0:00

So for this case, this was kind of

0:02

a so-called extensive disease case,

0:05

right? Looking at this MIP right away.

0:08

And remember, at least our institution,

0:10

we do the MIPs off the subtracted series.

0:13

Um, and right away you can see

0:15

this mass in the right breast.

0:16

Um, you know, pretty large, right?

0:19

Pretty easy to see and really

0:21

not looking at much else.

0:22

And the others are not seeing much else.

0:24

The other thing that it's really nice

0:25

to see on the MIP is, of course, the

0:26

background parenchymal enhancement.

0:27

And you get a sense of how much there

0:29

is and distribution of it in here.

0:32

You know, we're not seeing

0:33

very much at all, right?

0:34

A few little dots of enhancement.

0:35

Um, maybe not even really much that

0:37

we see here in the right breast.

0:40

So if we pull down our T1 fat

0:43

sat post-contrast, um, we can

0:45

see our corresponding mass here.

0:48

This is a really nice example of rim

0:50

enhancement, and you can see the sort of central

0:54

area that's not enhancing as much or maybe

0:58

not enhancing at all—secondary necrosis.

1:00

Um, the rim part of it is sort

1:03

of very nodular looking, right?

1:05

It's not a very smooth sort of rim enhancement.

1:08

Um, and then at the very bottom,

1:13

part of it, we see this focal susceptibility.

1:15

Susceptibility artifact, and

1:17

that's compatible with our bias to

1:18

clip and always abide by eclipse.

1:20

I always think it's important to mention

1:23

where the clip is in relation to the

1:25

primary finding you're seeing, right?

1:27

So in this case, I would say this is at the

1:29

inferior margin of the mass, and that's really

1:31

helpful for localization purposes, right?

1:32

Like, ideally, you might want to see the clip

1:35

essentially located, and you could say that

1:37

for other cases, but for this one, I would say

1:39

that it's at the inferior margin,

1:41

just so you know, for localization purposes

1:43

later, if you're going to be doing that.

1:46

Of course, in all these cases, where they

1:48

are cancers, which is our primary focus.

1:50

Of course, we always like

1:52

to look up in the excella.

1:53

And in this case here, I think the axillary nodes

1:57

all look very normal.

2:00

And, there were no

2:01

findings on the left breast.

2:02

So, you know, this is sort of your

2:03

classic straightforward cancer, right?

2:06

MRI done for extended disease, but we see just

2:09

the main cancer, and nothing else.

2:13

Um, and we can tell our surgeons that

2:15

this is your classic pyro at six, no

2:17

lymphadenopathy, uh, go on your merry way and

2:19

just plan for localization at a later point.

2:22

As I'm pulling this up again,

2:23

are there any questions?

2:26

I'm going to ask a question if that's

2:28

okay, while you're pulling it up.

2:29

Yes, please.

2:30

I'm pretty new to breast MRI, breast MRI.

2:33

So, um, I apologize for probably some pretty

2:36

basic questions.

2:37

No problem.

2:39

So you were mentioning on the left

2:41

breast, there were some very small

2:43

foci of enhancement on the other side.

2:46

And when I was going through that case, I went

2:48

through and I thought, "Oh, could those just

2:51

be little tiny enhancing nodules?"

2:55

Yep.

2:55

So what makes those nodules not worrisome?

3:00

And not worrisome.

3:03

Time and experience.

3:06

Yes.

3:06

I am chuckling because this is, I feel like

3:08

the age-old question in breast MRI is, is

3:12

that background enhancement or is that a mass?

3:16

And, uh, over time, I would say you

3:19

will develop a better sense of that.

3:22

Um, so.

3:23

But to try and answer your question, of course,

3:26

take a little bit to pull up again, but, um, so

3:29

looking at that MIP is really important, right?

3:31

So if you see, um, several areas of

3:37

small foci, and of course, foci is a

3:41

focus is disappearing from the lexicon,

3:42

I think in the next edition.

3:44

Um, but if you see, uh, several small foci,

3:48

if I can, um, zoom this up just a little

3:51

bit so we can look at that left side.

3:54

Um, you know, like this thing, this

3:57

thing, maybe something in here.

4:00

Um, and if you see that distributed,

4:02

let's say even in both breasts, you would

4:04

say, okay, that is classic background

4:07

parenchymal enhancement, right?

4:08

Um, it's all over the place.

4:11

Uh, none of them, no one in

4:13

particular stands out from the rest.

4:15

Um, the distribution is diffuse.

4:19

Um, you know, I think you should be confident

4:22

to say that's just background enhancement.

4:24

Now the hard part comes when there are

4:28

a few of them as in this case, right?

4:30

And maybe we only have them on one

4:32

side and see if I can pull up the

4:34

regular post and scroll through there.

4:37

Um, you know, so you know, for example,

4:40

is this thing a little focus there

4:42

that we need to do something about?

4:44

Maybe, maybe not.

4:47

You know, I don't see many others.

4:51

Find one real quick here.

4:52

Maybe, maybe one like right here.

4:54

Can you see my cursor, by the way?

4:56

There it is.

4:56

Yep.

4:57

Okay, good.

4:57

So, um, you know, a couple little tiny dots.

5:03

And I guess that is the

5:06

sort of the thing that I do.

5:07

Um, but really it's over time.

5:09

You just got to get a sense of what

5:10

you think is something that is real.

5:11

So in terms of me thinking

5:13

about, is it real or not?

5:15

I think, does it stand out from the rest, right?

5:17

Is this one thing I'm looking at

5:19

bigger than the others, or is the

5:22

enhancement different in some way?

5:23

You could look at CAD maybe if you wanted to

5:25

help you, like, does that one have washout and

5:28

all the rest don't? Something like that.

5:32

Um, uh, you know, And then, um, the other thing

5:38

that I start to think about is that if you

5:39

pick out the one that you're most interested

5:41

in and you start looking around either in that

5:44

same breast or the other breast and you say,

5:46

Oh wait, there's actually, there's another one.

5:48

No, there's another one.

5:48

There's another one.

5:49

Like if you start to get up to two or three

5:51

additional things that you're thinking

5:53

about, I would start to more heavily

5:55

consider maybe this is just background.

5:57

You know, maybe this is not something

5:59

that I need to work on.

6:01

Okay.

6:02

Um, the other thing, the other one to remember,

6:05

just in general, is that, that, um, that

6:07

inflow, or so-called cortical enhancement,

6:10

that we sometimes see at the margin of the,

6:12

um, fibroglandular tissue, that can sometimes

6:15

fool us as being, sometimes people think

6:17

of that as almost like segmental non-mass

6:19

enhancement, but I always try to think about.

6:21

Okay, remember that the contrast is going

6:23

to be taken up from the outer part of the

6:25

breast first, and we sort of get that cortical

6:28

enhancement pattern that sometimes that

6:30

can throw you off, too, but it's difficult.

6:33

It's the bottom line.

6:35

Good question, though.

6:40

Any other questions on that

6:41

case from anybody else?

6:42

Other people?

6:45

Okay.

6:45

I have one more question and then

6:47

I think I'll be good after that.

6:50

Okay.

6:50

Yeah.

6:50

The other question that I just wanted

6:51

to ask was, um, and I think this would

6:53

be super easy in this case for you to

6:55

show Mm-Hmm, when I was trying to, um,

6:57

measure the distance to the nipple.

7:00

Uh, yes.

7:00

Do you, do you take it off of the,

7:03

um, axial or the sagittal ? Yes.

7:06

Um, you're asking some great questions.

7:10

I'm just gonna move this outta the way.

7:13

Let's see here so I can see everything.

7:14

All right.

7:15

So I'm gonna, I'm gonna pull up a couple things

7:17

just to get, um, so we can talk about that.

7:20

And I think, um, Anu had the same question.

7:25

Yes.

7:26

Okay, so, um, this is a great question.

7:32

And, um, the, the bottom line is

7:34

that there's Also not a great answer.

7:38

So, and it depends on sort of who you are.

7:41

Um, but I will tell you my philosophy

7:45

and you can adopt it or not.

7:48

So, um, the first part of

7:50

the philosophy is that.

7:52

You're trying to describe where in, in

7:56

the breast you believe this mass is right.

7:59

And we typically use clock face position

8:02

and distance from the nipple, right?

8:03

So clock face, I think we

8:05

can all figure out, right.

6:50

Yeah.

6:50

The other question that I just wanted

6:51

to ask was, um, and I think this would

6:53

be super easy in this case for you to

6:55

show. Mm-Hmm, when I was trying to, um,

6:57

measure the distance to the nipple.

7:00

Uh, yes.

7:00

Do you, do you take it off of the,

7:03

um, axial or the sagittal? Yes.

7:06

Um, you're asking some great questions.

7:10

I'm just gonna move this outta the way.

7:13

Let's see here so I can see everything.

7:14

All right.

7:15

So I'm gonna, I'm gonna pull up a couple things

7:17

just to get, um, so we can talk about that.

7:20

And I think, um, Anu had the same question.

7:25

Yes.

7:26

Okay, so, um, this is a great question.

7:32

And, um, the bottom line is

7:34

that there's also not a great answer.

7:38

So, and it depends on sort of who you are.

7:41

Um, but I will tell you my philosophy

7:45

and you can adopt it or not.

7:48

So, um, the first part of

7:50

the philosophy is that.

7:52

You're trying to describe where in, in

7:56

the breast you believe this mass is, right?

7:59

And we typically use clock face position

8:02

and distance from the nipple, right?

8:03

So clock face, I think we

8:05

can all figure out, right.

8:05

That's pretty straightforward.

8:07

Um, distance from the nipple, of

8:09

course, gets more difficult, right?

8:11

Because it matters how you measure it.

8:13

So what I like to do is that, um, and

8:17

I do this for, uh, mammograms as well,

8:20

when you're going to ultrasound is to

8:21

try to sort of pretend, pretend that you

8:23

are going to be the next person, right?

8:25

So let's say you're going to be the

8:26

sonographer and you're going to say,

8:27

I'm going to try and find this thing.

8:29

And you have to remember the patient's

8:30

going to be laying on their back.

8:32

And so I try to sort of think, okay,

8:34

if I were, the transducer here.

8:37

How would I measure that?

8:38

Um, so in this case, right?

8:41

Um, I think we're first thing I figure

8:44

out are we below the nipple, right?

8:46

Yes.

8:47

It looks like we're below the

8:47

nipple or in the right breast.

8:50

Um, and we're lateral.

8:51

So let's say we're going

8:52

to be about eight o'clock.

8:54

Now the question is how far from the nipple,

8:58

and we know that it's up here, right?

9:01

It's not in the same plane.

9:02

So this is difficult.

9:04

Um, so people take one approach where

9:06

they go down to the nipple, sort of hold

9:09

their cursor there, move up to your spot,

9:11

and then they would measure from where my

9:13

arrow is to the mass, something like that.

9:16

Um, I think that is okay.

9:20

Uh, that is one approach.

9:21

Um, the other way to do it is to think about

9:24

sort of being the transducer or something.

9:28

And, uh, you might measure from where the nipple

9:31

sort of should be here on this image and then

9:33

come out, uh, laterally and measure it that way.

9:35

That's probably what I would do.

9:37

Um, to get a relative sense of it.

9:42

Um, some people I know will just

9:44

measure from, uh, their best guess

9:47

sort of here ish on this one and say,

9:49

okay, I'm going to measure like this.

9:51

Um, it gets a little bit dicey.

9:53

The other thing that I would say in general,

9:56

which is important to do is to try to put it

10:00

all together for your referring providers.

10:02

So if on every other study you said this is,

10:07

let's say eight o'clock and three centimeters

10:09

to the nipple, I wouldn't say, "Oh, this is

10:12

eight o'clock six," or something like that.

10:15

Measuring it some alternative way.

10:17

I think it's just going to lead to confusion.

10:18

All you're, you're all

10:20

talking about the same lesion.

10:22

So, you know, if my measurement is,

10:25

or, or maybe even five measuring my way,

10:29

but we've described it as eight o'clock

10:31

three for the rest, I would probably say

10:34

approximately three or something like that.

10:36

Um, I think you don't want to create any

10:38

more confusion than you have, uh, uh,

10:42

by, by, by, by describing a different

10:45

distance from the nipple, right?

10:46

Cause you will get the question,

10:47

"Oh, is this something separate

10:48

from what we described before?"