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Let's go to case 12.

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And I'm zoomed up on the left breast.

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But what I want to show you in this

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patient before I show you her MRI, is her mammogram.

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So this is a woman with very small, dense breasts.

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The scar that you you see here is

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from, the scar marker, is from a benign prior biopsy.

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She was called back from screening because of this group here of fairly amorphous

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calcifications, which was very posterolateral in that right breast.

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But they were new. There's some other little scattered ones

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that were not felt to be anything too much and there were no palpable masses.

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So she went to stereotactic biopsy of this posterior group from a lateral approach

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and they successfully got the calcifications.

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It came back as DCIS.

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And then she went on to...

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I'm sorry. It came back as both DCIS and

0:59

invasive ductal carcinoma, which people were a bit surprised about.

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And she then went on to have this MRI of her left breast here.

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And what I'm showing you on the left is the gadolinium-enhanced first phase.

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What I'm showing you on the right is the subtraction image.

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And we're just going to focus on one

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little area here and that's this area within the pectoral muscle here.

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Can you see that little area here?

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She also had a ton more enhancement in her

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breast and we were anticipating from the mammogram.

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And she did turn out to have

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very extensive multicentric invasive ductal carcinoma.

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You can just see how much she's got there throughout this breast.

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But she had this one area within the pectoral muscle.

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I'm going to show you on the...

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I have two other images here to show it.

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One is the delayed gadolinium.

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So this is slightly later into the sequence.

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Trying to get that over. Hang on.

2:21

It suddenly not panning on me.

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Now, you can see it here.

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Here's this little area.

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I'm going to show you that on the sagittal

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with any luck.

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Here it is on the sagittal.

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And then I have a T2 of the same area.

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And here is on the T2.

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I can zoom up on that a bit if I can get it to stop wobbling on me.

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So, let's put on the quiz questions for this.

3:24

Zoom on that area.

3:30

All right. So we've got quite a range of people, but a significant number did go

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for post biopsy changes, which is the correct answer.

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So what happened in this patient,

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let me take that zoom off a sec,

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is, what I didn't tell you is,

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as part of her path report, it did say normal pectoral muscle.

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So the stereo came in from the lateral aspect.

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Do you remember how posterior those calcifications were?

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And you see they're directly overlying pectoralis.

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And in a lady with a small breast, it's difficult to not get into pectoralis.

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So, you can see that this is high on T2, although it did have some enhancement.

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It directly follows the track of where the biopsy occurred.

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She had nothing else to suggest pectoral

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invasion and she had no pectoral involvement at the time of her mastectomy.

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Now pectoral invasion, although it definitely should be looked

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for and it should be commented on in the path reports,

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and you should say that in this particular case,

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the tumor, once we decided about this, abuts pectoralis,

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but does not invade it.

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Or you should say, if it invades it,

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but pectoral invasion is nonexclusion

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to surgery because they can remove some or all of the pectoralis muscle, if necessary,

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with a radical mastectomy.

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Chest wall invasion, it's got to be through pectoralis and into the chest wall.

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So that's a different condition altogether.