0:00

38-year-old, um, under a high-risk

0:03

screening, so no biopsy-proven disease yet.

0:05

Did a recent diagnosis of her

0:06

sister, age 34, with breast cancer.

0:09

Okay, so. Again, first thing we want

0:12

to look at is on our, you know,

0:16

and, um, you know, this is not a, not an

0:19

atypical appearance, I guess I would say,

0:21

you know, at first glance. Of course, we

0:23

can get into some more nuance here, but,

0:25

um, for a younger patient, right, um, um,

0:30

having a lot of background enhancement, so

0:32

this would clearly fall under the marked

0:35

background parenchymal enhancement, right?

0:36

Virtually the entire breast

0:38

on each side is enhancing.

0:40

Um, looking closely, of course, though, we

0:42

do see a little bit difference here, right?

0:44

Some of this looks a little bit more

0:45

enhancing than the other side, right?

0:47

Like a little denser in

0:48

terms of its enhancement.

0:50

Um, it certainly would give you a little

0:52

bit of pause if you were, you know, if

0:55

you weren't moving, moving too quickly.

0:56

Um, and then, of course, the right nipple,

0:58

um, looks, um, asymmetric from the left.

1:01

Now you can have asymmetric

1:03

enhancement of the nipple.

1:04

That's very common.

1:06

Um, but this one does stand out a little

1:07

bit more, even then more than your sort

1:09

of average asymmetry, I guess I would say.

1:12

Um, so, uh, we'll just pull

1:15

up the sub on this one.

1:17

Um, So, uh, you know, like some of the other

1:21

cases in this, uh, week's, uh, group, um,

1:25

there's a lot of enhancement here, um, a lot of,

1:28

uh, diffuse, uh, kind of non-mass enhancement,

1:31

you could maybe call it regional, or multiple

1:33

areas, multiple regions of non-mass enhancement,

1:36

um, looks like it's mostly confined to the

1:39

upper breast, right, coming down about, just

1:41

below the level of the nipple, I suppose.

1:43

Um, but extending from the interior to

1:45

posterior depth, we got some here, some

1:47

back here, and looks like it's getting

1:49

into the nipple with some almost kind

1:51

of rim enhancement of the nipple there.

1:53

Um, and then just overall enlargement

1:55

of the size of the nipple,

1:57

especially comparison to the left.

1:59

Um, those are all things

2:00

that you'd want to mention.

2:02

Um, I would say that it goes all the

2:04

way back to the chest wall, right?

2:06

No, um, but I would say there's no

2:07

evidence of invasion in the chest wall.

2:09

Um, I believe that, uh, the these this

2:15

node or maybe there were a couple nodes

2:17

on that right side level one nodes least

2:19

look a little bit mildly prominent.

2:21

Um, I think in this case, um, that reference

2:26

report, they said that that node was biopsied,

2:28

but was, um, was indeed negative in the

2:30

end, but that would be a very reasonable

2:32

call to, especially if you appreciated

2:34

some asymmetry in those nodes.

2:36

Um, so, you know, a bit surprising,

2:38

right, for this patient.

2:40

Person who's looking at this case, thinking

2:42

you're opening up a, you know, high-risk

2:43

screening exam on a relatively young

2:45

patient that you don't expect to see this

2:47

sort of diffuse, um, non-mass enhancement.

2:50

Um, this type of enhancement is,

2:52

um, a good example of, um, clustered

2:55

ring, and probably in this image here.

2:57

So, right, so you can see there's multiple

2:59

small kind of rings of enhancement, very,

3:01

um, classic for, um, DCIS, right?

3:05

So that's the ducts that you're seeing that

3:07

are have some enhancement of the, um, the ducts

3:10

themselves or atypical cells within the ducts,

3:13

um, giving that clustered ring appearance.

3:15

We don't really, I would say you don't really

3:16

see this very much at all, um, uh, pretty

3:20

uncommon, um, but it's good, a good indicator

3:23

for, um, Now, of course, if you have like

3:27

just a few areas that looked like rings, you

3:29

might want to also consider, um, inflammatory

3:32

cysts, like on the case from last week.

3:34

Um, but of course you'd expect that

3:35

to be a little more individual, right?

3:37

Or a few, a few areas, uh, a few,

3:40

um, inflammatory cysts, not like this

3:43

huge area of non-mass enhancement

3:45

with a bunch of rings, tiny rings.

3:48

Sorry for the silly question again, but

3:51

my, uh, mine is again on the other breast,

3:54

uh, because this one was very obvious, but

3:57

in the other breast there's a lot of, um,

4:01

a lot of blips happening and, um, uh, how,

4:05

how would we actually, um, again, give

4:10

significance to some of this is not because

4:12

there's, there's quite a bit, even on the.

4:14

On this image.

4:15

Yeah, like, like that blip over there.

4:17

That's here on the lateral fence.

4:18

Yeah, yeah.

4:19

Yeah.

4:20

I mean, I think it's a good question.

4:21

Um, it's certainly something that

4:23

you develop over time, right?

4:26

Sort of saying, do I think this little,

4:28

this little blip is worth it or not?

4:31

Um, yeah.

4:31

You know, I don't think anybody

4:32

would fault you for that.

4:34

Um, that one does stand out

4:36

a little bit from the rest.

4:39

Um, you know, it is background enhancement

4:42

is probably one of the most difficult

4:43

things that we have to deal with.

4:44

Right.

4:45

Uh, uh, and it is also true that, um, you

4:50

will see areas of background enhancement where

4:53

some look small and some portions of it are

4:57

look bigger.

4:58

Um, and that's okay.

5:01

You know, one of them has

5:02

to be the biggest, right?

5:03

Um, but you're trying to figure

5:05

out whether it really stands out.

5:07

Um, um, amongst the rest, I, uh,

5:10

didn't look at this earlier, but one

5:11

thing that you could potentially do

5:13

is look at some of the kinetics here.

5:15

Now, you know, I, um, I'm not a huge fan of

5:18

using kinetics for problem solving, um, because

5:23

it does get a bit difficult, but, um, you

5:26

know, we can see on this side that there's some

5:28

areas of, um, plateau and some washout in here.

5:32

And I'm seeing less of that on the left side.

5:37

And you might wonder about your area here.

5:41

Um, I guess my, My intuition would be that I

5:46

think that that left side is okay, um, but given

5:50

some of the enhancement kinetics that we see

5:53

in that one area and that one thing that stands

5:55

out a little bit from the rest, I don't think

5:57

it would be wrong to call that one and say,

6:01

I think we need to biopsy that one quick

6:04

question on the subject of kinetics.

6:06

Um, you know, in the sort of answer key for,

6:10

you know, for this case presented, you know,

6:12

mentioned delayed and plateau kinetics for that.

6:15

But, you know, when you look through it, I feel

6:17

like there, there's plenty of red in there.

6:19

And, you know, when you have something

6:21

so diffuse, how do you normally describe

6:24

something that has very, you know, mixed

6:26

kinetics, but obviously a good portion of

6:28

it has the more concerning washout features.

6:31

Yeah, in, um, at our institution, we, we have

6:34

agreed, um, to always report the worst kinetics.

6:39

So, if this case had, uh, some areas

6:43

that were red, um, then you would say

6:47

the worst kinetics initial phase are, you

6:49

know, um, rapid and delayed phase washout.

6:53

Um, that's how we report it.

6:56

Um, I have also, um, seen and done myself

7:01

at other institutions where you could

7:03

say, um, if you're reporting the kinetics,

7:06

you could say, um, "You know, uh, which I

7:10

think maybe not in this particular case,

7:11

but you could say something to the effect

7:14

of there's primarily, uh, persistent

7:17

kinetics with, you know, a few areas, focal

7:20

areas of washout or something like that.

7:21

Depending on, I think what you're

7:23

trying to say or prove, right.

7:26

You'd want, you could include a

7:28

statement, something like that.

7:30

Um, I think, I think both of those

7:33

things would be reasonable, but,

7:34

but we just report the worst ones.

7:36

The worst.

7:38

So I realized it, you know, someplace, some

7:41

cases, case by case, maybe judgment call.

7:43

But I feel like in one of the

7:44

cases from last week, there was.

7:47

The whole, the whole mass was, was plateau

7:51

with the exception of, you know, if you look

7:52

at the screen right now, you know, like a

7:53

little dot of red, you know, in one, in one

7:56

corner of it, you know, is that still, is that

7:58

still one that you would, I mean, yeah, is

8:01

that, is that sort of how, you know, how would

8:03

you handle a, you know, something like that?

8:05

Yeah, yeah.

8:06

Um, yeah, I guess, um, I don't think we've

8:10

ever, at least in our practice, have said like,

8:13

if it's one, if it's one pixel of red, do we

8:16

take it, you know, do we call that the worst?

8:18

Um, uh, so I don't know if

8:22

I have an answer to that.

8:24

That would be our sort of typical

8:26

approach. Even if there were a

8:28

smaller component, let's say it's like

8:30

10 percent of the mass or something.

8:32

We would still report

8:33

those, um, worst-case ones.

8:35

And I think that we do that because,

8:39

for the most part, we think of MR as more

8:43

of an anatomical exam and don't, you know,

8:50

if we see something on the, you know, the

8:54

non-CAD portions of the exam, right, like

8:56

let's say you have an irregular mass with

8:59

rim enhancement, even if the CAD looks

9:03

not worrisome, if it was all persistent, it

9:06

wouldn't change my management in terms of

9:08

recommending a biopsy for that thing, right?

9:11

So even if there is a dot of red and a

9:14

seed of blue, and I think that by the

9:17

anatomic exam it looks suspicious, then I'm

9:21

still going to recommend a biopsy, right?

9:24

Thank you.

9:29

In fact, I think, I think there are a number

9:31

of cases where I don't even look at CAD.

9:33

Um, you know, especially ones where you think

9:36

that the, you know, it's like a screening

9:38

exam and you're calling it negative.

9:39

I don't want to be led astray by

9:42

some tiny focus of washout that

9:44

I didn't anticipate seeing there.

9:45

And I really don't see anything on the regular,

9:48

um, you know, non-CAD portion of the exam.

9:50

So, um, try not to get too swayed by CAD.