ROJoson PEP Talk: MAR - Correcting an Error in Breast Ultrasound Diagnosis

ROJoson PEP Talk: MAR - Correcting an Error in Breast Ultrasound Diagnosis

1. October 19, 2024 1400H - 1500H Via Zoom Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis Empowerment objective - for laypeople to have an essential  understanding on “Correcting an Error In Breast Ultrasound Diagnosis” as part of their health management.

2. October 19, 2024 1400H - 1500H Via Zoom Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis Empowerment objective - for laypeople to have an essential  understanding on “Correcting an Error In Breast Ultrasound Diagnosis” as part of their health management. Welcome all! MUTE yourself but always show your video picture. Sign in your name, FB account, or email address in the Chat Box! Include names of companions attending. Use the Chat Box to ask questions and make comments while the PEP TALK is on. There will be group pictures at start and end of PEP TALK – show your face in video.

3. t Reminder after the PEP Talk: Take the Online Learning cum Evaluation Test Exercise (OLETE) for mastery of learning and have a perfect score to get a Certificate. Link is in Chat Box.

4. Reminder: 25 OLETE Certificates = 1 Voucher for ROJoson Medical Consultation either Face-to-Face or Telemedical.

5. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis Empowerment objective - for laypeople to have an essential  understanding on “Correcting an Error In Breast Ultrasound Diagnosis” as part of their health management. ROJOSON’S REQUEST: FEEDBACK TO THIS PEP TALK! Pls. type in your feedback in the chat box during the open forum and before we adjourn! Thank you!

6. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis Empowerment objective - for laypeople to have an essential  understanding on “Correcting an Error In Breast Ultrasound Diagnosis” as part of their health management. LET’S NOW HAVE A GROUP PICTURE TAKING BEFORE WE START PEP TALK PROPER IN 2 MINUTES! Pls. turn on your video! Show your face!

7. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis Empowerment objective - for laypeople to have an essential  understanding on “Correcting an Error In Breast Ultrasound Diagnosis” as part of their health management. ROJoson PEP Talk I have a Patient Empowerment Program in which I like to empower the lay people or patients to take control in the management of their health.

8. I started the PEP Talk on May 15, 2021 during the COVID19 Pandemic. There are 3 courses in the PEP Talk. I completed the Core Course on October 9, 2021.

9. From October 23, 2021 onwards, I have been tackling Health Disorder and Health Issue Courses. May 18, 2024 marks the start of YEAR 4 of ROJoson PEP Talk. How long the PEP Talk will last will depend on our enthusiasm , discipline and perseverance .

10. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis Empowerment objective - for laypeople to have an essential  understanding on “Correcting an Error In Breast Ultrasound Diagnosis” as part of their health management. My PEP TALK today is entitled: Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis

11. Contents What is a medical anecdotal report or MAR? Narration Insight / Reflection MAR Title: Correcting an Error in Breast Ultrasound Diagnosis Reporter: Dr. Reynaldo O. Joson Date of Medical Observation: 2024 Disclaimer: ROJoson PEP Talk contains ROJoson’s Thoughts, Perceptions, Opinions and Recommendations (TPORs) culled from experiences of ROJoson and writings of other health professionals . Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis

12. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis MAR: Correcting an Error in Breast Ultrasound Diagnosis GIST of MAR A 75-year-old Filipina one-year post-stroke consulted me on January 23, 2024 for a left breast mass noted two weeks prior. There was a dominant solitary solid left breast mass about 1.5 cm in size with ill-defined border in which my primary diagnosis was breast cancer. She opted for an ultrasound study which gave a diagnosis of an “island of fat” for the palpable mass. We decided to observe. She did not come back for follow-up until 6 months after. The mass at this time was accompanied by a slight skin retraction for which I strongly suspected cancer. Repeat ultrasound followed by a needle biopsy showed the mass to be suspicious for malignancy. We then operated on this patient.

13. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis MAR: Correcting an Error in Breast Ultrasound Diagnosis Some reflection and learning points and issues: Can ultrasound of the breast give a wrong diagnosis? Is ultrasound of the breast always 100% accurate? When does a breast surgeon accept an ultrasound diagnosis? When does a breast surgeon start suspecting errors in breast ultrasound diagnoses? What options are there for breast surgeons to correct an error in breast ultrasound diagnosis in a timely manner? ROJoson’s tips on management of similar situation

14. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis What is a medical anecdotal report or MAR? MAR is operationally defined by ROJoson as a brief written report on an actual medical event that involves an actual patient. The medical observation must have an impact on the reporter in terms of insight gained and which the reporter thinks is worth sharing with other people, usually for learning purpose. The MAR will have 2 parts: Narration Insight or Reflection

15. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis NARRATION I had a patient, ZAL, 75-year-old female, one-year post-stroke, consulted me on January 23, 2024 for a left breast mass noted two weeks prior.

16. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis NARRATION On physical examination of the breasts, there was a dominant solitary solid left breast mass about 1.5 cm in size with ill-defined border in which my primary diagnosis was breast cancer. She opted for an ultrasound of the breast to further evaluate the palpable breast mass.

17. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis NARRATION Ultrasound report: NO definite mass. A “fat island” is seen in left upper outer quadrant which may correspond to the palpable lump. NO ABNORMALITY SEEN. BI-RADS 1 - NEGATIVE NO DEFINITE MASS SEEN. PALPABLE MASS = FAT ISLAND.

18. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis NARRATION Because of the “tone” of the January 23, 2024 ultrasound report, with definite statements on fat island and negative abnormal mass, as a clinician, I have to accept the ultrasound diagnosis. With nothing 100% certain in medicine, I recommended MONITORING – self by patient and by me (“back after 2 months).

19. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis NARRATION Patient did not come back after 2 months (as advised). She came back for follow-up on August 6, 2024 (after about 6 months). At this time, I noted a slight skin retraction signifying the mass was closely adherent to the overlying skin. However, the mass was still movable. This finding was worrisome for breast cancer.

20. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis NARRATION Because of these worrisome findings for breast cancer, I gave her two options: Repeat ultrasound, breast, at same institution so a comparison and review could be made. Needle aspiration biopsy. She opted for repeat ultrasound of the breast.

21. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis NARRATION Repeat (08-06-24) ultrasound report: Ill-defined, irregular, spiculated solid mass, 1.3 cm. BI-RADS 4: suspicious abnormality BI-RADS 4 – SUSPICIOUS ABNORMALITY (FOR CANCER) Breast mass with suspicious features, left Breast mass, left, 2 o’clock, ill-defined, irregular, spiculated, 1.3 x 0.9 x 0.6 cm

22. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis NARRATION My primary diagnosis after the repeat breast ultrasound was BREAST CANCER, left. I discussed with patients the options for additional diagnostic procedure: Biopsy – needle, core needle, and open. She opted for needle aspiration biopsy.

23. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis NARRATION Needle aspiration biopsy showed atypical ductal cells, suspicious for malignancy. An operation was planned with a preop diagnosis of breast cancer with 98% certainty.

24. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis NARRATION Bases or reasons for the high degree of certainty (98%) of diagnosis of breast cancer: Needle aspiration biopsy (suspicious for cancer) Physical examination diagnosis (suspicious for cancer) Repeat ultrasound findings and diagnosis (BI-RADS 4) Age of patient (common in this age group)

25. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis NARRATION END OF NARRATION

26. Contents What is a medical anecdotal report or MAR? Narration Insight / Reflection MAR Title: Correcting an Error in Breast Ultrasound Diagnosis Reporter: Dr. Reynaldo O. Joson Date of Medical Observation: 2024 Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis End of Narration of MAR

27. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis MAR: Correcting an Error in Breast Ultrasound Diagnosis GIST of MAR A 75-year-old Filipina one-year post-stroke consulted me on January 23, 2024 for a left breast mass noted two weeks prior. There was a dominant solitary solid left breast mass about 1.5 cm in size with ill-defined border in which my primary diagnosis was breast cancer. She opted for an ultrasound study which gave a diagnosis of an “island of fat” for the palpable mass. We decided to observe. She did not come back for follow-up until 6 months after. The mass at this time was accompanied by a slight skin retraction for which I strongly suspected cancer. Repeat ultrasound followed by a needle biopsy showed the mass to be suspicious for malignancy. We then operated on this patient.

28. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis MAR: Correcting an Error in Breast Ultrasound Diagnosis Some reflection and learning points and issues: Can ultrasound of the breast give a wrong diagnosis? Is ultrasound of the breast always 100% accurate? When does a breast surgeon accept an ultrasound diagnosis? When does a breast surgeon start suspecting errors in breast ultrasound diagnoses? What options are there for breast surgeons to correct an error in breast ultrasound diagnosis in a timely manner? ROJoson’s tips on management of similar situation

29. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis MAR: Correcting an Error in Breast Ultrasound Diagnosis Reflection and learning points and issues: Can ultrasound of the breast give a wrong diagnosis? Is ultrasound of the breast always 100% accurate? YES, as illustrated in this MAR. Ultrasound of the breast may have a wrong diagnosis. Ultrasound of the breast is NOT always 100% accurate.

30. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis MAR: Correcting an Error in Breast Ultrasound Diagnosis Reflection and learning points and issues: When does a breast surgeon accept an ultrasound diagnosis? When there is NO marked discrepancy in the ultrasound and clinical (particularly physical examination) diagnoses AND there is NO inkling or hint that the ultrasound diagnosis is wrong.

31. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis MAR: Correcting an Error in Breast Ultrasound Diagnosis Reflection and learning points and issues: In this MAR, my primary diagnosis was breast cancer on January 23, 2024 before the ultrasound. My only basis for suspecting cancer was the ill-defined border of the mass. The degree of certainty was thus low, at just 60 to 70%.

32. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis NO ABNORMALITY SEEN. BI-RADS 1 - NEGATIVE NO DEFINITE MASS SEEN. PALPABLE MASS = FAT ISLAND. Reflection and learning points and issues: Because of the “tone” of the January 23, 2024 ultrasound report, with definite statements on “fat island” and negative abnormal mass, as a clinician, I was led to accept the ultrasound diagnosis. (MISTAKENLY LED though – in retrospect or at hindsight).

33. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis NO ABNORMALITY SEEN. BI-RADS 1 - NEGATIVE NO DEFINITE MASS SEEN. PALPABLE MASS = FAT ISLAND. Reflection and learning points and issues: Although a “fat island” is rare, it can exist. Also, the ultrasound is a tool that can more easily recognize a “fat island” than my physical examination. Beside, the ultrasonographer was so definite in its diagnosis (with no slightest doubt).

34. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis NO ABNORMALITY SEEN. BI-RADS 1 - NEGATIVE NO DEFINITE MASS SEEN. PALPABLE MASS = FAT ISLAND. Reflection and learning points and issues: Furthermore, a “fat island” can present with the same physical examination findings that I elicited.

35. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis NO ABNORMALITY SEEN. BI-RADS 1 - NEGATIVE NO DEFINITE MASS SEEN. PALPABLE MASS = FAT ISLAND. Reflection and learning points and issues: So, there was NO marked discrepancy in the ultrasound and physical examination findings AND I had NO inkling or hint that the ultrasound diagnosis was wrong.

36. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis Reflection and learning points and issues: As I said, with definite statements on fat island and negative abnormal mass, as a clinician, I was led to accept the ultrasound diagnosis. In retrospect, I was mistakenly led to believe the ultrasound diagnosis.

37. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis NO ABNORMALITY SEEN. BI-RADS 1 - NEGATIVE NO DEFINITE MASS SEEN. PALPABLE MASS = FAT ISLAND. Reflection and learning points and issues: In retrospect, I did NOT question (which I should have) the lack of detailed descriptions on the so-called “fat island”: No size No quality of border Solid or cystic Etc.

38. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis Reflection and learning points and issues: I gave the ultrasonographer the “greatest benefit of the doubt.” However, I had still some reservation – believing that there is no such thing as 100% correct all the time. I ADVISED MONITORING – self-exam and check-up (after 2 months).

39. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis MAR: Correcting an Error in Breast Ultrasound Diagnosis Reflection and learning points and issues: When does a breast surgeon start suspecting errors in breast ultrasound diagnoses? When there is a marked discrepancy in the ultrasound and clinical (particularly physical examination) diagnoses AND there is an inkling or hint that the ultrasound diagnosis is wrong.

40. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis MAR: Correcting an Error in Breast Ultrasound Diagnosis Reflection and learning points and issues: When does a breast surgeon start suspecting errors in breast ultrasound diagnoses? When there is a marked discrepancy in the ultrasound and clinical (particularly physical examination) diagnoses AND there is an inkling or hint that the ultrasound diagnosis is wrong.

41. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis Reflection and learning points and issues: In this patient, when she came back for follow-up on August 6, 2024 (after about 6 months), I noted a slight skin retraction signifying the mass was closely adherent to the overlying skin. This finding was worrisome for breast cancer.

42. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis Reflection and learning points and issues: So, follow-up is very important in detecting errors in earlier diagnoses, whether ultrasound or clinical, whether from ultrasonographer or breast surgeon.

43. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis MAR: Correcting an Error in Breast Ultrasound Diagnosis Reflection and learning points and issues: What options are there for breast surgeons to correct an error in breast ultrasound diagnosis in a timely manner? Surgeons will decide on the various options available, in consultation and with informed consent with the patient and relatives. A particular option is chosen based primarily on cost-effectiveness. THE MOST IMPORTANT THING TO DO IS TO CORRECT THE ERROR IN THE ULTRASOUND DIAGNOSIS THAT IS SUSPECTED TO BE PRESENT AS SOON AS POSSIBLE.

44. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis Reflection and learning points and issues: In this patient, upon discovery of error in ultrasound diagnosis, I gave her two options: Repeat ultrasound, breast, at same institution so a comparison and review could be made. Needle aspiration biopsy. She opted for repeat ultrasound of the breast first. This was followed by a needle biopsy. ERROR was thus corrected.

45. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis MAR: Correcting an Error in Breast Ultrasound Diagnosis ROJoson’s tips on management of similar situation For patients, be wary of the possibility of errors in breast ultrasound diagnosis. Be vigilant against this with the help of an expert breast surgeon specialist. It is important to have a follow-up to detect and be vigilant against errors in breast ultrasound diagnosis. The expert breast surgeon specialist will provide guide and advice on intervals of follow-up (this has to be religiously followed by the patients).

46. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis MAR: Correcting an Error in Breast Ultrasound Diagnosis ROJoson’s tips on management of similar situation For breast surgeons, be vigilant against errors in breast ultrasound diagnoses. Scrutinize the reports. Correlate with the clinical findings. Talk to the ultrasonographers as indicated. Always have a follow-up scheme to detect and correct errors that may be present.

47. Contents What is a medical anecdotal report or MAR? Narration Insight / Reflection MAR Title: Correcting an Error in Breast Ultrasound Diagnosis Reporter: Dr. Reynaldo O. Joson Date of Medical Observation: 2024 Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis Summary Take Away

48. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis MAR: Correcting an Error in Breast Ultrasound Diagnosis GIST of MAR A 75-year-old Filipina one-year post-stroke consulted me on January 23, 2024 for a left breast mass noted two weeks prior. There was a dominant solitary solid left breast mass about 1.5 cm in size with ill-defined border in which my primary diagnosis was breast cancer. She opted for an ultrasound study which gave a diagnosis of an “island of fat” for the palpable mass. We decided to observe. She did not come back for follow-up until 6 months after. The mass at this time was accompanied by a slight skin retraction for which I strongly suspected cancer. Repeat ultrasound followed by a needle biopsy showed the mass to be suspicious for malignancy. We then operated on this patient. Summary Take Away

49. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis MAR: Correcting an Error in Breast Ultrasound Diagnosis Some reflection and learning points and issues: Can ultrasound of the breast give a wrong diagnosis? Is ultrasound of the breast always 100% accurate? When does a breast surgeon accept an ultrasound diagnosis? When does a breast surgeon start suspecting errors in breast ultrasound diagnoses? What options are there for breast surgeons to correct an error in breast ultrasound diagnosis in a timely manner? ROJoson’s tips on management of similar situation Summary Take Away

50. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis Be always in touch with reliable medical information on CORRECTING AN ERROR IN BREAST ULTRASOUND DIAGNOSIS. Knowledge is power; it gives power. Use the 4Ks of Patient Empowerment: Kaalaman , Kakayanan , Karapatan and Kapangyarihan to gain greater control over decisions / make better decisions on management of CORRECTING AN ERROR IN BREAST ULTRASOUND DIAGNOSIS as part of your health management. Take Away in relation to Patient Empowerment

51. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis Empowerment objective - for laypeople to have an essential  understanding on “Correcting an Error In Breast Ultrasound Diagnosis” as part of their health management. This ends my PEP TALK today on: Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis

52. t Reminder after the PEP Talk: Take the Online Learning cum Evaluation Test Exercise (OLETE) for mastery of learning and have a perfect score to get a Certificate. Link is in Chat Box.

53. Reminder: 25 OLETE Certificates = 1 Voucher for ROJoson Medical Consultation either Face-to-Face or Telemedical.

54. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis Empowerment objective - for laypeople to have an essential  understanding on “Correcting an Error In Breast Ultrasound Diagnosis” as part of their health management. ROJOSON’S REQUEST: FEEDBACK TO THIS PEP TALK! Pls. type in your feedback in the chat box during the open forum and before we adjourn! Thank you!

55. Med Anecdotal Report - Correcting an Error in Breast Ultrasound Diagnosis Empowerment objective - for laypeople to have an essential  understanding on “Correcting an Error In Breast Ultrasound Diagnosis” as part of their health management. LET’S NOW HAVE A GROUP PICTURE TAKING BEFORE WE START Q&A AND INTERACTIONS! Pls. turn on your video! Show your face!