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Right.

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Here's our next case.

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I'm actually going to start by showing you a mammogram of this lady.

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So this is a 78-year-old woman who has

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remote history of left breast, invasive ductal carcinoma.

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She's status post left breast lumpectomy and radiation therapy.

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It was quite a few years ago now.

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And she presented with diffuse right breast swelling.

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So if you look at her mammogram here

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for a moment, and then I'm going to go across to her MRI.

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So here's her MRI.

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We'll start with the T2 slices here, and I'm pretty low here.

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I'm going all the way down.

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And you'll see why I'm doing this in a minute.

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So this is the T2.

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I'm going to come up on the T2, and I have

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orientated all these breasts so that they are in CT looking from the feet

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orientation, so to try and keep them conventional.

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So that's a T2 image.

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And then this, on the right-hand side I'm going to show you initially,

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is the subtraction.

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I'm going to put the axial images up in just a minute.

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Just note this area here, which is really incidental finding to this problem.

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Let me bring up the...

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hopefully, the CAD here.

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Just give it a moment to load.

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So this image here is going to be the

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G plus with the CAD on it.

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So I'll just scroll through that a moment.

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Come up to that little focal area.

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I'm going up.

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All right. If you'd like to put that poll up.

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All right. Well, there's one very smart

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person out there who got it right because the answer is...

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I'm not sure that's why it's showing red.

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The answer for this patient is congestive heart failure.

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Now, let's think about this on look Y,

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and we're going to come up on the differential afterwards.

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So let's go back.

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Let's look again at the T2 image.

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There's a couple of important things on the T2.

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First of all, both breasts have clear skin

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thickening, although it is more marked on the right breast,

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which is a non-irradiated breast, and the T2 enhancement overall is

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significantly more on the untreated breast.

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Although the skin is very thick

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and there's a lot of T2 signal in it, when you look at the subtraction image,

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there is no enhancement of that skin, and that's key for looking

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for inflammatory breast cancer. We'll come back to it in a minute.

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The other thing that I hope you notice is

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she has this large right-sided pleural effusion down here.

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Always look outside of the breast, on breast MRIs.

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You can pick up a lot of, not only incidental findings,

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such as bone mets,

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with metastases,

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but findings that can help you with the diagnosis, like in this case.

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When we go to the top slices,

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we're not seeing any adenopathy up in that axillary area,

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so there's nothing that would make us think of enlarged lymph nodes producing

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lymphedema, and it's on the side that she hadn't had the prior treatment for.

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On the original mammogram,

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she had diffuse thickening and enlargement

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of the right breast much more than the left breast.

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Well, this one this is edema in right greater than left breast.

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And the reason that the edema, she also had lower extremity edema,

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it's greater in the right breast, is because that breast was not irradiated.

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And when you irradiate a breast and they have fibrosis, that breast can no longer

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expand or react in the same way to edema as the normal breast can.

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Now, she did have this little incidental

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cancer which was found as...

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Well, as part of the MRI.

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I'm sorry. I'm scrolling a bit fast here.

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This little goober here,

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and that was a small invasive ductal carcinoma.

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But she actually died from her cardiac

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failure before anything was done about that.