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Hello and welcome to Noon Conferences hosted by MRI Online. In response

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to changes happening around the world right now and the shutting down of

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in person events, we have decided to provide free daily Noon Conferences

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to all radiologists worldwide. Today we are joined by Dr. Jenny Kohr for

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a lecture on diagnostic breast imaging after screening recall. Dr. Kohr

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is currently the Diagnostic Radiology Residency Program Director at Virginia

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Mason Medical Center in Seattle, Washington. Former breast imaging teaching

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coordinator, interests include breast imaging, patient communication, quality

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and safety, and medical education. A reminder, there will be a Q&A section

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at the end of the lecture, so please use the Q&A feature to

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ask your questions and we'll get to as many as we can before

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our time is up. We will be using the polling feature today,

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so be on the lookout for that. A reminder, the polling window can

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be moved on your screen if it's blocking something.

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That being said, thank you all for joining us today. I'll let Dr. Kohr take

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it from here. Okay. Good afternoon, everyone. I guess it's still morning

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for me in Seattle. Thank you very much for joining me for this

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talk. Hopefully you'll find it useful. I just wanted to pop in and

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say hello with my video and I'm going to be closing that now

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so it's not distracting to me. Okay, so we'll get started.

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So I'm going to be talking about the diagnostic workup after screening recall.

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I have no disclosures. So as I said, I'm going to be talking

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about the imaging workup after patients are recalled from screening mammograms.

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Primarily I'm going to be talking about the mammographic workup and show

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some ultrasound exams. I'm going to be showing both

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2D digital mammogram as well as some tomosynthesis images as well.

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I'm going to briefly review additional mammographic views and localization

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techniques during this talk. And I will also give some examples of pitfalls

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along the way to hopefully avoid. So we'll start with the first case

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here. I'd like to start by just discussing how I approach

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working up a finding from screening exams. So

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before I even look at any of the additional views obtained,

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I start with a basic screening exam. I go back to the screening

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and I look at it myself and I try to assess my level

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of suspicion for the finding. So I'm showing here case one.

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We'll focus in on this case for a few slides to get started.

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So as I said, I start with the screening exam.

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I put my detective hat on and ask myself a bunch of questions

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when I'm looking at that screening exam. Is the finding the patient has

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called back for new or increasing in size, density, or conspicuity? Is it

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developing any suspicious features such as architectural distortion or associated

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calcifications? Could the finding been previously excluded from the image?

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Is it very close to the chest wall or in the upper inner quadrant,

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for example? Could it have been previously obscured as the patient's breast

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tissue involuting? Is the finding suspicious enough just on the screening

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exam that ultrasound is warded pretty much regardless of what I see on

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the additional mammographic views? Are we actually looking more at an extent

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of disease workup and biopsy planning for something that's very suspicious

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for malignancy? Or on the other hand, could the finding be just normal

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breast tissue due to differences in positioning or technique?

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Could the finding be artifactual due to superimposition of normal breast

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tissue, which is related to positioning as above? So back to our case.

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Anyone see anything here? So there's a little area that's a bit asymmetric

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in that upper quadrant on the left side compared to the right side.

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So we're still talking about the screening exam here. We'll take a closer

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look at this finding. Here's just a zoomed up

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photographic magnification, not a real magnification of the finding.

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Doesn't really look like a mass, but there's definitely some tissue there.

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So this is an asymmetry. It was only seen on the MLO view, wasn't

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seen on the CC. It really lacks any convex borders that suggest it's

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a mass. There may be some interspersed fat.

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Most of the time, asymmetries represent summation artifacts and superimposition

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of normal breast structures. Is that the case here?

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Well, how about putting our detective hat on again and looking at some

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older comparisons? So this patient hadn't had a mammogram in three years.

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You can see I've put up the three year comparison side by side

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with the current images. And there really wasn't much in that area before,

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maybe a little wispy tissue, but not much. And we'll take a closer

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look here. So it looks like there is a change.

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So again, here's our question. This is a polling question.

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Could this finding just be superimposition? So the options are,

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yes, it could just be superimposition. No, it's not superimposition. Or

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I'm not sure. I'd really like some more information.

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Okay. It looks like most of you are not sure and that you

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would like more images. And about 10% or less were thinking it was

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summation artifacts. So great job. Let's go on with the case.

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Okay. So we got more images. This finding was not actually visible on

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the full lateral view or the exaggerated lateral CC view. But you can

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see here on the magnification image that it looks denser.

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It's kind of overlying the pectoralis map now. And then maybe we can

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just see the edge of it on that lateral mag.

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So I pulled up the photographic enlargement of the MLO and compared it

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to the mag side by side. Whoops, sorry.

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And you can see this definitely got denser and more suspicious looking.

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Maybe even some speculations. And you've already seen a little bit of what's

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coming next. So we looked with ultrasound. And you can see this finding

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was way up in the axillary tail, which explains why we weren't able

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to see it on the lateral view or the XCCL view. And this...