0:00

So this case is a little different, but a good,

0:03

I think, reminder to think about technique and

0:07

quality when you're looking at MRI exams, right?

0:11

So, you know, same issues apply in

0:14

terms of positioning of the breast.

0:19

Um, you know, and we certainly have seen and you

0:24

will see a few cases of this more in the

0:27

course later, but we have certainly seen many

0:30

cases of poor positioning on MRI, which can lead

0:34

us astray, right? Either in visualization or

0:38

gives you some artifact that makes it impossible

0:40

to, you know, visualize a portion of the breast,

0:44

um, or, you know, could even create things that

0:45

look like masses that aren't, um, so, um,

0:49

in this case, of course, positioning is good.

0:51

But the issue that came up is that,

0:56

um, we didn't actually get any

0:59

sort of contrast in the patient.

1:01

So this, sorry to rotate that one.

1:06

Um, we have the pre and Thanks.

1:10

Post contrast images here.

1:12

Um, and they look, you know,

1:14

exactly the same, right?

1:15

We really don't see any contrast in the heart.

1:17

We should be seeing quite a bit in the

1:19

heart, and we don't see really any at all.

1:22

So this is, uh, kind of a

1:23

failed contrast administration.

1:25

And, of course, this patient, um,

1:28

has not had an adequate study.

1:30

Um, and it needs to return

1:32

for a repeat, repeat study.

1:33

And really, this sort of thing should

1:34

be caught by your technologists.

1:37

Um, but if they don't, uh, you're

1:38

the last, last stop for that.

1:39

And you can bring that up.

1:44

So nothing really, nothing really

1:45

to see there in the breast.

1:46

I mean, I guess they did have a couple of

1:47

little findings here, probably some, uh,

1:49

cysts that are, uh, have some either blood

1:52

or proteinaceous debris in them.

1:55

I'm giving a little bit of T1 signal there.

1:57

Um, but nothing else to see there,

1:59

nothing else that we can see, because

2:01

we don't have any contrast on board.

Wk 1, Case 5 - Review

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0:00

So this case is a little different, but a good,

0:03

I think, reminder to think about technique and

0:07

quality when you're looking at MRI exams, right?

0:11

So, you know, same issues apply in

0:14

terms of positioning of the breast.

0:19

Um, you know, and we certainly have seen and you

0:24

will see a few cases of this more in the

0:27

course later, but we have certainly seen many

0:30

cases of poor positioning on MRI, which can lead

0:34

us astray, right? Either in visualization or

0:38

gives you some artifact that makes it impossible

0:40

to, you know, visualize a portion of the breast,

0:44

um, or, you know, could even create things that

0:45

look like masses that aren't, um, so, um,

0:49

in this case, of course, positioning is good.

0:51

But the issue that came up is that,

0:56

um, we didn't actually get any

0:59

sort of contrast in the patient.

1:01

So this, sorry to rotate that one.

1:06

Um, we have the pre and Thanks.

1:10

Post contrast images here.

1:12

Um, and they look, you know,

1:14

exactly the same, right?

1:15

We really don't see any contrast in the heart.

1:17

We should be seeing quite a bit in the

1:19

heart, and we don't see really any at all.

1:22

So this is, uh, kind of a

1:23

failed contrast administration.

1:25

And, of course, this patient, um,

1:28

has not had an adequate study.

1:30

Um, and it needs to return

1:32

for a repeat, repeat study.

1:33

And really, this sort of thing should

1:34

be caught by your technologists.

1:37

Um, but if they don't, uh, you're

1:38

the last, last stop for that.

1:39

And you can bring that up.

1:44

So nothing really, nothing really

1:45

to see there in the breast.

1:46

I mean, I guess they did have a couple of

1:47

little findings here, probably some, uh,

1:49

cysts that are, uh, have some either blood

1:52

or proteinaceous debris in them.

1:55

I'm giving a little bit of T1 signal there.

1:57

Um, but nothing else to see there,

1:59

nothing else that we can see, because

2:01

we don't have any contrast on board.

Report

HISTORY:

44-year-old woman presenting with a palpable right breast mass. US guided biopsy of mass showed invasive ductal carcinoma ER+ PR+ Heu2+. Right axillary node biopsy was negative.

Summary of prior imaging:

Mammography: Extremely dense breasts with ill-defined 4cm mass RUOQ Ultrasound: 3.5 cm lobulated vascular hypoechoic mass 11:30 4cm FN. 2 cm right axillary node with thickened cortex.
Breast MRI: NA

FINDINGS

Quality control issues: ☐None ☒Poor/lack contrast bolus ☐Poor fat suppression
☐ Susceptibility ☐Movement ☐Other: Click or tap here to enter text.

Background Parenchymal Enhancement: Minimal
Amount of Fibroglandular Tissue: Extreme fibroglandular tissue

LEFT BREAST
Narrative: Multiple cysts, no enhancing lesions

Associated findings LEFT breast: ☐Nipple retraction, ☐Nipple involvement, ☐Skin retraction, ☐Skin thickening, ☐Skin invasion-direct, ☐Skin invasion-inflammatory,
☐ Pectoral muscle invasion, ☐Chest wall invasion, ☐ Architectural distortion

Non-enhancing findings LEFT breast: ☐High ductal signal pre contrast T1, ☒Cyst(s),
☐ Hematoma/seroma, ☐Post therapy skin/trabecular thickening, ☐Non-enhancing mass,
☐ Architectural distortion, ☐Signal void from clips

Fat containing lesions LEFT: ☐Fat necrosis, ☐Hamartoma, ☐Post-operative seroma/hematoma with fat

Lymph nodes LEFT: ☒Normal axillary, ☐Abnormal axillary: description, ☐ Abnormal internal mammary: description

RIGHT BREAST
Narrative: Lack of intravenous contrast negates evaluation of this study. Known IDC is seen as 3.5 cm “non enhancing” mass with peripheral clip artifact. Multiple cysts

Right breast lesion 1
Lesion type: Mass
3.5 cm. Upper outer Quadrant. 11:00 Radian. 4 cm from the nipple
Mass/post-surgical change: Shape:Oval/lobulated. Margins:Circumscribed , Enhancement
cannot be evaluated.
BI-RADS:6: Known biopsy-proven malignancy – Appropriate action should be taken

Associated findings RIGHT breast: ☐Nipple retraction, ☐Nipple involvement, ☐Skin retraction, ☐Skin thickening, ☐Skin invasion-direct, ☐Skin invasion-inflammatory,
☐ Pectoral muscle invasion, ☐Chest wall invasion, ☐ Architectural distortion

Non-enhancing findings RIGHT breast: ☐High ductal signal pre contrast T1, ☒Cyst(s),
☐ Hematoma/seroma, ☐Post therapy skin/trabecular thickening, ☒Non-enhancing mass,
☐ Architectural distortion, ☒Signal void from clips

Fat containing lesions RIGHT: ☐Fat necrosis, ☐Hamartoma, ☐Post-operative seroma/hematoma with fat

Lymph nodes RIGHT: ☐Normal axillary, ☒Abnormal axillary: At least 2 mildly abnormal nodes, largest 16 mm with a clip artifact, ☐ Abnormal internal mammary: description

Extramammary findings: None

SUMMARY: Failed contrast bolus. Known 3.5 cm Right IDC does not therefore enhance

RECOMMENDATIONS: Repeat study as soon as possible

Case Discussion

Faculty

Petra J Lewis, MBBS

Professor of Radiology and OBGYN

Dartmouth-Hitchcock Medical Center & Geisel School of Medicine at Dartmouth

Sheryl G. Jordan, MD

Professor, Department of Radiology

University of North Carolina School of Medicine

Ryan W. Woods, MD, MPH

Assistant Professor of Radiology

University of Wisconsin School of Medicine and Public Health

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Wk 1, Case 5 - Review