0:01

Our next case is a 70 year old woman

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who had a remote history of left breast cancer

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and recent diagnosis of left invasive lobular carcinoma.

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And we did an MRI to evaluate extent of disease.

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I can recall that she was being seen for routine follow-up

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and she had a left lumpectomy with a lot of distortion

0:24

at the lumpectomy site.

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And it just seemed like the distortion was more

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significant on the left than it had been before.

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And the right side, we thought was normal.

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She had a lot of dense tissue in the lateral breast

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but nothing new.

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And this was a 2D mammogram by her choice.

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So we recalled her for the apparent,

0:46

increase in distortion in the left breast.

0:50

And then she had a further evaluation with ultrasound that

0:55

showed some very vague mass like areas on ultrasound.

1:00

It was just a little bit difficult to know exactly where

1:05

the cancers were, how many there were.

1:08

It seemed like there was more than one.

1:10

I think she had two biopsies showing invasive lobular carcinoma,

1:13

so that we thought the MRI would be very helpful.

1:17

Just going to show you her MIP,

1:19

and this is her left breast, which is smaller than the

1:22

right because she's had a prior fairly large lumpectomy,

1:25

and this shows multiple masses in the lateral left breast.

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So,

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you know, that's the area that we were interested in.

1:35

We thought her right breast was normal,

1:38

mammographically,

1:39

but

1:41

surprisingly, there's a large enhancing mass.

1:44

They are in the lateral right breast.

1:46

So we're going to investigate this a little further.

1:51

I'm going to show our T1-weighted images

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and our post contrast images.

1:57

And just looking at that area where we

2:00

were interested in the left breast,

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there's a lot of non mass enhancement with

2:06

kind of smaller irregular masses and this,

2:10

most of this had already been biopsied.

2:13

It was a little bit more extensive than

2:15

we thought, and of a larger area.

2:19

And she had already been treated previously with

2:23

lumpectomy and radiation to this breast.

2:29

But several masses, they are on the left.

2:31

And then, the surprise finding was this quite large mass.

2:36

Almost 3 cm mass in the right breast

2:40

that was hiding in this area of extreme fibroglandular tissue,

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like her overall pattern is heterogeneous, but she's,

2:51

she's pretty glandular right in this area.

2:54

And on her 2D mammogram,

2:56

that was completely dense. And of course,

2:58

2D we had no thin slices to go through, but we,

3:03

totally couldn't see this large mass that was sitting right there.

3:08

So,

3:09

we were

3:12

very worried about that mass on the right side.

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So, we did a second look ultrasound.

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That's what had been recommended.

3:19

And a second look ultrasound was performed,

3:21

showed a mass and it was biopsied,

3:24

and it was an invasive carcinoma.

3:27

So,

3:28

this patient elected to have bilateral

3:31

mastectomy in light of these findings.

3:35

And I have to credit MRI here because the mammography

3:43

did not find this mass on the right side, and it actually

3:46

is quite significant,

3:49

biologically significant mass.

3:54

And, you know, we also looked at T1-weighted source images,

3:58

pre and post contrast,

4:01

and it just shows you that that mass is sitting here in a sea of

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fibroglandular tissue, so easy to, easy to hide.