0:00

This is left breast IDC.

0:03

Prior lumpectomy patient.

0:06

Okay.

0:07

And I'm going to start at the top and then

0:10

come down, and you can see that these things

0:12

are pretty readily seen, pretty

0:14

evident, uh, up front

0:17

on these T1 pre, uh, non-fat sets.

0:20

'Cause you can actually see the axilla, um,

0:22

the axillary surgical site compared to the

0:25

normal right side, and then coming down.

0:28

And then you can begin to see some

0:30

other subtle but possible, uh,

0:33

sites of architectural distortion.

0:34

She's also got susceptibility

0:36

artifact from clips.

0:38

Um, so that's our, that's

0:40

our lay of the land anatomy.

0:43

All right.

0:44

So these are the subtracted images we, as we

0:46

talked about, and I have reformatted them.

0:49

And so, um, I wanna remind you that in the

0:52

classic, um, uh, breast-conserving therapy

0:55

setting, uh, the same thing holds true on MRI as

0:58

holds true on, um, um, mammogram and ultrasound.

1:03

Now, which is that you often have architectural

1:05

distortion in the affected breast.

1:07

You may have seromas as we do in this case,

1:09

this, uh, this breast does have a seroma

1:12

as you may recall from the, um, from the

1:14

T2 images in your gold standard report.

1:17

And also the, um, there's

1:19

usually a size discrepancy.

1:21

Now I must tell you, this is a bad

1:23

example because the left breast

1:25

is actually larger than the right.

1:27

And that is not, as best I

1:28

can tell, because of any

1:30

post-procedural issue.

1:31

The seroma is relatively small.

1:34

But, um, what Dr., um, Dr.

1:37

Lewis submitted this for two specific reasons.

1:39

And one is that the treated breast,

1:41

especially post-radiation, is going

1:44

to have, um, less, uh, background

1:46

parenchymal enhancement for some time.

1:48

It does not classically persist forever

1:50

and ever, but for some period of time.

1:52

And this was, um, this was a newly, uh,

1:55

relatively newly treated breast cancer.

1:58

So for some period of time, um, Uh, be mindful

2:01

and don't over-call background parenchymal

2:04

enhancement in the contralateral breast, okay,

2:07

the normal breast, because that is normal

2:09

background parenchymal enhancement. It's just

2:11

that it's suppressed in the ipsilateral treated.

2:14

And then there's also a nice little example

2:16

right here of a biopsy-proven fibroadenoma.

2:21

Again, I take exception with the fact that

2:23

you have better fibroadenomas in the

2:27

course, and you'll see others of them.

2:29

But remember that a dark internal

2:31

septation in a circumscribed mass that

2:33

is T2 bright and may or may not enhance

2:38

has a very high likelihood of benignity.

2:42

So it's the presence of the

2:43

dark internal septation that

2:49

increases the likelihood of benignity.

2:52

All right, so that's it.

2:53

So the two teaching points for this were VCT

2:56

changes, both anatomically, as well as on

3:00

imaging with the kinetics and the enhancement,

3:04

and then that fibroadenomas that can be seen.

3:09

All right, any questions at all at this point?

3:12

And in which case, I'll just go

3:13

to the final one, and then we can,

3:15

we can talk some more after that.

3:19

Can I just ask something?

3:20

So initially when I looked at this case, I saw

3:23

they were linear, um, it just appeared like

3:27

clumped, like, um, non-mass enhancement.

3:32

But then when I went back to the T2, I thought

3:35

probably it was ductal ectasis and not real.

3:39

Because I thought it was just too diffuse to

3:42

be real, not mass like DCS kind of picture.

3:48

I don't know if you saw.

3:51

Yeah, yeah, no, I, I agree.

3:53

I think, and remember that what you need to

3:55

be looking at are the subtracted images.

3:58

The T1 pre-images sometimes

4:00

have hyperintensity on them.

4:02

And so the fact that there are seemingly hyper-

4:06

intense areas on the T1 post. If they were,

4:10

If they were, if they were T1 pre-bright.

4:14

Uh, not so much the T2, but if they were T1

4:16

pre-write, they're going to subtract out.

4:18

So always remember, honestly, and

4:19

that's my, um, that's my shortcut cue.

4:22

A lot of people say to go to the MIPS.

4:24

But I find that the use of the subtracted

4:28

image, subtracted scroll images, as

4:31

my first diagnostic enhancing image.

4:34

Obviously, I like the anatomy on the, um, pre-

4:38

contrast non-fat sat, but rather than going

4:41

to the MIP first or rather good than going

4:43

to the source data first, I always go to

4:45

the first subtracted for that very reason.

4:47

Um, because I think you get to skip, uh,

4:50

some gnashing of your teeth, um, based on

4:54

what you saw on the non-contrast, pre-image,

4:57

uh, T1 images, and then the post.

5:00

First pass, so I agree.

5:02

I think that's a, I think that was

5:04

a good, very, very nice observation.