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Breast MRI Case 4

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0:00

Now we have a comparison case for this,

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and then we'll talk a little bit more about these things.

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And that is this case here.

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I also have a mammogram to show you on this.

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This is case number four.

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This is a 54-year-old who presented

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with right breast pain and swelling.

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I'll just give you a moment looking at that.

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And then we're going to go over to the MRI.

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What I'm showing you on the left-hand image here,

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let's brighten up a little bit for you,

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is the subtraction gadolinium-enhanced...

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I'm sorry,

0:46

on the right-hand image is a T2, left-hand image is a T2.

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Got myself confused here.

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This is T2 here.

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And on the right-hand side is the subtraction after gadolinium.

1:04

So I'm going to scan

1:05

through those a little bit.

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Coming up.

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And then we're up in the right axilla now.

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And I'm also going to show you the CAD MIP,

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Let's make sure it's got the same orientation.

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So, this is the right breast, the symptomatic breast on this side.

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Can we have the poll go up, please?

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Let's see the results of that.

1:56

Okay, nice.

1:57

So most people got this inflammatory breast cancer.

2:00

So let's look at the similarities

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and the differences between this study and the prior study.

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On the mammogram,

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apart from it being the opposite breast, the changes are very similar.

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We have diffuse skin thickening.

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We've got enlargement.

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We've got increased diffuse density and we've got coarsening of the trabeculae.

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The differences really come on the MRI.

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Now, on the T2 images, there is still a high T2 signal throughout

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that right breast, similar to we saw in the last patient.

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Again, we can see the skin thickening, although it's much more unilateral this time.

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And we can see high T2 signal within the skin.

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The difference is really

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in the enhancement pattern, I'll get rid of this MIP,

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and we'll go back and look at that subtraction.

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Just flip it a little bit there.

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Give it a little bit...

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A little windowing to help here.

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And what we're seeing on this is

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A. This patient has a lot of enhancement within

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the breast parenchyma itself, multiple speculated masses.

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And we have enhancement of the trabeculae.

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So what we're seeing down here are the trabeculae themselves,

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which were thickened on the patient's mammogram are enhancing.

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And then is skin enhancement.

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And that is really important for making

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the diagnosis of inflammatory breast cancer.

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When we go further up the breast,

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all the way,

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we can see she has some small lymph nodes up in this

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left axilla, but really nothing sort of very prominent.

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Certainly not anything that you

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would expect to give lymphedema, which was one of the other choices.

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So there is a significant differential

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for patients who have diffuse swelling of a breast and thickening

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of the trabeculae on the mammograms.

4:00

Similar to those two mammograms.

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Inflammatory breast cancer is always the one that we are concerned about,

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and that's the one that we need to make sure that we're not going to miss.

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For inflammatory breast cancer,

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you're going to see multiple areas of enhancement within the breast

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with enhancing trabeculae, diffuse skin thickening, with enhancement to the skin.

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We can't make the diagnosis

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of inflammatory breast cancer from an MRI, but we can certainly suggest it.

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And if they haven't already,

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we would recommend they do a skin biopsy to make that diagnosis.

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With lymphedema and cardiac failure, you're going to see, again, high T2 signal,

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again, skin thickening, but you should not see enhancement of the trabeculae.

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You should not see enhancement of the skin.

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With patients who have diffuse mastitis, it gets a little bit more tricky.

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Nobody should really be imaging patients

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who have acute mastitis by MRI because you're likely to get yourself into a lot

5:00

of trouble, because it's going to have a lot of features which are very similar.

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It does not usually have this degree of intense wash-out.

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It's not usually this diffused,

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it tends to be more local, but you will have some skin enhancement.

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Not as much skin enhancement as you do here.

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You'll certainly have skin edema.

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But most of the enhancement tends to be

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within the breast parenchyma rather than the skin.

Report

Faculty

Petra J Lewis, MBBS

Professor of Radiology and OBGYN

Dartmouth-Hitchcock Medical Center & Geisel School of Medicine at Dartmouth

Tags

MRI

Implants

Breast

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