 Hello everyone and welcome to Indian Radiologist. Today I will be taking you on a tour of all the activities and programs that are scheduled for this year as well as for early Jan next year. We begin the Indian Radiologist section with the Journal Club. Now the Journal Club is a unique program that has been crafted out and created by Dr. Mitusha Verma as well as Dr. Gauri Aguja. In this program what we intend to do on the third Sunday of each month is that we take you through interesting articles that are coming about in the world of Radiology. We will discuss them, we will dissect them and also look at what options that Journal gives us in our day-to-day radiology practice. This is a wonderful event especially for resident doctors because they get to present any article of their choice related to that topic and we have exciting prizes in store. So the registration for this program is free but mandatory. So we would request you to just come on to our website and have a look at the Google form and just type in your name and voila you'll be part of the wonderful Journal Club that is going to start very shortly. The next program is the masterclass series. You know that we've had these wonderful masterclass series both last Sundays of a complete MSK overview. That again is a very basic fee so we would request you all to join in for that program. The third program is post Diwali and it is CTBuzz. So once again CTBuzz this time is online and hopefully this is the last CTBuzz that is online and we hope to go on site once again. We have Sandrad as our chief sponsor for this event and what we intend to do in CT is that we intend to make it a complete overview. So we're going to cover neck, chest as well as abdominal CT. So again this program will have papers, posters, quiz contests and the whole range of stuff that we always do. The last and not the least of course is Sonobas. So we've had two Sonobas so far one the on-site one in 2019 December which was a great hit with more than 650 delegates and then we had Sonobas virtual this Jan which had more than 2,000 delegates registering for the virtual event. This time we are going to go hybrid so it's a mixture of both online as well as on-site event and this is going to be in early Jan. This is Jan 8th to 9th and the details of this program will be coming up very shortly on our website. So stay tuned in with us and we will be giving you more information on all these events very shortly. Thank you and take care. Bye bye. Gauri shall we start? Hello friends and we welcome you to this new initiative by Indian radiologist as Dr. Sanjeev Manisar explained. The Radiology Journal Club and this we are going to have as a monthly academic event online and last month in the Sunday we had neurology case discussions. We had two articles which we discussed and the articles were shared afterwards and also we had two cases which were discussed. We are going to improvise on the format as per your feedbacks and as per our expert suggestions and today we present to you the second Radiology Journal Club which is dedicated to breast imaging topics and this we have with us the chief expert in the country about breast imaging that is our own Dr. Shilpa Lard. Thank you. So the chief coordinator and the program has been designed completely by Dr. Shilpa Lard and helped by myself Dr. Mithusha Verma and my colleague Dr. Gauri Ahuja as well as Dr. Gayatri Hershey and these are the core organizers of all these events of Indian radiologist and we are thankful for their constant support and guidance in spite of their busy schedule. Dr. Shailendra Singh sir, Dr. Jignesh Thakkar, Dr. Sanjeev Mani, Dr. Deepak Patkar sir, Shilpa ma'am and Mamta ma'am and we are thankful to all our education partners specifically because without their support these kind of events are not possible and we would request all of you to spread the word around the Journal Club is a new initiative and we want your feedbacks and support. All this will also be hosted on the YouTube channel by Indian radiologist so you can definitely go back and review and revise whichever part you want to and even the articles which we are going to discuss and which we are going to see through they are going to be shared with you so that you can review them later. So, thanking bears for their constant support and with this the concept where we are going to discuss about the recent advances, recent literature and see what all new is coming up and also do a kind of short meta-analysis with our experts. You can also suggest if you have some cases to be discussed maybe in the next Journal Club we are going to include that part as well and some of you can also participate in presenting these articles and journals so last time we had these two articles on neuroimaging and interesting cases and today we'll have a good discussion about another controversial topic in breast imaging. So, let us start with the discussion but before we go ahead I would just request Shilpa ma'am to kindly guide us through the entire Journal Club the way we are going to have it in the next one or one and a half hours and then we can start with the Q's discussion. Thank you, Mitusha. Thank you for the kind introduction. I can do none of this without the constant help and support of two big pillars here for me. One is Mitusha Verma, other is Gauri Ahuja. Also, the two people without whom we can do none of this is Dr Deepak Patkar Sir, Dr Sanjeev Mani Sir and the two others who are in the background all the time, Dr Shailene Prasik Sir and Dr Chignesh Thakkar Sir. So, I pay my due respect and gratitude to everyone here and the one person Dr Gayatri Hershey who has offered to discuss these cases without full knowledge of what the histopathology diagnosis is. So, for her it is an online Viva. So, thank you Gayatri for volunteering to be our our our baker of the case today. So, what we are going to do today is we will show you a case and as is the case with radiology images. When we see a radiology image we think in our mind I know the diagnosis. Most often after a few years of practice we really do but unlike mathematics medicine is not always 2 plus 2 is equal to 4. Every once in a while there is a diagnosis that comes in front of us which is controversial which means we don't know how to take the management forward. What should we do okay and that is the kind of case we are going to discuss. When such a thing happens in medicine what do we do we go out there and we ask our colleagues if you had a case such as this how would you manage when our colleagues say that this is kind of what I would do the next best thing to do is go out there into the online world and find out what people are doing globally nationally literature over the years how people have been handling these cases and what their experience has been. So, this is exactly the purpose of the journal club to take up cases which have been challenging for us in our own practice and to read relevant literature to understand how best we can handle or manage these cases. So, today we discuss one such case and we have picked out on two articles which kind of tell us you know you could go this way or you could go this way okay. So, we want to bring it in front of the audience how we practice medicine. This journal club is meant to help us improvise our understanding of medicine and also to make us understand why engineers go to work and do work whereas doctors go to work and practice medicine because we are constantly learning okay. So, with that I would request Mitusha to take us through the case and I would request Gayatri to describe the findings on this case and as a radiologist what is it that she would expect to find in the diagnosis and to take us through the differentiates. Over to you Mitusha. Thank you ma'am and with this now it's time to start. So, we have with us Dr. Gayatri Hershey she is a fellow at Nanavati Super Speciality Hospital with us and she has completed her DMRD and DNB. So, welcome you Gayatri and thank you for being there with us today. Let's start with the case this is the short clinical history. This is a 44 year old female with strong family history of breast and ovarian cancer. So, as such the person herself she has no major complaints just a very very strong family history. So, she came for a routine screening mammogram and these are the mammograms which we have with us and you may please start your description. So, these are the screening mammography images medialateral oblique view and here what we can see this is a optimal projected mammogram. We can see the pectoralis major in oblique convex city in the upper portion of the mammogram and the if we draw the nipple line posterior nipple line there is a symmetry in the left breast what we can see on these mammographic images. So, I would like to see the cranio cordal view also. So, unfortunately in this case we did not have the cranio cordal view because some part of the imaging had already been done outside but on the medialateral outside out of the city in a smaller place and we were not completely convinced that the images were of optimal quality. Therefore, 3D tomosynthesis and bilateral MLO views were repeated and we saw some micro calcifications unfortunately they are not projected well. So, we went ahead and did spot magnification views. So, in this spot magnification view I can see the few pleomorphic calcifications in a regional distribution. So, these are concerning for neoplastic etiology and there is actually on the previous mammographic image there was asymmetry also in this region. So, I would like to do ultrasound for further and if it is needed tissue sampling. Let's look at the ultrasound image. So, one question for you before we go ahead when we do spot magnification views Gayatri what are the views that we use for spot magnification? Do we use the CC and MLO view or do we use the CC and ML projection? CC and ML projection. Excellent. And is it just a digital magnified image or are there any special prerequisites required for spot magnification views? I actually don't know. So, I will explain that. This is a good point and this is an area of confusion for a lot of resident and fellows. Therefore, this is something that we should bring up. So, spot magnification views are done in two projections. One is the CC projection and the second is a ML projection. ML projection means it is at 90 degrees and why do we do that? Because if the calcifications are within the CIS then on the straight lateral view they'll layer out. But if they are pleomorphic and in a segmental or regional distribution they will not layer out. So, it gives us an idea whether we are dealing with a fibrocystic breast or we are dealing with something more concerning. Therefore, we obtain that ML projection. The second point is how different are spot magnification views from the regular views? We use a smaller focal spot when we do spot magnification views and there is a standoff paddle that is used. Why do we do that? Because it not just digitally magnifies the image but it is a true magnification such that the resolution is maintained and that resolution is important because we want to assess those microcalcifications. When we say pleomorphic or monomorphic what we are trying to see is the morphology of those calcifications. Are they all uniform dots? Are they all dots and dashes? Are they V shaped, Y shaped? But to see that we need good resolution and therefore we do spot magnification views with the standoff paddle and a smaller focal spot for optimal morphologic evaluation of those calcifications. So, you rightly describe this as pleomorphic microcalcifications. So, when we describe microcalcifications we describe first the morphology of those calcifications. Are they pleomorphic or are they monomorphic? Next, we describe the distribution of those calcifications. Are they in a linear segmental microcalcifications? Are they involving an entire segment? So, pleomorphic microcalcifications in a segmental distribution, are they involving an entire region? Which means one whole quadrant, are they pleomorphic microcalcifications in a regional distribution so always go step by step by step when you are describing microcalcifications remember just like the pilots we are in a autopilot mode but to get into a autopilot mode we have to train our mind to get into the habit of going through the same protocol of of reviewing and describing so we don't miss out on lesions okay so when I describe this or when we describe this as radiologist we say there are pleomorphic microcalcifications in a segmental distribution involving the upper outer quadrant of the left breast and extending to the base of the nipple areola complex am I seeing nipple flattening that also I will describe I'm not seeing nipple flattening there is no nipple inversion and based on the mammographic views I don't see any skin thickening there is no nipple inversion there is no skin thickening however there is an asymmetry associated with the pleomorphic microcalcifications as soon as I say something associated with the microcalcifications whether there is an asymmetry or a mass I'm saying that I want to do some additional evaluation and for evaluation of that I would like to do an ultrasound for correlation so you rightly pointed out that you would need to do the ultrasound okay so far we have come up to here and let's look at the ultrasound images now so do we have a yes so now on this ultrasound image this is what we see in the right retroereolar region would you like to describe it Gayatri yes ma'am this is a irregular hypoechoic mass region in the same left upper outer quadrant and there is a needle track also seen in this image in the previous image this does not have the needle track this is the previous image yeah this yeah there is a needle track there are two images so this is the one where we don't see the needle track so you can describe this one for the lesion characterization so this is a irregular hypoechoic mass in the breast parenchyma okay without any obvious calcifications seen on this sonography image okay so another pointer like your description is correct but again we follow a protocol when we describe breast lesions and we stick to by rats lexicon in your mind you go in this order you know what is the shape there can only be three shapes it can be oval it can be round or it can be irregular what is this is it a oval mass this is a irregular mass irregular mass then we go to the margins what are the margins like are you seeing irregular margins are you seeing speculated margins are you seeing angulations along the margins are you seeing micro lobulations along the margins this is how you go in your mind okay what is the margin like so in this mass there are few angulations yes not like actual speculated lesion in this yeah so that's the correct description you you are seeing an irregular margin it is not a smooth margin it is not a smooth ecogenic margin like you would have in say a fibroidinoma or a smooth imperceptible margin like you would have in a cyst this margin is what we describe it as irregular and you rightly pointed out there are also angulations so if you were to draw a line you know at along the edge of some of the margins you could actually make a obtuse angle or a right angle along the margin so there are angulations along the margin okay and are we seeing micro lobulations not really I'm not seeing a margin like a monaco biscuit here okay so these are the descriptors we use then we describe the ecogenicity of the mass per se what is the ecogenicity like is it homogenously hypoechoic it is is it heterogenously hypoechoic is it an echoic or is it ecogenic what is the ecogenicity this is heterogenously hypoechoic correct so that that becomes the second part so three parts we have done we've done the shape we've done the margins we have done the ecogenicity now we want to see for any associated findings are you seeing any extension along the ducts there is there is an extension along the on the left side yes so there is introductory extension too and this is corroborating with what we saw on the mammogram we saw tubular structures on the mammogram there were micro calcifications but this looks like there is there is a mass which is an irregular mass with uh angulations uh an irregular margin it is a heterogenously hypoechoic mass plus there is introductory extension hypoechoic introductory extension so now put the two things together your description on your your findings on the mammogram plus your findings on ultrasound use of pleomorphic micro calcifications in a segmental distribution which is corresponding to this irregular hypoechoic mass uh with introductory extension so what is it that you would worry about what would be your differential diagnosis in a case such as this she is invasive carcinoma invasive carcinoma that is a good thought could there be anything associated since you're seeing micro calcifications would there be anything associated with the invasive carcinoma dcis so every cancer would start as a ductal carcinoma inside too which means the cancer cells are inside the duct when it breaches the duct and it comes out it becomes an invasive cancer so two components can coexist and that is what we are suspecting in case that the two components are coexisting of course there is a irregular hypoechoic mass with introductory extension which uh which is there plus there are pleomorphic micro calcifications so i'm thinking we could be dealing with the invasive carcinoma with associated dcis so in a case such as this is there a differential diagnosis in your mind or you're pretty certain this is what it must be no correct even my thought was the same i didn't have any differential in my mind this is book picture there are micro calcifications there is a suspicious mass this needs a biopsy we're dealing with the invasive cancer with dcis here okay so how should what should be our next step forward so when we see a suspicious mass what should we do ultrasonic guided biopsy or vacuum assisted ultrasonic guided biopsy okay so um like um this is a good point you have brought up here Gayatri uh what kind of biopsy should we choose in this case should we do a 14 gauge ultrasound guided core biopsy or should we do a vacuum assisted biopsy i can see why you think so because you're seeing micro calcifications therefore you're wondering whether you should do a vacuum assisted biopsy that is a good thought however when you see a mass as such on ultrasound then it is a good practice to go ahead with a core biopsy a simple core biopsy will do the trick for you because you're already seeing a mass which looks like an invasive cancer right and our accuracy rate with a 14 gauge core needle biopsy for getting concordant findings is about 96 percent so 96 percent of the times you are going to get an accurate diagnosis with 14 gauge core needle biopsy therefore if you're seeing a mass on ultrasound the easiest way to do a tissue diagnosis is ultrasound guided core biopsy with a 14 gauge needle if this mass was absent and if you had only seen pleomorphic micro calcifications and you did a ultrasound and you were like you know thinking maybe there are calcifications here maybe I'm not sure then the best step forward would be to do a stereotactic vacuum assisted biopsy for the micro calcifications okay but we always try to take the easy way forward first in this case ultrasound guided core biopsy and that's exactly what we did and Mitusha can you share with us what was the diagnosis yeah sure then atypical lobular hyperplasia now what is this I was suspecting DCIS with a full-blown invasive cancer and the diagnosis has come as atypical lobular hyperplasia what is the first thought that comes to your mind when you see a histopathology diagnosis such as this what are you supposed to do what is your role as a radiologist guy first role as a radiologist further MRI can be performed to confirm this and any other means contralateral breast that is also necessary for a treatment planning okay so this is a good thought but before we do the MRI there is one step that we are expected to perform the step is to establish radiology pathology concordance or discordance which means you have to first ask yourself I was suspecting an invasive cancer with DCIS but the histopathology diagnosis is showing atypical lobular hyperplasia do I agree with this histopathology report or not that is the first question you ask yourself second thing you ask yourself is if I do not agree with this histopathology report then what is the next best step to do should I repeat the biopsy or should I do some additional investigations okay so these are the two steps that have to happen after a biopsy is done so my first question is do you agree with this histopathology diagnosis you were thinking DCIS invasive cancer with DCIS and this has come up to be atypical lobular hyperplasia is it concordant or is it discarded for radiographic diagnosis it is not correlating with the pathological absolutely absolutely that's the correct answer so what we are seeing on the mammogram and ultrasound is not fitting in with what the histopathology is showing so we could do one of two things either we could repeat the biopsy a higher grade biopsy which is a vacuum assisted biopsy or we could ask for a surgical excision biopsy okay in this case when we asked for a surgical excision biopsy the surgeon said hold your horses before I take this patient in for surgery she's only 44 years old I want to know what is the true extent will you guys do MRI first okay so more investigation is not a replacement for biopsy but in a controversial situation we can do a higher end investigation in the form of MRI which is functional imaging it is not just structural imaging but it is functional imaging so in keeping with that plus given the fact that the patient has a strong family history her mother had breast cancer her grandmother had ovarian cancer and one of her masses also had breast cancer and she died of breast cancer very early so but the patient had been reluctant to do BRCA mutation testing genetic testing so we don't know her genetic test testing status okay but she comes for her mammogram and screening regularly okay so keeping all this in mind we decide to go ahead with the MRI and what does the MRI show us yeah so as we know the story till now we have got a histopathologic diagnosis but now the big question is the assessment of the extent and as ma'am explained for that MRI was performed for this patient so these are the MR images and we have few sections which we have selectively chosen to show so here you can see that as ma'am said it is a functional imaging and not just a structural imaging and dynamic multi-phasic post contrast images were obtained and we can see and appreciate that there is a symmetric non-mass enhancement in the left breast and if we see on these axioms and the sagittal projection there is almost a near-complete involvement of the entire superior sphere superior half of the breast so it's like the extent wise it's quite an extensive large area which is involved much beyond what was seen on the mammogram and even the ultrasound so this is what MRI came up with that the extent is really large and whenever we are deciding on the treatment the area which is involved as it is quite large it has to be probably mastectomy if it is surgical option so that is the big question which ma'am will take us through and guide us through so Shilpa ma'am anything else you would like to tell about the MRI and then we can take it further no you described it very well so what we have seen on the MRI is as compared to the right breast the left breast looks slightly enlarged and we also noticed that there are multiple areas of asymmetric non-mass enhancement involving the entire superior hemisphere of the left breast in fact what we saw on the mammogram was just the tip of the iceberg we only saw a few micro calcification even an ultrasound we saw a small irregular hypoechoic mass which was less than two centimeters in maximum dimension but on the MRI look at the number of foci of asymmetric non-mass enhancement it is involving the entire superior hemisphere so now with the diagnosis of atypical lobular hyperplasia and the known strong family history of breast cancer what is the right step forward she is only 44 she has not even started her family yet okay and she would like to know what is the breast treatment plan would she should she undergo a mastectomy or should we keep her under surveillance what should be the proper management plan if she undergoes a mastectomy and all this is plain simple atypical lobular hyperplasia is it a decision that has been justified that is point one and point two is if she's under surveillance remember guys she's your baby like you know as a radiologist you are still under the scanner every time she undergoes a scan she's going to ask you this question okay is everything okay and remember if you or I were in this position we have something which is called a high risk lesion it is not potentially cancer and somebody was asking us to get a mastectomy done at the age that we are in like you know we are still young old is like many many times my daughter says yes mama are you young I say yes I am young I will be old when I turn 80 years old till then I am young okay but jokes apart these are real life decisions for real life people and we want to make the best possible decision for our patients so what do we do we go to literature and we find out what is the best possible option for this patient okay so what is the first question that we have here so ma'am for our all our residents who have joined and for all those budding radiologists interested in breast imaging with the case scenario we came across till now I would like you to please ask answer a few basic questions before we go to the actual literature review so what exactly is lobular carcinoma like DCIS we all have been learning about and knowing about but what is this entity of lobular carcinomas ma'am okay so lobular carcinoma under this they encompass two things atypical lobular hyperplasia and lobular carcinoma in psyche okay these are the two things that they that they put okay how is it different from DCIS DCIS typically involves a tumor growth along the walls of the duct okay but when we are talking lobular carcinoma this is a tumor growth inside the tdlu terminal duct lobular unit so if you think of the terminal duct lobular unit think of a of a branch of a tree you know you have a main stem and then you have smaller stems and then after that there are these leaves that are there think of the ductile system of the breast as such you know there is the main duct and from their smaller ducts which go out and at the end of the ducts are these terminal duct lobular units okay and within these terminal duct lobular units there is proliferation of proliferation of epithelial cells so how do they differentiate between atypical lobular hyperplasia versus lobular carcinoma inside too there are very subtle differences there what they say is the number of distal lobules which are involved so if there are only two or three terminal duct lobular units which are completely filled with with tumor cells then they call it atypical lobular hyperplasia but if all those terminal duct lobular units are filled with tumor cells plus they are dilated distended as they call it then they call it lobular carcinoma inside too and this lobular carcinoma inside too also they differentiate into two parts one is classic and one is pleomorphic as the name suggests just like with micro calcifications when we say pleomorphic it is different sizes and shapes say literally similar thing okay we won't go into the pathologic nuances but these are some basics about the pathologic nuances that we need to know as radiologists and that is only what i'm explaining to you if they are different different pleomorphic different different sizes of those of those uh um uh interductal uh interductal cells then they call it pleomorphic lcis if they are uniform they call it classic lcs why is this important because pleomorphic lcis has a higher incidence of turning into a full-blown cancer okay there are two school of thoughts there atypical lobular hyperplasia is a is not a direct precursor of malignancy for example dcis is a direct precursor of invasive breast cancer the same way atypical lobular hyperplasia is not considered a direct precursor of malignancy but it is high risk the presence of atypical lobular hyperplasia indicates that there is a higher risk that the woman may develop a cancer just as the radial scar by itself is not a cancerous lesion but the associations it is associated with atypical ductal hyperplasia adh dcis and tubular carcinoma therefore it is considered high risk it is not a direct precursor of malignancy okay it is the same way for alh and lcis they are not direct precursors but they are high risk but the risk is not small okay the risk ranges between 27 percent to 40 percent imagine if i was told that there is a 40 percent chance that you could eventually develop cancer then i would be worried because as an average risk woman my risk for developing breast cancer is about 8 to 10 percent okay that's all every woman by virtue of being a woman we all have that 8 to 10 percent lifetime risk of developing breast cancer but does that mean we undergo mastectomies no just because there are higher incidents of road traffic accidents on western express highway do we stop driving cars no we take all the adequate precautions and we do what we need to do but here we are talking about risk of 27 to 40 percent so how should we deal with it and this is the question we are trying to answer so we have selected two articles today for the discussion our decision making factors for surgical excision or active surveillance what should we do should we just keep her under observation or should this woman undergo a mastectomy what are people doing worldwide in cases such as this let's look at the literature and with this thought in mind we have selected two articles and both these articles are from ajr okay so i will share the first article here okay mitusha can you see this article yes ma'am surgical outcome of biopsy proven lobular neoplasia yeah ma'am we can see yeah yeah is there any difference between lobular carcinoma in situ and atypical lobular hyperplasia this was published in ajr in 2012 okay but i thought it was one of the better articles and what they have done is they have they have looked at everything in this article they have looked at all the biopsy proven lcis and alh when we put lcis and alh together we call it lobular neoplasia okay and they try to assess the difference you know between pure lcis and pure alh lesions regarding their radiologic presentation and the malignancy upgrade rate after surgical excision and they also evaluated the outcome of the lesions that were not excised but only followed up what happened to those patients who decided not to have a mastectomy okay and for the women who did not have a mastectomy or any surgical excision they kept them under surveillance for about two years okay two years is a not a very long time but long enough time to know that it did not grow into a full-blown cancer okay and they also documented the upgrade rates okay like we explained earlier for microcalcifications and coincidentally most of these lesions are detected as microcalcifications on the mammogram or they are incidental findings at the time of a biopsy okay however there are some articles out there that say that if you have done a poor needle biopsy with a 14 gauge needle and eventually the patient undergoes a surgical excision then something that was adh will become dcis something that was dcis will become invasive cancer at the time of surgical excision okay but this article says that whether they did the biopsy with a 14 gauge needle or whether they did the biopsy with a 10 gauge vacuum assisted device they did not find a big upgrade rate when the patient underwent a surgical excision or the upgrade rate was same for 14 gauge for needle biopsy as well as 10 gauge vacuum assisted biopsy okay so coming to the results what they found was cancer upgrade rate was documented in 17 of the 43 lcis okay means 40% of the women who underwent surgical excision okay for lobular carcinoma in situ had full-blown invasive lobular cancers okay 11 of the 40 ALH atypical lobular hyperplasia which means 27% had some kind of upgrade so they either had dcis ductal carcinoma in situ or an invasive cancer and two of the six combined ALH and lcis lesions surgically excised for a total malignancy upgrade of 34% now is that a risk factor we are willing to take okay both lcis and ALH lesions presented mammographically in most cases as microcalcifications just as it was in our case none of the patients followed up for the mean period of 51 months like you know the 14 patients small number of patients decided not to undergo any surgical excision but for that time period of 51 months not like you know they they underwent a follow-up for a really long time three four years and they did not develop any malignancy so what is the conclusion what is the conclusion of this author here okay according to him if you notice here they are saying that when pure ALH lesion was the most aggressive lesion found on poor needle biopsy malignancy was documented after surgery in 27% cases with no significant difference from lcis where 40% of the patient had malignancy so according to this author in absence of prospective randomized studies and evidence of factor predicting malignancy the debate will continue as to the optimal management of these lobular neoplastic lesions on poor needle biopsy however they conclude by saying the results of our study in concert with the previous ones reported prompt us to recommend surgery in all patients diagnosed with lobular neoplasia on poor needle biopsy that is the conclusion of this study and they have looked at a fair number of lesions okay they looked at a total of their biopsies which was 14435 core needle biopsies that were performed between 2004 to 2008 of which 126 patients had biopsy proven lcis or ALH okay and based on the 126 patients they are concluding that their upgrade rate to some form of malignancy ranged between 27 to 40% for lcis it was up to 40% and for ALH which was our patient a typical lobular hypoplasia it was 27% and they are recommending that surgical excision be done in our case it would amount to a full full mastectomy okay so we were still not convinced that this is what we should offer to our patient for a 27% risk should she undergo mastectomy okay so we reviewed one more article and before I review that article are there any comments that anybody from the audience would like to make any questions that you would like to ask me okay Mithusha ma'am till now we have not received any specific question okay we can start the review of the second one and all of you who are listening you can just post your queries in the chat box or the Q and A box so it's like an active discussion we are looking at so you can definitely whatever your thought processes are you can actually suggest also if you have a different opinion in this area absolutely so we will look at the second article now just as we were we were still thinking given that our patient has a 27% risk of developing a full blown cancer should we ask for a mastectomy in this case so we looked at this article Mithusha can you see it now yes ma'am yeah so this is also from AJR and what they did was and this article was published in November 2016 okay and what the it is titled core breast biopsies showing lobular carcinoma in situ should be excised and surveillance is reasonable for atypical lobular hyperplasia so what we concluded from this study was LCI should be excised and ALH should be kept under surveillance and to back their recommendation what is the what is the study they have done okay so I'll read the objective here the purpose of this article was to determine the upgrade rate to DCIS or invasive cancer at excision at the same site of the percutaneous breast biopsy finding of atypical lobular hyperplasia or lobular carcinoma in situ using current imaging and strict pathology criteria but their study is quite robust also okay they looked at all the biopsies from January 2006 to September 2013 a total of 32,960 core biopsies were performed of which 1084 core biopsies found ALH or LCIS remember in the previous article they had 126 core biopsies that showed ALH or LCIS in this it is 1084 so literally 10 times more okay so it gave us a little more confidence for 447 lesions in 433 women this was the only high-risk lesion at that site and no ipsilateral malignancy so all we are dealing with here is ALH and LCIS okay and what did their results show their results showed that among these 447 lesions 22 which is 4.9% were malignant at excision including 10 invasive cancers okay they were all negative and 12 DCIS the upgrade rate of LCIS was 9.3% and that of ALH was 3.5% after excluding five cases with radiology pathology discordance and reclassifying one core from ALH to LCIS at review the upgrade rate for LCIS remained higher than that for ALH but having said that it is still not that high in this study and they concluded that excision is recommended for LCIS on core biopsies because of its 8.4 to 9.3% upgrade rate okay now after reviewing 10 times more the number of lobular hyperplasias this is the upgrade rate they have come up with 9.3% for LCIS excluding the discordant case patients with other high-risk lesions or concurrent malignancy the risk of upgrade of ALH typical lobular hyperplasia was about 2.4% surveillance at 6, 12 and 24 months can be performed in lieu of excision because a short delay in diagnosis of a few malignancies is not expected to cause harm okay remember the first thing that we have to remember is as doctors first do no harm Hippocratic oath that's the oath we do we do not want to under diagnose but we do not want to over diagnose also having said that what did they conclude this is a meta analysis they looked at everything that has been published in literature so far regarding ALH and LCIS and after reviewing everything they got these 1084 cases and of these 1084 cases they found that LCIS was the one that was upgrading more number of times than atypical lobular hyperplasia okay however remember in our case there was one exception as compared to regular LCIS and ALH okay the exception was her personal history okay in this article also in the end they have mentioned to us that in conclusion the upgrade rate to malignancy at excision was statistically significantly higher after a concordant core biopsy diagnosis of LCIS okay women between 40 and 59 years of years old have particularly low upgrade rates younger women will have a lower upgrade rate is what they are saying law villa neoplasia lesions in women with a family history of breast or ovarian cancer were more likely to be upgraded even in this article although they are saying that atypical lobular hyperplasia can be kept under surveillance they are warning us that women who have a family history of breast or ovarian cancer are more likely to be upgraded so even if they are saying that in our case there is a 3.5 percent upgrade rate from ALH to a full blown cancer our patient there is a potentially potential chance that she could fall into this category simply because of her strong family history but they also warn us that the upgrade rate was not statistically significantly in the subset of women with suspicious calcifications calcifications was the predominant finding in all these cases okay so how do we conclude in these cases we continue to recommend excision after a finding of ALH at biopsy of non-calcified lesions because ALH is not expected to produce such a finding on imaging so in our case there are two findings that favor that the patient should have excision it is her strong family history and in addition to micro calcifications she also had a mass so in this article after reviewing 1084 lesions which included LCIS and ALH they concluded that LCIS has a higher upgrade rate than ALH but if ALH is associated not just with micro calcification but also with a mass and if the if the woman has a family history of breast or ovarian cancer then automatically her risk of upgrade increases so based on these two articles we conclude that our patient in this situation should definitely have this discussion about having a mastectomy than being under surveillance but remember these are controversial lesions and every case has to be treated case based everything has to be accounted for before a big decision like a mastectomy is done for our patients so with that I conclude discussion of these two papers and I open the and I would request Mithusha to open the forum for for discussion for questions if anybody has questions or if Mithusha you have some questions so ma'am people have not yet started posting their questions but I think they will soon do it so just a few things like is it there any rule of like to phylactic bilateral mastectomies or only unilateral will be suggested now for this patient. There is one more thing that would have to be done before we offer any kind of mastectomy to this patient and that would be genetic mutation testing okay that is one missing link in this whole thing you know given her strong family history plus her diagnosis of a high risk lesion she definitely needs to have BRCA mutation testing the whole panel okay and if she is BRCA one or BRCA two mutation positive then the entire thing changes then the decision becomes easier but if she is BRCA mutation negative she does not have a genetic predilection for having for being high risk in that and in that regard then maybe we could still have a discussion with her about surveillance. So if it is BRCA positive mutations are positive then let me like bilateral mastectomies for that would be that would definitely be a consideration because BRCA one mutation carriers have a 89% lifetime risk of developing breast cancer so like I said an average risk woman has eight to nine percent lifetime risk of developing breast cancer a BRCA one mutation carrier has 89% lifetime risk a BRCA two mutation carrier has a 50% lifetime risk in our patient she also has a high risk lesion which is multi-centric okay so that makes her risk even higher with the strong family history high risk lesion BRCA mutation carrier then it is a no-brainer then it should be bilateral mastectomies with reconstruction okay so thank you for that also ma'am as a radiologist is there any role of PET CT scan as because we have done MRI everything for her so is there any role of PET CT as a further investigation modality anywhere no not not for these precursor lesions PET CTs are usually done for staging of invasive cancer now this was not even a full-blown cancer at the time of diagnosis it was just a precursor lesion so PET CT has no role to play in cases like this okay ma'am so no need of further like staging it like whole body extent or anything there's no need not as a baseline study yes not at all like this is not an invasive cancer so there is no question of this this spreading to any other parts of the body and one more thing like there was a radiology and pathology discordance in this particular case because on ultrasound it was looking more invasive as compared to it just turned out to be in C2N lobular back ALH so do you think ma'am any repeat biopsy just to remove the sampling bias is required or is it we are sure that it is just like ALH and not invasive yeah so here is the thing considering that this is a big decision for the patient undergoing a mastectomy for a precursor lesion like you know for a not a precursor but a high risk lesion then we could we could consider repeating the biopsy with a bigger needle like a 10-gauge vacuum assisted biopsy before subjecting the patient to complete mastectomy but having said that most of the articles out there most of the literature review is telling us that they did not find a statistically significant difference between a 14-gauge core needed biopsy versus a 10-gauge vacuum assisted biopsy when it came to upgrade rates there must be a few cases but you know as they say a few spoilers don't make a summer like you know only if you see a few cases it does not mean that is the rule okay so therefore but having said that you know in a case such as this I would definitely entertain the idea of doing a vacuum assisted biopsy before subjecting the patient to a mastectomy thank you for that ma'am just one more question like for this patient we did like mammography and then MRI biopsy was done earlier before the mammary so if you have any suspicious like area in oral ultrasound and mammography should we go for MRI first and then if possible MR are guided biopsies or like just planning it and after doing MRI so we have a better guidance for the sampling area so anything like that ma'am very very good question so here is the thing it is it is always the temptation should I do an MRI first but if you're seeing clear-cut findings like you were seeing in this case there were pleomorphic microcalcifications there was a suspicious mass in this case you don't need an MRI to come to a diagnosis what you need is a biopsy what you need is a tissue diagnosis so first is always biopsy and after the biopsy to look for the extent of disease perhaps we can do an MRI okay or to look for contralateral malignancy if there is a dense breast then we can do an MRI and in that case it may prompt us to do a second look ultrasound or a second biopsy of another lesion perhaps that is a possibility but MRI will never replace tissue diagnosis okay ma'am so that definitely helps because we get confused in various situations and as radiologist patients are like looking towards us to guide them further correct absolutely what should we do next this their question right so just taking it further ma'am suppose about this case we decided on mastectomy for this particular patient but if for the situation provided if we decide for active surveillance not for this patient but for some other patient then how much should be the frequency what should be the frequency of that like repeat scans and it should be mammoplus sono or only sono how should it be done ma'am oh well this would need a very active surveillance active surveillance like high-risk screening as part of high-risk screening the surveillance protocol is every six months she's under some form of surveillance so if she has a mammogram and breast ultrasound in january then she will have a contrast enhanced breast MRI in june okay then again if everything is stable both on the mammogram that was performed in january and on the MRI that was performed in june as compared to the previous mammogram and MRI then she goes back to the next year same protocol every six months alternating every six months mammogram once MRI once that is the that is the surveillance protocol thank you ma'am one more question is there a rule of contrast enhanced mammography or in these cases ma'am yeah that is currently being evaluated can contrast enhanced mammography be used as a screening tool for younger women the answer still remains to be found as more and more literature comes out we will know also with MRI there is no radiation involved and these are high risk women who are much younger screening protocols start for them in their 30s therefore it is very important to be cognizant of the fact that there is a fair amount of radiation involved with doing a mammogram plus contrast enhanced mammography so i think the you know the logical answer here is it is better to do a contrast enhanced MRI for surveillance rather than doing a contrast enhanced mammography but it remains to be seen as more and more literature gets published we will know better thank you ma'am for taking all those questions in the chat box i couldn't find any further questions but people are putting in positive feedback excellent and i think the discussion helped all of us to come across the doubts we had and come across with the solutions to them as well yes so thank you very much Mithusha for taking us through through this entire session and thank you Gayatri for volunteering to take this case thank you Gauri for being in the background and doing all the all the gritties and management and of course without Dr. Patkar sir and without Dr. Mani sir we can't execute this and then Dr. Shaili Bresing and Jignesh Thakur so thank you everyone we look forward to feedback from all our participants about did you like the format how would you like us to improvise and you know what would you like us to do differently it is your feedback that helps us make do things better and differently at the end of the day we are all learning and we are here to learn from you and we are here to be involved in the teaching so thank you to all those who were who were participating on a Sunday morning taking the time off from their families thank you everyone thank you everyone and stay tuned for the upcoming journal clubs this is a monthly event we are planning and we'll be taking about neuroimaging, breast imaging, body imaging, oncoimaging and musculoskeletal imaging every month one a topic at a time we are going to share these articles with you on a google drive link so that you can review them later as well and the next journal club will be pertaining to body oncoimaging so please stay tuned and the post will be put on various social media platforms as well as on our channel and this also will be shared on the youtube channel of indian radiologist so please do subscribe for the same thank you once again for your support and thank you bears for your kind support for this academy event so with this we come to an end of the session for today thank you all for your positive feedbacks we also require your feedbacks how to improvise about it so we welcome you for that as well