0:00

Her history was a 35-year-old high-risk

0:02

female presented with a calculated

0:04

lifetime risk of 32%.

0:06

In the states and by American Cancer

0:09

Society, um, white paper way back

0:11

in 2007, but it hasn't changed.

0:14

Anybody with a calculated lifetime risk

0:15

above 20 percent is in fact eligible

0:18

for, um, high-risk breast cancer,

0:20

uh, breast MR, uh, cancer screening.

0:23

So we, um, I, um, the anatomy

0:26

is not the T1 pre or not pre.

0:28

Are not particularly helpful in this

0:30

case, although it is a lovely example.

0:32

I'll show it to you.

0:33

It's a lovely example of bad field of view.

0:35

You should not have more than half of

0:39

your screen occupied by the air in front

0:42

of the patient or in this case beneath.

0:44

Remember, these are prone in the air around

0:48

the patient and the lungs themselves.

0:50

So this is a, it is a nice example.

0:52

The T1 pre's of, um, of, uh.

0:56

Uh, bad field of view.

0:58

Um, it's also a really nice

1:00

example of dense breast.

1:01

So I do think the T1 pre's again, I don't

1:04

mean to be focused on them wholly, but

1:06

the T1 pre non-fat set give you a really

1:09

nice estimation of the breast, the amount

1:13

of breast parenchyma, the breast density

1:15

analog, and that is required in all reports.

1:18

At least here in the States.

1:20

Okay.

1:21

So, that being said, you can also also

1:23

get a hint already of what a problem is

1:25

going to be in this case, which is that

1:27

her breasts are seemingly quite asymmetric.

1:30

It's not the case, but that they

1:32

certainly are projecting asymmetrically.

1:34

So, then I'm going to go on now

1:35

to the subtracted image.

1:38

Part of the reason I'm going to go

1:40

over this in the manner that I am.

1:43

Oh, 1 more thing.

1:44

One more thing for the A relatively newer MR.

1:47

48 00:01:47,770 --> 00:01:50,500 interpreter get to know what machine

1:50

and or what platform is going to be

1:54

presented to you and work through

1:56

that or rearrange that to your liking.

2:00

From my perspective, I find it much easier

2:02

to, um, to assure that my images are

2:05

flipped anatomic, as if I'm reading a CT

2:07

or other cross-sectional imaging, and if

2:10

I, as if I am, um, uh, starting at the,

2:14

at, uh, cranial and scanning caudate.

2:17

Other people, uh, many platforms actually

2:20

scan from, um, bottom to top and, um, display.

2:23

Prone, but I assure that each time I

2:27

review, um, I'm reviewing in that manner.

2:30

And so this is the way we're going to review it.

2:32

This is anatomic and we're starting at the top.

2:34

This case stumped many of you.

2:37

I've already corrected your case 3

2:39

submissions and uploaded them to Olivia, but.

2:42

This case seemed to stump most of you actually.

2:45

And so I just wanted to point out that

2:46

there was a lot of focus on this, um,

2:50

apparent non-mass enhancement bilaterally.

2:53

Um, and let's go ahead and

2:56

just dispense with that.

2:57

This is normal picture framing.

2:58

It's very pronounced in this case, and it is,

3:01

um, oddly asymmetric, which can definitely

3:05

be, um, the confusing and confounding.

3:08

Um.

3:10

Uh, which is kind of all the more reason

3:12

I was happy that we had, um, at the

3:14

time of my, um, learners had read it

3:17

out at UNC wrongly and had read it

3:20

as diagnostic and had called her back.

3:22

Well, or had called it by rights

3:24

for as did many of you, by the way.

3:26

So, um, welcome to breast, breast fellowship,

3:29

I suppose, because that's exactly how it was

3:31

read by our fellows and upper-level residents.

3:35

But, um, the, the thing that's actually

3:38

more important and of significance

3:40

is that you can tell that the coil

3:42

is actually pinching the left breast.

3:45

The nipple is not dangling freely.

3:47

It's not positioned symmetric

3:48

with the right side at all.

3:50

And so, honestly, the impingement

3:53

of the coil related to

3:57

breast placement in the coil may be exactly

4:00

why, um, it looked like it was asymmetric.

4:03

And it may when in point of fact,

4:05

it's just normal picture framing.

4:06

And so there are three points

4:08

I want to make about this case.

4:10

Um, number one, we want to emphasize

4:13

the need for correct positioning.

4:14

The breast should be as symmetric, especially

4:17

if they are not post-therapy in any manner or

4:20

have not been surgically altered in any manner.

4:23

And this was a young woman

4:25

who had never had surgery.

4:26

And so she was just, she should

4:29

have been positioned symmetrically

4:31

and should look symmetric.

4:32

And, as you know, in the follow-up

4:33

scan that we did on her, she did those

4:37

images, I think, have already been

4:38

provided to you the field of view issue.

4:41

There's just nothing but air gap and

4:44

wasted information from here from here up.

4:49

Uh, and from here down on each image

4:53

that I realize that's not anatomic the

4:54

way she was positioned, but and then

4:56

lastly, the picture framing and, um, let

4:59

me just remind you what picture frame.

5:01

It's a great, um, it's a great and very

5:04

common, particularly in young patients, um,

5:07

in young patients, uh, high-risk screening MRI.

5:09

R.

5:09

S.

5:10

So the, um, so it is a form of, um,

5:13

background parenchymal enhancement.

5:15

It relates to the normal

5:17

arterial inflow of the breast.

5:20

It is at the periphery of the breast,

5:23

and because of the way many breasts are

5:25

scanned, um, it just so happens that either

5:29

the superior quadrants or the inferior

5:33

quadrants will be the ones that asymmetrically

5:36

fill in from the periphery.

5:39

It is also true that both inferiorly

5:42

and superiorly the breast,

5:44

fill in from the periphery.

5:45

And so in some instances, you really

5:47

do have a bonafide picture frame,

5:50

and in other instances, as in this case,

5:52

um, you kind of have to use

5:54

your imagination. But you begin to see,

5:57

in particular, um, two sides of a picture frame,

6:01

and particularly if you saw it on the left

6:03

side, um, as well, which you probably would

6:06

have, were it not for the fact that the coil

6:09

is pinching her and, um, impeding inflow.

6:15

I don't think it would have

6:15

stumped as many of you as it did.

6:17

We would have had far fewer indicators

6:20

as abraded for the right breast had the

6:24

left breast been appropriately positioned.

6:27

And so in essence, it's a benign pattern of vascular inflow.

6:29

Enhancement is a type of

6:31

background parenchymal enhancement, but

6:34

it is very specifically called

6:35

picture framing, and it must indeed be

6:37

distinguished from a non-mass enhancement.

6:40

So that's it.

6:44

Those are the 3 teaching points for this case.

6:48

I'll just, in terms of time, refer you back to

6:51

part 2 of this case.

6:52

So this should be a byproduct.

6:59

Excuse me, technical repeat hardly ever

7:01

have byproduct zeros in breast.

7:05

We don't use them at all when the

7:09

study is deemed to be diagnostic,

7:11

but additional imaging is needed.

7:13

But in this case, it was a repeat

7:15

technical repeat that was needed.

7:18

And so that's it.

7:19

So, positioning, field of view, and one.

7:23

Any questions?

7:25

Just a quick question

7:27

about the, um, about the technical repeat.

7:29

That was because of the positioning, not

7:31

because of the picture framing, correct?

7:34

Correct.

7:34

That was because of field

7:35

of view and positioning.

7:37

Honestly, more positioning and

7:40

pinching and impeding of the left

7:42

breast than the field of view.

7:45

I think honestly, I think he

7:46

can work around field of views.

7:48

It's annoying, and you know, you have

7:50

to reframe virtually every sequence

7:53

to assure that you get that distracting,

7:55

detracting black around it out of the

7:57

way by zooming all of the sequences.

7:59

It's annoying, but it's not,

8:02

it doesn't, it doesn't pose a barrier

8:04

per se to the to the to the MR.

8:08

201 00:08:08,820 --> 00:08:11,950 Imaging itself, whereas the impingement

8:11

of the left breast and, um, and, um, how,

8:16

um, oddly, um, oddly positioned it was

8:19

and also the impingement of enhancement

8:22

or the possible impingement of enhancement

8:24

in the left breast reduces the sensitivity

8:27

of, um, screening for that left breast.

8:29

That makes sense.

8:31

Yes, thank you.

8:32

Okay.

8:32

Yeah.

8:32

Yeah.

8:33

These are great.

8:34

Am I, um, am I at a clip and at a, uh,

8:37

is this to the participants liking?

8:39

Is this to the scholars' liking?

8:41

I mean, that's my main question.

8:42

I'm here to serve you and.

8:45

I want to make sure that I'm

8:48

speaking clearly, that I'm covering

8:49

topics that you think are germane.

8:51

There are several.

8:52

Oh, one thing.

8:53

I didn't want to say there are several

8:54

positioning and other technical issues

8:58

that you should familiarize yourself with.

9:00

And the great news is that

9:02

they are so it's so easy.

9:06

There are two, these are all these book goodies.

9:08

There are two radiographics articles

9:10

that are, um, that are commended to

9:12

you at the end of the gold standard

9:16

report for Case 5 to Radiographics.

9:19

They're both in 2007.

9:22

Active links were provided

9:24

to, um, to all of you.

9:26

And so one is Jen Harvey's, you know, she's

9:30

a dean now, her article, and one is Mary Mary

9:34

Mahoney, who is a chair now, her article.

9:38

So there are two of them.

9:38

The references are numbers 1 and 4.

9:42

That are listed on the gold standard and

9:45

honestly, I don't even think you need

9:47

to read the articles, but by all means,

9:49

pick the Radiographics articles up.

9:51

And they are, as you all, as you

9:53

all probably know, um, uh, designed

9:56

to have, um, good illustrations.

9:58

And so most of the issues and how to

10:01

solve them are very well illustrated.

10:03

So I commend those two to you.