity. This is a case that nobody wants what to do with this case. But the first thing that we had to do is decrease the fluid. So we send the patient to interventional, to put a catheter. It was drained like a 30 cc of bloody fluid. And we have this solid portion. And an ultrasound-guided corneal biopsy was performed and came back as invasive micropapillary breast cancer. This was the surgical specimen. And regarding invasive micropapillary carcinoma, it's a rare variant of the invasive daughter carcinoma of the breast. It's clinically aggressive, often associated with axillary metastasis, with high risk for local recurrence. And irregular mass is the most common mammographic and sonographic imaging finding. This is a case that was quite rare. And the takeaway points, now that you have been enlightened, is that there is no one-size-fits-all for surveillance in patients with history of breast cancer. You have to take into account the patient's history, the molecular subtype, prognosis, and treatment received. Be aware of the different invasive lobular carcinoma patterns. Be aware of this pattern. I have missed a couple of cancers because they have this pattern, which is very difficult to detect. Ultrasound is always recommended in men with pulmonary abnormality, even if the mammographic findings are typical of gynecomastia. Be careful with the BRAS3 in older patients and with new findings. There will be an update on solitary dilated duct. Stay tuned. Primary angiosarcomas are often seen in young patients and can be hyperechoic on ultrasound. I just want you to remember that the small angiosarcoma can be completely hyperechoic. So just keep in your mind whenever you do an ultrasound in a young patient. Approaching a mass with a large fluid collection can be challenging. It is sometimes necessary to drain the fluid with a cutter to enable a true evaluation of the mass and a biopsy. Thank you so much. Good afternoon. I'm Dr. Sherry Kuzmiak, professor of radiology at the University of North Carolina. Just bringing the slides up here. So we've had these interesting and difficult cases. You've worked things up. You've used all the modalities in your toolbox. Now it's time for radiologic pathologic correlation. All right, the objectives for this case-based lecture are recognize and understand challenging cases to avoid a delayed diagnosis of breast cancer, learn strategies for applying a skillful approach to radiologic pathologic correlation in breast imaging. All right, case number one. We have a 44-year-old black female. She presents with a palpable mass in her left breast. The patient reports the mass is tender and it has increased in size over the past three months. All right, here's her mammogram. You can see here's our MLO view, the CC. So in that medial upper inner quadrant to the left breast, posterior depth, there's approximately one centimeter round mass. Maybe there's some prominent lower level lymph nodes here. Here's the spot tomo. It is round. Notice it's higher in density on the tomo imaging. And look at the margins. The margins are very indistinct in this non-calcified mass. What are you going to do next? You're going to do an ultrasound, of course. So here's the ultrasound of that round mass, hypoechoic. Notice the margins are not circumscribed. They're indistinct, little micro-lobulated. Looks like there's just a faint but visible echogenic rind. It's not vascular. All right, so differential diagnosis. Young black woman. Things could it be? You're thinking, first of all, you want to put the worst first. So malignant things. So invasive breast cancer, no special type, especially with a round mass, probably a triple negative breast cancer. Certainly could be invasive ductal carcinoma with medullary features, a mucinous cancer. But most mucinous are in post-menopausal women. Maybe a papillary carcinoma. But, boy, it's really in that posterior aspect of the breast. Maybe a solitary met, but no history of any primary. What are some benign things this could be? It could be a fibroepithelial lesion. Papilloma, once again, very in the posterior aspect of the breast. Could it be stromal fibrosis? So stromal fibrosis is commonly seen in pre-menopausal women. It can be also seen in post-menopausal women on hormone replacement therapy. It can range from anything from a nice round to oval circumscribed mass to architectural distortion. All right. So you do your biopsy. You take your multiple samples. You send it off. And now you wait for your pathologist. And you're going to do your RADPATH consensus or correlation. All right. It comes back as a granular cell tumor. The pathologist sees this sheet of these large cells with this eosinophilic granular cytoplasm. So you're like, this wasn't even on the list. Is this even a breast thing? So the answer is, is this concordant? So you've got to ask yourself in daily life. I see some people shaking their head no. I see some people shaking their head yes. Well, yes, this is benign. And it's also concordant. So granular cell tumors. They're a benign neuroectodermal tumor derived from Schwann cells. 8% occur in the breast. Most common sites are head and neck and the tongue, the GI, and the respiratory tract. With epidemiology, these benign granular cell tumors are more common in females than in males with a mean age of 54. However, they're also more common in young black females with a mean age of 41. Clinically and on imaging, granular cell tumors can mimic breast cancer. These non-calcified masses. So prognosis is great. It's benign, local excision, minimal risk of recurrence. So benign, concordant, and recommend surgical consultation. All right, case number two. A 77-year-old female presents for routine screening mammography. She's had a history of a right lumpectomy for an invasive ductal carcinoma, no special type. She had a little one-centimeter luminal A breast cancer, no nodal involvement. That was back in 2012. She completed radiation therapy and five years of adjuvant endocrine chemotherapy. Three years ago, she had a symptomatic right retrorheal or papilloma that was excised. So here's her mammogram. So the first thing is you hope that someone in your group picks this up because this one you're going to have to do a lot of digging from her old studies of what is what. So on her MLO, here's some skin scarring. And this more deep area here is her actual lumpectomy. More anteriorly were the surgical clips. That's where she had her papilloma excised. However, in the lateral aspect of the breast, just deep to the skin, we have this oval, non-calcified mass. Notice that the margins here on the spotome are speculated. So you're going to do an ultrasound. Here's that somewhat oval mass, heterogeneous in appearance, certainly not circumscribed margins. You have that big echogenic rind around it. It's avascular. All right, so what's your differential diagnosis? She's already had cancer once. Could she get cancer again, especially after the, you know, the breast cancer survivors here lecture? Certainly could be invasive breast cancer, no special type, invasive ductal. Could be invasive lobular, certainly papillary carcinoma. Could also be DCIS presenting as a mass. What are some benign things? Could be a papilloma. She's had one already, but this certainly doesn't look like, you know, a very classic papilloma. Fat necrosis or stromal fibrosis. All right, so you do your needle core biopsy, take your multiple samples under ultrasound guidance, put your clip in, post-procedure mammogram, everything lines up. It comes back as fat necrosis. So the pathologist saw these lipid-laden macrophages, so these big areas here, this is the fat. They look like giant marshmallows here on the H and E. So fat necrosis. So for this mass, how many people think it's concordant? How many people say yes, this fat necrosis concordant? How many people are saying no? All right, so kind of 50-50. Actually, it is concordant. So this is benign, this is concordant. And you can do, you know, either a short-term follow-up, someone may say six months, or just back to regular screening. So fat necrosis is the result of trauma. Benign inflammatory process of aseptic, saponification of fat, characterized by those lipid-laden histocytes, multinucleated giant cells and degenerating adipocytes. It can mimic breast cancer on clinical exam and on imaging. So the appearance can be quite variable. In the early stage, as is in this case, it can be an irregular mass. In the later stage, kind of a mixed-density mass with indistinct margins until it matures into that classic and beautiful oil cyst, and certainly calcifications can be associated with it. So this was benign, concordant, and just, you know, follow-up with imaging. But certainly it was suspicious. You had to biopsy it to prove it wasn't a malignancy. All right, case number three, we have a 62-year-old female presenting for a screening mammogram. She's had a history of atypical ductal hyperplasia in 2020, and then when she went on to surgical excision of it, there was no upstaging, so just ADH. All right, here's the finding on her mammogram. Yeah, there's some round ones here, but this is certainly not classically benign calcifications. You have your BI-RADS here. You can, you know, match these up. You can see those linear branching calcifications, so certainly suspicious morphology. There are BI-RADS 4C. Look at the positive predictive value, 70%. So you're already thinking when I go to, you know, put a needle in here, get my samples, you're already thinking cancer, cancer, cancer is going to be your, you know, first, second, third, fourth, and many other guesses to follow. So you do your vacuum-assisted core biopsy. You got great calcs in your sample. God, you can't wait for the pap to come back. So things you're thinking of before you even went in the room to do the biopsy. DCIS, DCIS, DCIS, DCIS. You certainly could have some invasive breast cancer in there, especially those invasive breast cancers that are HER2 positive. Some benign things, maybe fat necrosis, but I'm certainly not going to show you another case of fat necrosis. You know, fibrocystic changes. Don't even put it on the list as the differential. All right, so you do your biopsy, and it comes back benign breast tissue, sclerosing adenosis, and no calcifications are identified. Is this concordant? Definitely not. So it's benign, but it's discordant. So on your pathology report, you have benign findings, no calcifications. You have lots of calcifications in your specimen x-ray, and these are the calcifications you're not, like, squinting at the screen going, I think there's a few flecks there. Oh, I'm sure there are. We'll just send it to pathology. All right, so what should you do next? Well, you can pick up the telephone, type a little message or something through the electronic medical records or an email to your pathologist and say, dear pathologist, send me the blocks. I will x-ray them. I will find those calcifications for you. So we x-rayed the blocks. We found those extra calcifications that they didn't see before. So we told them which blocks to continue to cut extra levels. So the pathologist then goes back, cuts the levels, and it ends the report. And so on pathology, now we have ductal carcinoma in situ, grade 3 with necrosis, and the calcifications that show up as kind of these purple dots here are now present with the DCIS. So they report that out, calcifications with DCIS. So now, is this concordant? Yes, absolutely. So malignant, concordant, surgical consultation is needed. So remember, if you have no calcifications in the pathology report, call the pathologist, have them cut deeper levels, x-ray the specimen blocks if needed as well. All right, case number four, we have a 46-year-old female who's recalled from a screening mammogram. So here's her 2D. Eh, not too exciting. Thank God for 3D, right? So what do you see? At least a 3-centimeter area of architectural distortion. Absolutely beautiful. You know, it's kind of pulled in. I always tell patients, it's like you take your finger and snag a sweater how it bunches in. You could also say it looks like a little spider web where it's kind of pulled in as well. So what are you going to do next? Are you going to send your technologist, or are you going to go in and do an ultrasound? Well, there's no ultrasound correlate. All right, so what's your differential diagnosis? Ooh, it still looks bad on imaging. You know, where are you giving it? A Byrod's 4B at least? So things that are malignant, that's architectural distortion. Invasive breast cancer, no special type. Your invasive ductal carcinoma. Certainly invasive lobular carcinomas from the examples that we just had. Some benign things. Radial sclerosing lesion. Your radial scar. Complex sclerosing lesion. Stromal fibrosis. Sclerosing adenosis. Proliferative fibrocystic changes. Fat necrosis. Surgical scar. This patient had no history of surgery before. All right, so you sample it, and on needle core biopsy it comes back as fibro fatty tissue. No atypia, no carcinoma. And you're thinking, hey, it's before the holidays. You know, she'll have great news. It's not cancer. But then you look back at your report, and who knows, you may have to do the RadPath correlation when your colleague is out of town. So you look back on what was done, and you notice in the report only five samples were obtained. The patient had difficulty holding still during the procedure. So it's this fibro fatty tissue. Is that concordant with the architectural distortion? Yes? No? Excellent. If you ever get fibro fatty, don't believe it. So this is certainly benign and discordant. So what are you going to do next? Well, you're going to make that phone call of shame and call the patient, hey, everything so far is looking good. No cancer, no atypia. But we really need to get more tissue. Really sample it. Make sure that we didn't miss anything. So the patient was rebiopsied. More tissue was acquired. And then the pathology came back as a radiosclerosing lesion. So for this architectural distortion, is this concordant? Yes, absolutely. And it's also a nice radiology pathology correlation as well. So those are kind of the helpful tip for architectural distortion. If you're doing 9-gauge, make sure it's vacuum-assistant. Take 12 samples. All right, so a radial sclerosing lesion has this beautiful central fibroelastic core, kind of pulls in the glandular tissue, kind of traps it in. The myoepithelial layer is still intact. However, atypian carcinoma may involve or arise in association. There is no specific factors for etiology and certainly can mimic an invasive breast cancer. All right, so we're in that era of tomosynthesis. We're seeing more architectural distortion. We're seeing a lot of tomo-only architectural distortion as well. There's an increase of like 50% to 75%. However, the positive predictive value for a DBT only finding for architectural distortion, that positive predictive value for malignancy, is actually lower than if you detect architectural distortion on 2D. So just be mindful. If you have an architectural distortion sonographic correlate, the positive predictive value for malignancy is about 10% to 70%. However, what if you don't have a sonographic correlate for that architectural distortion? Well, that positive predictive value for malignancy, it is not zero. It's about 8% to 33%. So architectural distortion, tomo-only finding, no sonographic correlate. Make sure you biopsy it. Architectural distortion remains a suspicious finding that justifies a tissue diagnosis. All right, case number five. 25-year-old. She's BRCA1 positive, baseline MRI. So I'll give you a moment to look at it. Here's her post-contrast axial and T1. Here's the sub. So you're looking at the imaging. In the right, well, it looks a lot brighter than the left. Don't dismiss it and call it as, well, it's just picture framing, right? It's just breast tissue. She doesn't have any priors. Don't call it a bioreds 3. Give it a bioreds. Don't call it a zero. Are you going to call it a 4A? Are you going to call it a 4B for this irregular mass, maybe with some non-mass enhancement extending out? So, you know, tell it like it is on the MR. Don't leave it for your poor colleague who's going to do the mammogram or ultrasound next to figure out what to do. So she has a diagnostic mammogram and second look ultrasound for this area, and they're normal. So are you just going to dismiss it? No, you still have a suspicious finding with MRI. So what could this be? Well, differential diagnosis for that irregular mass. She is a BRCA1 positive patient. Invasive breast cancer definitely is very worrisome. Is it an invasive ductal? Is it a lobular? Could it be DCIS? What about some benign things? Could it be pseudoangiomatous stromal hyperplasia, also known as PASH? Stromal fibrosis, it can look like everything. Radial sclerosing lesion or fibrocystic changes. So you go ahead, you do your MR biopsy, you get some great samples, you put the marker clip in, wait for the pathology to come back, and so you do your RADPATH correlation. It comes back as pseudoangiomatous stromal hyperplasia, PASH. The pathologist sees just kind of this pink bubblegum, kind of stroma oncologen with these empty slit-like spaces. It is PASH. So for this mass that we've seen on MRI, is this concordant? Yes? How many people think yes? How many people think, no, oh, my gosh, she's a BRCA1 patient, did I sample the right area? Anyway, it is concordant. This is benign. It is concordant. So PASH is a benign proliferative stromal lesion, seen in pre-menopausal women. However, it can also be seen in post-menopausal women who are on hormone replacement therapy. PASH is most commonly seen as non-mass enhancement on MRI. However, in this case, it can also present as an irregular mass. And the findings of PASH are indistinguishable from malignancy, not only on MR, but also on ultrasound and mammography, so certainly a biopsy is needed. And then the last case, kind of a fun one, she's a 41-year-old high-risk patient, has a baseline screening mammogram. All right, it's the end of the day. She has her bilateral mammogram, her tomos. Don't strain yourself. It is normal. So she's high-risk. What are you going to do next? She's going to have a screening MRI, right? Of course. So here is her MRI, her post-contrast subtracted image, her axillary saggel. In that lower outer quadrant of the left breast, you see at least a 10-centimeter area of non-mass, clumped enhancement. It extends all the way to that nipple, real or complex. You're looking at the MRI. You actually pull up the mammogram again like, oh, God, did I miss something or did one of my colleagues? And that MR shows you the non-mass enhancement, and the mammogram is normal. So what's your differential diagnosis for that? She's at high risk. Ooh, that MR looks horrible, doesn't it? Well, malignant things. DCIS, of course, could be invasive breast cancer, either invasive ductal or invasive lobular, but usually those are more mass, but they can present as non-mass enhancement. What about some benign things? Well, certainly high-risk lesions, atypical ductal hyperplasia, LCIS, PASH, radial sclerosing lesion, and fibrocystic changes. So how many sites would you sample? Are you going to do a one and done? Are you going to do two sites, three, four? Are you going to make a human pin cushion out of her? You certainly want to try to get the extent of disease for that non-mass enhancement. I think doing an anterior and a posterior extent is reasonable. One, you could miss stuff. Who wants to have three or four biopsies? So do an anterior and posterior extent. You wait for the pathology to come back. You're pretty happy with those samples that you got. And so the pathology, for the anterior, it was atypical ductal hyperplasia, and also for the posterior, it was atypical ductal hyperplasia. So for this non-mass enhancement, is that pathology concordant? How many people say yes? How many people say no? It is concordant. So high-risk. So benign high-risk concordant recommends surgical consultation. So atypical ductal hyperplasia is a proliferative lesion. It's a non-obligate precursor to invasive breast cancer. It has similar cytologic and architecture features to low-grade DCS, and basically it's the size and extent is smaller than DCIS. If it only involves one to two ducts and if it measures less than two millimeters, your pathologist is going to call it ADH. That's why it's important to get good samples. Also, mammography with ADH usually presents as calcification. On MRI, it's quite variable in appearance. It can range everything from non-mass enhancement to a mass. And there's no specific MRI feature to predict subsequent upgrade to malignancy at surgical excision. And the upgrade rate for atypical ductal hyperplasia on surgical excision is 20%. This high-risk patient had a mastectomy. She had over 10 centimeters of DCIS along with that atypical ductal hyperplasia. So, conclusions. Form a differential diagnosis prior to biopsy. What are you going to accept as the pathology for the results? Ensure adequate tissue sampling. Help the pathologist make a diagnosis. Maybe instead of, you know, a couple samples, just get one more, just in case. And then radiologists, we need to close that RADPATH loop. We worked hard to find the lesion. We worked hard to work it up. We have now biopsied it. We owe our patients to close that RADPATH loop. So is that pathology concordant? Is it discordant? And then make the appropriate recommendations. You know, follow-up imaging and when, and certainly surgical consultation as needed. Anyway, thank you so much for your time and attention, and thanks for staying until the end. Thank you.

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