0:00

This is a patient who's had a history of right

0:03

sided breast cancer status post lumpectomy,

0:06

nodal excision, and radiation treatment.

0:11

So I'm going to start here

0:13

with the T1 pre FATSAT images.

0:16

Now there's not, not everybody

0:19

does this as a sequence.

0:21

Um, if you don't do this as a sequence,

0:23

I would highly recommend that you do.

0:25

Um, it has a number of things

0:28

it's really useful for.

0:30

One is it's probably the best anatomy image.

0:34

Um, it's also really good for looking for

0:37

fat necrosis, as we'll see in this patient.

0:39

It's good for looking for fat in lymph nodes

0:42

and it'll get you out of a lot of trouble.

0:43

So I highly recommend it.

0:45

So the first thing that's very obvious on

0:47

this is that the treated breast, the right

0:49

breast, has very extensive skin thickening.

0:54

Um, that right breast appears larger

0:57

than the left, despite the fact that this

0:59

is, um, the patient has had radiotherapy

1:02

on this side and surgery on this side.

1:04

So, you know, that's a little bit unusual.

1:07

Um, probably a little bit of

1:08

trabecular thickening as well.

1:11

Um, while I'm on the T1, um, pre FATSATs.

1:16

If you look down here at the

1:17

lumpectomy site, we have fat necrosis.

1:20

So this has pretty extensive fat necrosis here.

1:23

Uh, and we'll see that on the

1:25

subsequent slices as well.

1:27

So, you know, very nice, um,

1:30

internal fat in this area.

1:33

Um, when we come up to the axilla, we

1:37

have some, uh, we'll look at those on

1:39

the T2, actually, they'll be better.

1:41

We're going to ignore the left breast

1:42

because the left breast is normal.

1:43

The next most important slice on this, uh,

1:46

sequence for this patient is going to be the T2.

1:49

Um, again, always make sure you look at

1:52

the T2 and you can see on the T2 that

1:55

this, um, thickened skin is very edematous.

2:00

There's some edema within the breast,

2:02

but particularly edematous skin.

2:04

Uh, we come up, the fat necrosis doesn't

2:07

really have any increased T2 signal.

2:10

Um, this is the, uh, central node,

2:14

uh, resection site here that we're

2:17

seeing up in the right axilla.

2:18

So it's a big breast.

2:20

It's edematous, and it's got skin thickening.

2:24

Here are the CAD images for the

2:30

first post-injection sequence.

2:33

And what we're seeing here is that

2:34

despite that skin being so thickened,

2:37

there is no enhancement in it.

2:39

There's also no enhancement in the

2:41

surrounding, um, around that fat necrosis.

2:45

And I wish I could show you that.

2:48

So you see on the MIP here, we've got,

2:50

um, fairly, um, significant background

2:53

parenchymal enhancement within the

2:55

breast parenchyma bilaterally, but we're

2:57

seeing no enhancement in that skin.

3:00

So this is a patient who has lymphedema.

3:02

Um, whenever you see skin thickening, we're

3:05

going to be looking, our differential is going

3:07

to be, um, you know, inflammatory breast cancer,

3:10

which is what we always worry about, in which

3:12

case we're going to see enhancement of the skin.

3:14

And I think you haven't

3:15

had a case of that already.

3:16

There is a case of it somewhere in the series.

3:19

Um, edema and lymphedema.

3:23

So edema can be due to cardiac failure,

3:26

for example, which is usually symmetrical.

3:28

Lymphedema, which is obviously asymmetrical.

3:31

Um, I've seen lymphedema both in

3:34

surgical candidates like this, who've

3:36

had lymphatic resections, usually,

3:39

um, total axillary resection, but we

3:42

do see it in central node resections.

3:46

Um, and I've also seen it in

3:47

patients who have extensive

3:50

lymph node disease in the axilla,

3:52

producing edematous breast from lymphedema.

3:56

Um, patients with acute mastitis,

3:59

um, same as on a mammogram, can really

4:01

fool you into thinking they've got

4:02

inflammatory breast cancer and vice versa.

4:05

You're going to have enhancement

4:06

within the breast and within the skin.