0:00

We put this case in because this actually

0:04

sort of caught several of you out when you're

0:06

interpreting it, but you shouldn't feel bad

0:09

about that because um, this was actually

0:13

misread by one of my faculty, and it was,

0:17

um, sent for an ultrasound evaluation of this

0:21

area of apparent enhancement, um, with washout

0:25

kinetics in the upper part of the right breast.

0:29

So the clue here is when you go across,

0:32

and you look at the non fat-saturated,

0:38

Let me flip that for you.

0:41

When you look at the non fat-saturated

0:43

sequence, and you look in that same

0:46

area up here, there's nothing there.

0:50

Okay, there's, there's no area of, um, signal

0:55

loss in the upper breast that's going to

0:58

suggest that there is a mass lesion there.

1:03

Um, if you look on the sagittal image, let me

1:06

just shrink that down out of the way, then in

1:09

that area, there is a fold in the breast and

1:13

that fold in the breast has resulted as

1:16

it, you know, does pretty much anywhere in

1:18

the body if you're not careful in a lack of

1:20

fat suppression, just at that one focal area.

1:26

So that would be sort of a, you know,

1:27

a problem in itself, but should have

1:30

been sort of identified pretty easily.

1:33

Um, but then as some of you guys

1:35

identified, which, you know, was,

1:38

I think, um, fairly challenging.

1:41

So, um, kudos to you to get it, that there

1:44

was not only a fat suppression artifact,

1:47

but there is a movement artifact between

1:50

the, um, the pre. Let me do the, see if

1:53

I can get the pre. Let me do that here.

1:57

This is the pre fat-sat,

2:01

and then, I'm sorry, this is the pre

2:04

contrast, and then this should be the

2:07

post-contrast, if I've got those right.

2:10

Let me see if I can get them to link together.

2:14

So when you go up to the top slices, if

2:18

you look here, you're seeing more of the

2:20

breast here. Then you are here and so

2:24

the effect of the patient moving between

2:26

the two slices along with this focal area

2:29

of poor fat suppression has produced an

2:31

area of pseudo-enhancement, and this is.

2:37

not uncommon to have pseudo-enhancement.

2:41

Do we just see it because we've got areas?

2:43

This was a sort of pretty nice one to see it.

2:46

You can even see it in the core, you

2:47

know, this is all using the same data.

2:49

So you're going to see it again here.

2:51

So my advice to you in these kinds of

2:54

cases, particularly when it's something

2:55

very superficial, is to make sure that you

2:58

look at all the slices, see if you think

3:01

that that's a real abnormality or not.

3:03

Now we can get the same type of pseudo-

3:06

enhancement if you have, for example, a

3:12

you have movement between two slices, you

3:15

have a cyst that is T2 bright, where the

3:19

patient has moved between the two slices.

3:21

So that in one slice, it's

3:23

appearing in a different place.

3:25

Uh, in one, in the pre-GAD, it's appearing in

3:27

a slightly different place to the post-GAD.

3:30

And that's going to look on the

3:31

subtraction, like it's enhancing.

3:34

So again, always go back to the native data.

3:36

Remember, you know, the original data is

3:38

the one that you need to sort of go back

3:41

and make sure that something's real or not.

3:43

Um, if you have...

3:45

Um, if you have a patient

3:49

with ductilectasia that has

3:55

increased signal, um, from

3:58

proteinaceous contents.

4:00

Oops.

4:00

I stopped that, fading out.

4:01

So if you have it with, uh, you know,

4:04

somebody with ductilectasia has increased

4:07

signal from proteinaceous content.

4:10

Contents and they move between the two

4:12

slices and the software is not able to, um,

4:15

do sufficient movement correction, that's

4:18

going to look like ductile enhancement.

4:20

And obviously, you're going to think about DCIS.

4:22

So again, go back to your original data, your

4:25

pre-contrast and your post-contrast and confirm

4:28

you can see it on that in this situation.

4:30

Don't just rely on the CAD.

4:32

And don't just do subtractions.

4:34

It's a lot of movement between the two studies.

4:37

Both the subtraction and the

4:39

CAD are completely unreliable.

4:43

Any questions about that?

4:47

You beautifully showed the island of uh,

4:50

Arachnema in the right breast on sequence and

4:53

it was missing on the non-contrasted study.

4:56

So you're trying to tell us that the

4:57

movement has created that pseudo-lesion.

5:01

Correct.

5:02

It's in this patient, she

5:03

had two things going on.

5:05

She had, I'll just go back to

5:06

looking at those, um, slices here.

5:10

She had poor fat suppression, which

5:12

you could see on the sagittal.

5:15

So, no, don't stall.

5:18

So here, this is, this is the

5:20

area we're interested in, right?

5:22

So she's got this fold in her breast

5:24

with poor fat suppression right there.

5:29

And then on the, which one have I got here?

5:31

Pre-post.

5:34

And then when we've got the pre, let's

5:36

check, I got the right studies here.

5:38

When we go up to that top slice.

5:43

Let's see if I can do this slowly.

5:45

Do you see how on, there's

5:47

movement between the two slices?

5:48

So here we've got post-contrast and

5:51

we're seeing that area where we're

5:53

not seeing it on the pre-contrast.

5:57

And the only reason we're

5:57

not slowly starts appearing.

5:59

Right.

6:00

And then it starts appearing.

6:01

So she's only moved, you know, probably

6:04

two slices, if that, between those two,

6:07

between those two studies, but that's

6:10

enough on the subtraction to make it look

6:12

like it's enhancing with washout kinetics.