0:00

Now we have a comparison case for this,

0:04

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

0:07

And that is this case here.

0:10

I also have a mammogram to show you on this.

0:17

This is case number four.

0:19

This is a 54-year-old who presented

0:21

with right breast pain and swelling.

0:25

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

0:29

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

0:33

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

0:38

let's brighten up a little bit for you,

0:41

is the subtraction gadolinium-enhanced...

0:45

I'm sorry,

0:46

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

0:50

Got myself confused here.

0:52

This is T2 here.

0:56

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.

1:16

Coming up.

1:24

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

1:30

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

1:38

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

1:40

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

1:48

Can we have the poll go up, please?

1:54

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

2:03

and the differences between this study and the prior study.

2:08

On the mammogram,

2:09

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

2:12

We have diffuse skin thickening.

2:15

We've got enlargement.

2:16

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

2:22

The differences really come on the MRI.

2:26

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

2:31

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

2:35

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

2:39

And we can see high T2 signal within the skin.

2:43

The difference is really

2:44

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

2:48

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

2:55

Just flip it a little bit there.

2:57

Give it a little bit...

3:00

A little windowing to help here.

3:03

And what we're seeing on this is

3:05

A. This patient has a lot of enhancement within

3:09

the breast parenchyma itself, multiple speculated masses.

3:13

And we have enhancement of the trabeculae.

3:17

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

3:21

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

3:25

And then is skin enhancement.

3:28

And that is really important for making

3:30

the diagnosis of inflammatory breast cancer.

3:34

When we go further up the breast,

3:37

all the way,

3:39

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

3:43

left axilla, but really nothing sort of very prominent.

3:46

Certainly not anything that you

3:47

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

3:51

So there is a significant differential

3:53

for patients who have diffuse swelling of a breast and thickening

3:57

of the trabeculae on the mammograms.

4:00

Similar to those two mammograms.

4:02

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

4:06

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

4:10

For inflammatory breast cancer,

4:12

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

4:16

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

4:22

We can't make the diagnosis

4:23

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

4:26

And if they haven't already,

4:27

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

4:32

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

4:41

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

4:45

You should not see enhancement of the skin.

4:48

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

4:54

Nobody should really be imaging patients

4:56

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.

5:05

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

5:09

It's not usually this diffused,

5:11

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

5:15

Not as much skin enhancement as you do here.

5:17

You'll certainly have skin edema.

5:19

But most of the enhancement tends to be

5:21

within the breast parenchyma rather than the skin.