0:00

This was a screening sort of exam.

0:03

And I think this case is very difficult.

0:09

So single MIP image, right?

0:11

And looking at this, I would even say,

0:13

if I was first looking at this case,

0:14

I would say, I don't see anything.

0:16

Yeah, it looks great.

0:17

Um, no real enhancement here.

0:19

Um, it's a little hard to see the

0:20

breast tissue here in this, this one.

0:22

The heart's really enhancing a lot in this case.

0:25

Um, but then I would go on to

0:27

our next, um, uh, series, right?

0:30

And we can look at the,

0:37

sorry, this one.

0:44

And I would scroll through and I think what

0:46

makes this difficult is that on your standard

0:50

T1 FATSAT post-contrast image, um, you

0:56

know, this is ultimately our finding here.

0:59

Uh, it's basically on, you know, a few slices

1:03

and maybe arguably best seen on one slice.

1:06

Um, and you have to say, well, does

1:08

this stand out, stand out from the rest?

1:10

Yes.

1:11

Uh, and then I think the thing that

1:13

gets a little bit concerning about this

1:14

is the, uh, distribution here, right?

1:16

So we have this kind of linear area of non-mass

1:19

enhancement, which would be somewhat concerning.

1:22

You might wonder, is this just, um,

1:25

ductile signal that we've seen, right?

1:27

And you want to look at your pre-contrast Uh,

1:29

fat sat image for that try and exclude that.

1:33

Um, and then, of course, the thing that's

1:35

most important on this one is getting to

1:37

the sub right to try and subtract out that

1:41

area and hopefully make that stand out more.

1:42

And it does indeed stand out more in this case

1:44

here, um, with this sort of linear, uh, image.

1:49

Area of non-mass enhancement, which

1:50

is staying to the base of the nipple.

1:51

And of course, and anybody, especially

1:53

this patient is a big BRCA carrier.

1:55

This would be, it would

1:56

raise your suspicion a bit.

1:58

Um, the other thing in this case is

2:00

that I feel like, um, it is a bit easier

2:04

maybe to see on the sagittal view.

2:08

It's right here.

2:08

I'm trying to get to the exact slice and there's

2:11

a little area of non-mass enhancement again.

2:15

So I think this is really tough.

2:16

Um, I think you have to be

2:17

very astute on this one.

2:19

Um, not to just blow by that area.

2:21

And also, um, you know, you're, you're

2:24

a little bit led astray by that MIP

2:25

that doesn't really show that, um,

2:27

show that area of enhancement either.

2:30

Hi, sorry for the, uh, another silly question.

2:32

Um, so just considering its linear form.

2:38

So, um, if there's vascular, um, you

2:42

know, uptake of contrast, um, would

2:45

it not show up in the subtraction?

2:46

Is that how we differentiate from ductile?

2:48

Yes, that would, that would

2:50

help, uh, um, for sure.

2:53

Uh, the other thing is that with a vessel,

2:58

hopefully you could follow it along, right?

3:01

Uh, that you could see it, you know, link up

3:03

to other vessels or something like that, uh, to

3:05

help you try to distinguish between those two.

3:09

Like I just had a case just like this, uh,

3:10

yesterday, uh, I was doing a biopsy and, uh,

3:14

there was this sort of linear, sort of pigeon

3:16

is kind of area of non-mass enhancement.

3:18

I thought, Oh, that's just like a vessel, but I

3:20

couldn't really link it up to any other vessel.

3:21

So, uh, the jury's out whether what that was

3:24

or not, but, um, but I think it was linear

3:27

non-mass enhancement and not just enhancements.

3:30

Thank you.

3:32

Can I just follow that up with please?

3:35

So in this case here, um, with the

3:37

management, how would you manage this one?

3:42

Would you have a second look,

3:43

culture, sound or anything like this?

3:47

Yeah, I think, you know, so part of that is,

3:51

um, an institutional sort of question, right?

3:53

Sort of how generally you

3:55

want to operationalize this.

3:58

Um, at our institution, we have our radiologists

4:03

make a decision about how likely they

4:06

think something will be seen by ultrasound.

4:10

And if the thought is that if it's not that

4:13

likely, then it only contributes to needless

4:17

delay for the patient, uh, and so it would

4:19

be easier for us just to go straight to MRI-

4:22

100 00:04:22,344 --> 00:04:25,305 guided biopsy if you sort of think for the

4:25

most part that you're not going to see it.

4:28

Now, are there some sort of things that we

4:31

can use to help us determine that question?

4:33

Yes, but none of them are great, right?

4:35

So the things we typically use are

4:37

you're more likely to see something

4:38

on ultrasound if it's a mass.

4:41

And greater than 10 millimeters.

4:44

Now, can we find things smaller than that?

4:46

Sure, but those are the things that help

4:48

you, uh, have it be more likely that

4:52

you're going to see it on ultrasound.

4:54

Um, also position in the breast, right?

4:55

If something is centrally located

4:57

behind the nipple, you're going to go

4:58

ultrasound, probably going to be thrown

5:00

off by nipple shadowing or trying to

5:03

get, trying to image behind the nipple.

5:04

That could be difficult.

5:07

Um, so if something is more superficial,

5:09

like let's say lateral part of the

5:10

breast and my thought those would be more

5:12

likely to be seen on targeted ultrasound.

5:16

Um, so in this case, what I would probably say

5:19

is, look, I don't think I'm going to see this.

5:20

This is a very small area of

5:22

linear non-mass enhancement.

5:23

You might see some kind of ductile thing or

5:26

maybe some something within the duct, but I

5:29

think it would be very nebulous on ultrasound.

5:31

And I would, I would probably just go

5:33

straight to him or I'd advise you here.

5:36

Uh, can I ask a question?

5:37

I don't know if you can hear me.

5:39

Yes, I can hear you.

5:39

Please.

5:40

Uh, okay.

5:41

Thank you.

5:42

So I'm from South Africa, by the way,

5:43

and I'm just listening to everything

5:45

and I'm enjoying it very much.

5:47

So the two things I wanted to ask you, um,

5:51

just on a technical level, the first one is.

5:54

The kinetics are the color mapping, right?

5:57

Am I right?

5:57

That's right.

5:58

You're correct.

5:59

There's no graph to see, correct?

6:01

That's right.

6:01

We have not provided the actual graphs.

6:05

Yeah.

6:05

Okay.

6:06

I just wanted to know, I wasn't missing

6:08

something when I called things up.

6:09

You're right.

6:10

Yep.

6:10

You got it.

6:11

I never saw much red.

6:13

So yeah, I don't remember them being washed out.

6:16

Okay.

6:16

And then, and then on that, with that DCI,

6:19

it's possible these are also AD. That, that,

6:22

so that indicates there, yeah, there's not,

6:24

there was, do you call that sub-threshold?

6:27

Yes.

6:27

It, it, it could have, or

6:29

do you say that's negative?

6:30

I'm, I'm not quite sure what's up.

6:32

Well, I, you know, I think, yeah, yeah, right.

6:36

So, um, certainly we, uh, haven't provided

6:40

you, like, every little bit, and part of that,

6:41

it's a technical sort of thing, it's hard

6:43

to provide the actual, like, graph for each

6:46

thing, unless we gave you an ROI or something.

6:47

But anyway, um, so we've given

6:50

you this color image, right?

6:52

Which are kinetics.

6:53

And I think you could, at least at

6:56

the outset, um, um, interpret that

7:01

either of those ways, either the idea

7:03

is that the sub-threshold, right?

7:05

That it didn't meet our color mapping threshold.

7:07

And of course, that is, that is set

7:09

by the user or your program, right?

7:11

So we use Dynacat at our institution,

7:13

for example, you can set that threshold,

7:15

um, uh, for colorization, you know,

7:18

anywhere between 50 and 100 percent.

7:20

So, um, so that is one

7:23

part of a technical thing.

7:24

You'd want to make sure that

7:24

you sort of evaluate that.

7:26

Thresholding criteria for colorization.

7:29

Um, the second thing that I'd like to say is that

7:33

CAD should really just be an adjunct to your

7:38

anatomic and, uh, contrast assessment, right?

7:42

So you shouldn't necessarily be led

7:45

astray by seeing an area that you think

7:48

is truly linear non-mass enhancement

7:50

in a patient that is high risk.

7:53

You shouldn't be led astray by negative

7:55

CAD or you know, a sub-threshold

7:58

kinetic assessment.

8:01

You should still go ahead and do the

8:03

biopsy and provide further evaluation.

8:07

Um, the same thing is true the other way.

8:10

So if you see something and I think a

8:12

lymph node is a really good example of this.

8:14

If you see a lymph node and by all of your

8:17

other tools, you say that's a lymph node, right?

8:20

I can see a fatty hilum.

8:21

I can see a vessel nearby that

8:22

looks like it leads into it.

8:24

Um, then it's a lymph node and

8:27

it can be benign and that's fine.

8:29

But if you look at color,

8:30

you would see that it has washout.

8:31

Right.

8:32

And so you don't want to be led

8:33

astray by something that, "Oh, that

8:35

looks like it has some washout there."

8:36

Well, of course it does.

8:37

It's a lymph node.

8:38

It's so sad.

8:39

It's so bad washout.

8:39

Right.

8:40

So, um, so I would be a little bit careful

8:43

about using CAD as the decision maker.

8:46

Um, I like to use it more as something

8:49

that will verify what I'm thinking, right?

8:52

So if you say, "Oh, I see this area of linear

8:54

non-mass enhancement," and let's say it did

8:55

have some kinetics to it, you say, "Great,

8:57

yeah, okay, I agree, that sounds good, right?

8:59

That looks like it does, it does stand out,

9:01

even for CAD, and CAD supports my findings."

9:04

But if it doesn't, and you were still worried

9:05

about it, then I wouldn't, I wouldn't go

9:07

using CAD as that sort of tool.

9:11

Okay, thank you very much.

9:12

And then can I just ask one very basic

9:13

question because I was thinking about it.

9:16

Post-contrast, fat set, everything,

9:18

uh, everything lights up.

9:20

But of course, because the neovascularization

9:24

on tumors, they appear brighter and maybe

9:26

there's fibroadenomas, it might be or might

9:30

not be enhanced more than the breast tissue.

9:34

So, so in subtraction,

9:37

what are you subtracting out?

9:39

Of course, the fat isn't there

9:40

anymore because it's fat, fat as well.

9:42

You're subtracting out. There

9:43

must be a threshold then, like

9:45

in post-contrast mammography.

9:47

Yes.

9:48

There's a threshold.

9:49

That, that gets subtracted out and anything

9:52

above that, and where do fibroadenomas lie?

9:55

In other words, I had a case, one of those

9:57

cases I wasn't sure, is it smooth lobulated

10:00

fibroadenoma or was it in fact fibroadenoma?

10:02

Breast tissue.

10:02

So if it's breast tissue, can you say that

10:05

subtract out for the fibroadenoma weren't?

10:07

That's right.

10:08

That's right.

10:08

Um, so I think we, I always think about

10:11

the subtraction as trying to draw or

10:13

trying to subtract out all that sort

10:15

of background enhancement stuff, right?

10:17

Um, stuff that will be there, um,

10:20

early on, um, that you're going

10:22

to try to sort of remove, right?

10:25

So the, the, the background tissue,

10:28

background enhancement, hopefully

10:29

you get some of that taken out.

10:31

And then the things that are true

10:33

findings, truly enhancing, um,

10:36

you will, um, will still remain.

10:40

So I think your

10:41

interpretation is correct of it.

10:44

Okay.

10:45

Thank you very much.

10:46

So, okay.

10:47

It's like it is a little bit. You have

10:49

background in hormones, but like the

10:51

first lady was saying BPH and then Okay.

10:54

Yeah, I think it becomes a decision thing.

10:56

Not everything gets suppressed and I get it.

10:58

Right?

10:58

Yeah.

10:59

Yeah, it depends on yes. So

11:00

there's that whole gray area.

11:02

Yes.

11:02

Yes, there's so much gray

11:05

morphology and all that and yes.

11:07

Yeah.

11:08

Okay, but thank you.

11:09

Okay.

11:09

Yeah, you're welcome.

11:10

You're welcome.