0:00

Another case of treated breast

0:03

cancer status post mastectomy.

0:05

So, the history that was provided here was

0:09

that this is a high-risk screening breast MR.

0:12

She's a younger woman, 58, and,

0:15

good on each one of you if you don't

0:17

think 58 is young. I'm at

0:21

the stage, I think 58 is pretty young.

0:23

Pretty young.

0:24

Um, she has a prior history of right

0:26

breast cancer status post right

0:27

mastectomy and tram reconstruction.

0:30

So I'm going to convince you that once you've

0:32

seen a TRAM and once you recognize a TRAM,

0:35

you're never not going to recognize it.

0:36

They all look exactly alike.

0:38

Like, or they look pretty,

0:40

they look pretty darn alike.

0:41

So, um, so let me just scroll here.

0:45

We're going to start at the top.

0:47

See, I'm even struggling with

0:48

somebody else's platform here.

0:49

Okay, we're going to start at the top and

0:51

come down, and it's evident immediately

0:55

that we don't have symmetric breasts.

0:57

Parenchyma, um, that we have the contralateral

1:01

left breast looks far more normal on the

1:03

T1 pre non-fat sets, with returns

1:06

in terms of rests of parenchyma,

1:09

glops of tissue as you, as it were.

1:11

And then, um, also very

1:13

similar, different surgery.

1:15

I'm sorry, different surgeon,

1:16

but analogous appearance.

1:19

We've got the abdominal fat.

1:22

And then we've got that little bit of

1:24

leftover epithelium that used to be the

1:26

chest, and then we've got that line, and

1:28

then we, we have the, we have the, um,

1:30

the vascularized flap itself, um, here.

1:35

Now, what's going to be different in this

1:37

case is this case has a lot more going on

1:40

than did the, than did my asymptomatic

1:43

completely normal TRAM case from a moment ago.

1:48

And in fact, this was what, what, in part,

1:52

was plaguing the patient. The patient

1:53

had pain; the patient had palpable masses,

1:56

and then the question becomes, well, what

1:59

are these? Are these of concern at all?

2:01

So I'm going to remind you in terms

2:03

of our, I'm going to remind you.

2:06

So I want you to just be reminded of this.

2:10

Be reminded of this, um, content of fat here.

2:14

Um, and there's, it's a very typical

2:17

appearance, um, uh, um, for fat.

2:21

You can actually see the fat,

2:23

the fat, uh, the fat intensity.

2:25

All right, and then, um, this

2:27

is a very straightforward answer

2:29

once I get it re-rotated here.

2:31

Rotate, rotate, and re-windowed.

2:35

And you'll see that, um, there we go.

2:39

What we have is, um, there we go.

2:44

So we have, um, tissue, uh, that

2:47

is actually overtly fat-containing.

2:50

Admittedly, some of it enhances in

2:52

an inflammatory manner, admittedly.

2:55

But nonetheless, the tissue itself

2:59

is, um, consistent with fat necrosis.

3:02

So we have a TRAM with fat necrosis.

3:05

Arguably, MR is not the manner to

3:08

actually, um, to actually determine

3:11

that we are just having to avoid, um,

3:16

the teaching point of this case.

3:18

Honestly, it's avoiding an overdiagnosis

3:21

of fat necrosis as malignancy.

3:24

So in this case, the next step would

3:26

be a diagnostic mammogram, um, plus

3:30

minus ultrasound because the findings

3:32

will be very characteristic, as we

3:33

all know, as breast on, um, mammogram.

3:37

Okay, any specific questions? Classically, you

3:41

would just use split screens or in our case,

3:44

you know, 2 on 1, or a 4 on 1, and just confirm

3:47

that the enhancing masses.

3:51

Are indeed, you flip these enhancing masses.

3:55

I can get this window and leveled

3:57

so we can even see where we are.

3:59

There we go.

4:00

That the, um, that the, that the

4:02

enhancing masses are, in fact, merely fat.

4:05

So another, uh, utility of those, um, uh, of

4:09

starting with the pre, um, the pre-contrast

4:13

non-fat set images. In this case, it very

4:15

nicely delineates both the anatomy, the fact

4:19

that she's a high-risk patient who has had

4:21

breast cancer, but also all of the, um, fat.

4:24

Fat necrosis is quite common, by the

4:26

way, in the setting of the flaps.

4:28

They've gotten better at it, uh,

4:30

but, uh, fat necrosis now plagues us

4:32

in the setting of the oncoplasties.

4:34

Do, do any of you have sites that

4:36

have oncoplastic surgeons that

4:38

are doing a lot of fat grafting?

4:40

In which case, you should be

4:41

giving this, uh, along with me.

4:45

We could do this session in tandem.

4:46

We could do a whole session on fat necrosis

4:50

together because we, many of us in the

4:54

business learned about fat necrosis in

4:56

the setting of, in the setting of the

5:00

patients who had had these trans flaps.

5:02

They're the ones that seem

5:03

to be the most plagued by it.

5:04

Although certainly, lots of

5:04

lumpectomy patients have

5:07

fat necrosis, but now, no doubt,

5:10

hands down, we see it most frequently

5:12

in the patients who have had oncoplasty

5:14

procedures, in whom the, in whom the, the,

5:18

the fat, the free fat, the free fat in.

5:22

Actions and, um, uh, other, um, other plastic

5:27

procedures are yielding a lot of fat necrosis.

5:31

So anyway, anybody have any experience

5:33

with that at your institution?

5:36

If not, it's to come, I promise that made it to

5:39

you yet breast breast surgery, a lot of plastic

5:45

surgeons at this point for patient satisfaction.

5:48

So patient satisfaction is superior.

5:52

All right, so those were the

5:53

teaching points on that case.