0:01

We're going to look at case 8 here.

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And the history on this patient is

0:12

that she is going...

0:14

She is a...

0:20

Okay, so she has...

0:22

She's a 43-year-old woman who is six months

0:25

after diagnosis of right breast invasive ductal carcinoma.

0:30

And she has status post, right-sided lumpectomy and right-sided radiation

0:35

treatment, which she's just completed a couple of months ago.

0:39

So I'm going to show you here her

0:43

subtraction on the right and her gadolinium enhanced image on the left.

0:50

I'm going to give them a moment to just load up there.

0:54

So let me come up and show you two things.

0:57

So the right breast is the breast that was treated.

1:02

The left breast was not treated.

1:13

So I want you to look, first of all, at the left breast and we'll talk about

1:18

the right breast afterwards, but this case is actually about the left breast.

1:23

I'm going to scroll through here.

1:33

Okay, that's a little strange because what I was looking at is no longer on these images.

1:38

I may have loaded up the wrong one.

1:40

I do apologize.

1:41

Well, while we're here...

1:48

Oh, there we go.

1:49

Okay.

1:52

So, looking at the right-hand image,

1:55

which is the gadolinium plus,

1:58

compared to the left-hand image,

2:01

which is a subtraction.

2:04

Looking at the left breast only.

2:08

And the abnormality I want you to focus on

2:11

is this high signal stuff in the retroareolar area.

2:18

So let's have the question for that one.

2:32

Just showing you the T2 on the left now.

2:37

Okay, good. This is ductal ectasia.

2:40

Now, the reason it's ductal ectasia,

2:44

although it's not high on T2 signal, and some will have high signal on T2

2:50

and some won't, depends on the protein content.

2:52

You can see that this has

2:55

very high signal conforming to a diffuse ductal pattern with the ducts dilated.

3:00

But they're very smooth.

3:02

Okay. There's no lumps and bumps here,

3:06

there's no clumps.

3:07

They're just smoothly distended ducts filled with high signal material.

3:12

The key is, when we looked at the subtraction image,

3:17

that there was no

3:19

increased signal within that high signal.

3:25

So in other words, the gadolinium

3:30

minus image have the same

3:36

high signal within it as did the gadolinium post.

3:42

So if you see this,

3:44

you've got to make sure that you look very carefully at the pre-gad.

3:49

This is the pre-gad image now that I'm showing you

3:51

on the left hand side to see if you saw the same abnormality.

3:55

Now, one thing that can really catch you out here when you're doing this clinically

3:59

is if the patient moves a little bit between the pre and post-gad images,

4:05

that subtraction is going to show you what looks like ductal enhancement.

4:10

So you need to make sure you look at the pre-gad images with the post-gad images,

4:14

not just a subtraction, to ensure that you're not being mistaken into that.

4:19

Let's just see if we can come up to here. There you go.

4:21

And you can see the... Here's...

4:22

Oh, that's not a gad minus. I'm sorry.

4:25

This is both gads, but you would see exactly the same on the minus gad.

4:29

So duct enhancement is going to be bright on both the pre and post-gads.

4:35

It shouldn't show on the subtraction,

4:36

but it may show on a subtraction if you do not have...

4:41

if you have movement.

4:42

Now, the other thing I just wanted to show you in this patient is note how her

4:46

right breast is...

4:50

got skin thickening and it has enhancement.

4:53

This patient, as I said,

4:54

was only a couple of months after their radiotherapy.

4:57

And so in this case, seeing enhancement here is not concerning.

5:03

We expect to see diffuse enhancement in the breast, particularly in the area,

5:07

the tumor bed when it's this close to the surgical period.