0:00

So our first case is a 37-year-old.

0:03

A history of right breast

0:04

enlargement and erythema.

0:06

Undergone multiple rounds of antibiotics,

0:08

minimal decrease in the degree of erythema,

0:11

and eventually gets onto this MRI exam.

0:14

And, um, like I mentioned last time,

0:17

um, you know, everybody should have

0:18

kind of a hanging protocol in mind

0:21

or a process for reviewing images.

0:24

Mine.

0:25

I always tend to look at the MIP

0:28

exam or the MIPS series first.

0:30

Um, this really helps you get a lay of the land

0:33

in terms of background parenchymal enhancement.

0:35

And then if there's anything major going on,

0:37

obviously, in this case, we can see there's

0:38

something major going on on the right side.

0:40

Um, and you can also get even a

0:42

good sense of whether there's going

0:43

to be any lymph nodes to look at.

0:45

Um, So, you know, in this one I would say

0:47

already that, you know, this is matching up

0:49

with our clinical history, right? The right

0:51

breast looks enlarged, we see this large area

0:54

of enhancement within the breast, and then at

0:57

least one or two enlarged axillary lymph nodes.

1:00

And then on the left side, um, you know, this,

1:03

I kind of. This sort of thing here is all

1:05

good for background parenchymal enhancement,

1:08

tiny little areas of non-mass enhancement,

1:10

or even almost sort of mass-like looking.

1:13

Um, and then this larger thing here, which

1:15

we can maybe even tell already, it probably

1:17

looks like a little intramammary lymph

1:18

node with a little bit of a fatty hilum.

1:20

So, um, I usually will, um, look at the

1:25

pre-contrast Axial T1 as well as the non-FATSAT version, and then the pre-contrast

1:32

Axial T1 FATSAT, um, and I think those are

1:35

helpful, um, especially the non-FATSAT

1:39

for looking for any biopsy clips or any

1:41

other metal artifacts, um, that might

1:44

lead you to know that there's a clip there

1:47

or the patient has had surgery before.

1:49

Sometimes it can be a little bit

1:50

hard to tell in the case of something

1:52

like bilateral breast reduction.

1:55

Um, but then I will, um, quickly get to the, uh,

1:58

Axial T1 fat set post-contrast, which of course

2:01

is kind of our main workhorse imaging study.

2:05

And usually in a typical workstation

2:08

environment, I would look at, uh, both

2:11

the post-contrast axial T1, um, side

2:16

by side with the sub of that.

2:21

And that can help you, um, just to

2:23

make sure that verify that what you're

2:24

seeing is sort of true enhancement.

2:28

So, uh, as we look through here, um, right

2:31

away, we can see that there are, uh, you

2:33

know, a large portion of the right breast, um,

2:36

has multiple areas of non-mass enhancement.

2:41

Um, throughout, uh, the rest, um, you could

2:44

describe these as, you know, some of these

2:45

could be considered kind of individual

2:47

masses with additional non-mass enhancement.

2:51

And either way that you

2:51

describe that is probably okay.

2:53

Um, the most important thing here, I

2:56

think, is to give an accurate assessment

2:58

of the extent of disease, right?

2:59

So you want to make sure that

3:00

you measure that entire area.

3:02

Um, you can measure off the MIP sometimes,

3:05

which can be helpful to get sort of an overall

3:07

extent of disease, uh, sort of picture.

3:11

Um, to provide that to your referring providers.

3:15

The other thing that's obvious in this

3:16

case, of course, is that the patient

3:18

has diffuse, um, skin thickening

3:20

almost throughout the entire right breast.

3:22

Excuse me, the entire right breast.

3:25

Um, now in this case, I don't definitely

3:28

see any enhancement in the skin.

3:30

Um, and that sometimes does come up.

3:32

Um, it looks like to me here in

3:34

this case, it's more really just,

3:36

um, some hypervascularity, right?

3:38

Um, and probably some edema in the skin.

3:40

Um, it doesn't necessarily

3:42

mean that skin isn't involved.

3:44

Um, in fact, it probably is, especially in

3:46

this case, but, um, but we just don't see any

3:48

definite enhancement in there, and that's okay.

3:52

Um, of course, we want to move on to the, sorry,

3:55

I'm probably making it all a little busy with

3:56

this scrolling, but, um, of course, we want to

3:58

move on to looking at the axillary lymph nodes.

4:01

Um, and we can already see, um, you

4:05

know, one enlarged abnormal, uh, level

4:07

one lymph node, another one back here.

4:10

Uh, and of course, we want to

4:11

then therefore look at level two.

4:12

Two as well, a couple of tiny nodes

4:15

here, which you might, at least you could

4:17

mention these are interpectoral ones.

4:19

And then here's a traditional level two.

4:21

And there's maybe a level three here, a

4:23

little hard to tell, um, difficult whether

4:26

you'd want to actually call that or not.

4:28

Um, but you certainly could

4:29

mention it as a possibility.

4:32

Um, but most of the abnormal

4:33

nodes are here in level one.

4:35

And this is important for your

4:37

surgical referring providers, right?

4:40

Can easily get to level one nodes; you

4:42

know, level two and three are more difficult.

4:44

And so you want to be able to leave them

4:46

and tell them, yes, this is something

4:48

you want to look at or go for, um,

4:51

and try and, um, address surgically.

4:54

On the other side, the left

4:55

breast in this case is negative.

4:57

This does indeed look like a benign

4:59

intramammary lymph node, um, here, and just

5:03

a few small areas of, um, what I would

5:05

say is either mild or maybe even moderate,

5:08

um, background parenchymal enhancement.

5:11

Um, in these cases too, where you do have

5:15

quite an extensive disease in the breast.

5:18

Um, you do want to make sure that you look in

5:20

other areas, um, bones, liver, lung, um, to look

5:24

for any sort of possible metastatic disease.

5:26

And using the localizer, of course, for

5:28

that purpose is also, um, also a good idea.

5:32

I should also say that, um, I haven't looked at

5:35

any of your cases for this weekend, uh, but this

5:39

would be very appropriate here to raise the,

5:41

um, the question of inflammatory breast cancer.

5:45

Now, we do need to remember that

5:48

inflammatory cancers are, um, you

5:51

know, it's a clinical diagnosis.

5:53

It's not really an imaging diagnosis per se,

5:55

but we can, um, lead the clinicians to say, Hey,

5:58

you probably want to check out the skin here.

6:00

Um, and probably consider a

6:01

skin punch biopsy in this case.

6:03

Um, that was done here, uh, this particular

6:05

case, um, from my institution and the skin

6:08

was positive, and this was considered an

6:10

inflammatory, uh, inflammatory breast cancer.

6:15

Can I ask, uh, just a very quick question?

6:18

Um,

6:20

In the one of the videos that was, uh,

6:24

In our initial, um, course prerequisite

6:28

things to watch, uh, there was a discussion

6:31

about, uh, making an assessment of

6:33

asymmetric breast enhancement, uh, which

6:36

is just the normal fibroglandular tissue.

6:40

Obviously, in this case, it's very

6:41

clear that there's a big difference.

6:43

Big discrepancy with a lot of secondary findings

6:46

to say that this is going to be malignancy.

6:50

But if it was just an asymmetric

6:52

enhancement of one breast versus the

6:55

other, is it really just looking for other

6:58

features that would make, make sense?

7:00

Make you think more of a malignant process

7:03

as opposed to it just being asymmetric.

7:06

Yeah, that's a good point.

7:08

I would say sort of looking for other features

7:10

like you're saying, um, and you'd want to

7:12

include that, like whether you think that

7:14

you're seeing masses or a mass or masses in

7:18

that area of abnormal asymmetric enhancement.

7:22

The other thing that I would suggest

7:23

looking for is, um, you also want to

7:26

try to see if, if you do see some,

7:29

you know, a real definite asymmetry.

7:31

Um, in terms of enhancement, you do

7:34

want to try to explain that, right?

7:36

So either what you hope is that you look

7:39

back over time and the patient is sort

7:41

of always that way for whatever reason,

7:43

um, and you can therefore say, look, it's

7:46

asymmetric, but it's always been like that,

7:48

and it's nothing new on this current exam.

7:50

Um, or you might, um, try to discover,

7:54

um, a piece of their clinical history,

7:56

such as they had radiation on that side,

7:58

only on that side for some reason.

8:00

And that is therefore causing the

8:02

appearance of asymmetric enhancement.

8:05

Um, so I try to dig a little bit more into

8:07

the clinical history when I see that, um,

8:10

or try to explain it and say, yes, this

8:12

is just what this patient looks like.

8:14

The other part of it is that, of

8:16

course, um, we are most challenged

8:18

by this when it's a baseline exam.

8:21

Uh, uh, and, um, we know that there

8:24

can be some asymmetric enhancement.

8:26

It's going to depend sort of on the

8:28

case, whether you think that's going to

8:29

be kind of called or not, or something

8:31

you want to go ahead and biopsy.

8:32

And certainly in my practice and

8:36

all practices, uh, you will end up doing

8:38

biopsies on things that are just background

8:40

enhancement, because it looks, you know,

8:42

confluent, and it looks like it's something

8:44

real, and it turns out that it's nothing.

8:47

Um, but we also know that, um, that if

8:52

you look back over multiple prior exams, um,

8:55

assuming that you're not necessarily that there

8:58

are, there are going to be some differences

8:59

in timing of the menstrual cycle, that you're

9:01

going to see different patterns of enhancement.

9:04

Um, and so having some asymmetry is okay,

9:08

but you need to sort of develop this sense

9:09

of whether you think that yes, that's just

9:11

part of the patient's normal pattern or

9:13

it's something significantly different.

9:15

Um, so I know that's a little bit like

9:17

nebulous, that description, but, um,

9:19

Those are the sort of things that I do.

9:21

Okay, thanks.

9:24

Um, looks like another

9:24

question about dimensions.

9:27

Um, so, you know, in this case, if, if you

9:30

look at that gold standard or reference

9:32

standard report, um, I think we do, I

9:34

did have some, um, dimensions in there.

9:36

Um, but if we can measure, uh, dimensions on

9:40

this system.

9:41

But, you know, this case is one where

9:43

you might consider, um, the MIP here.

9:46

And let's see if we can actually do

9:47

it, but I would probably just go,

9:48

yeah, here we go straight, uh, back.

9:50

So I was, uh, it looks like we don't

9:52

actually get a measurement, but if, if

9:53

you could get a measurement based off

9:55

of this on your, uh, imaging system, I

9:57

would measure something like that as being

10:00

kind of sort of the overall dimension.

10:01

And then of course, you'd want to try to look

10:03

at the sagittal and do something similar,

10:05

but, you know, you can also say in words,

10:08

it involves almost the entire breast.

10:10

Um, what would be another way of describing it?

10:12

And sometimes these cases where it's so

10:14

extensive, it's almost easier reporting in the

10:16

sense that you say, you know, there's extensive

10:18

non-mass enhancement involving all four

10:20

quadrants and measures, you know, approximately

10:23

80 millimeters AP by 75 transverse by, you

10:27

know, 65 cranial-caudal or something like that.

10:31

Um, that's usually sufficient

10:32

enough to tell your providers that

10:34

you think that it's everywhere.

10:35

So good questions.

10:42

Okay.

10:43

Oh, can I just ask one more?

10:44

Sorry.

10:45

Yes.

10:45

Um, on the left breast, you know, if you look

10:49

at this MIP, that's just projected as well.

10:52

Um, I know that we're not supposed to give

10:56

importance to too many of those blips, but,

10:58

and in this particular case, especially when

11:01

this is an obvious pathology, is inflammatory,

11:03

something looking so inflammatory on the right.

11:05

But that looks like a segmental,

11:08

um, almost double pattern of.

11:11

Yeah.

11:12

Like this right here.

11:12

Uh, do we completely, yeah.

11:14

Mm-hmm.

11:14

Do we completely ignore that?

11:16

Uh, I would, um, you know, I think, uh,

11:19

so I guess what I would do is if, if you

11:20

looked at the MIP and you said, look,

11:22

well, maybe that's, you know, maybe

11:23

that's segmental, uh, non-enhancement.

11:25

There.

11:25

I want to look at it.

11:26

I would certainly spend some time looking

11:28

through the axial, the actual axial slices

11:32

and try to determine if you think that

11:33

it actually really is segmental, right?

11:35

Because you've got to remember, this is a

11:37

2D image, right, that we're getting, um,

11:41

at least in this showing you.

11:42

Right here, of course, we could, we could

11:44

rotate it a little bit and try to see,

11:45

but it gets lost in the other tissue.

11:47

But, um, you know, I would say that it

11:49

looks like at least there's some vertical

11:51

distance between these and looks a little

11:53

more diffuse, but I would verify that on

11:55

the axial slices to try to try to see.

11:58

If it, if it did kind of match that

12:00

segmental pattern, then yes, this would

12:02

become more suspicious, and you might

12:03

want to consider doing a biopsy of it.

12:07

But otherwise, looking at this, my first

12:09

guess would be, oh, this is probably just

12:10

some background enhancement that we're seeing.