0:04

Now, this last case, this is one where the MIPs

0:07

is, I think, really the most helpful in this.

0:10

Now, I love the MIPs for breast MR, and I always

0:13

start my review sequence by looking at the MIPs.

0:18

Um, you know, sometimes, you can,

0:21

you've pretty much read the entire

0:22

study by the time you've looked at the MIPs.

0:24

They're great for looking for

0:25

background for income enhancement.

0:28

They're great for looking for symmetry.

0:30

And in this case, if you look at the

0:32

MIPs, you can very clearly identify

0:36

that this got very asymmetric nipple

0:38

enhancement and some sort of flattening.

0:40

But probably thickening of that nipple

0:43

and then that she has segmental non-mass

0:46

enhancement in the right breast, pretty

0:48

much nothing in the left breast at all.

0:50

Now, a lot of this is sub-threshold so it's not,

0:54

you know, it's pretty low-grade enhancement.

0:56

Now let's look at the, uh,

0:59

subtractions, hopefully.

1:02

So here's that really

1:03

asymmetric nipple enhancement.

1:04

And nipple enhancement is tough because

1:06

there's quite a wide variability in the

1:11

degree of nipple enhancement in patients,

1:13

particularly in younger patients.

1:15

But it should be pretty symmetrical.

1:17

Um, it would, unless the patient's had

1:19

radiation treatment on the other breast.

1:21

So this is clearly asymmetrical.

1:23

And then here we're seeing that.

1:29

Segmental, plumped, non-mass enhancement.

1:32

Um, segmental enhancement is always the most

1:36

concerning for malignancy, followed by linear.

1:39

Um, and this was DCIS.

1:42

Now, the fact that it is kinetics, the sub-

1:44

threshold should not stop you calling it.

1:48

Um, I don't find the kinetics very reliable

1:50

for DCIS, particularly if it's low grade.

1:54

Um, This is a classic case of Paget disease.

1:58

Um, I withheld the history because otherwise

2:01

it would have been pretty obvious, but she

2:03

presented with, um, an eczematous right

2:07

nipple and had a skin biopsy of that prior

2:10

to having the MR done and she was sent for

2:13

MR for staging; her mammogram was negative.

2:16

Um, so sort of a nice case there. So look

2:18

carefully at the nipples, look for symmetry.

2:22

When you have a patient who has, like

2:25

that last case that we saw where they had

2:28

extensive non-mass enhancement, always look

2:30

very carefully to see if that goes up into

2:32

the nipple because it's going to make a

2:34

significant change to the surgical management.

Wk 4, Case 5 - Review

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0:04

Now, this last case, this is one where the MIPs

0:07

is, I think, really the most helpful in this.

0:10

Now, I love the MIPs for breast MR, and I always

0:13

start my review sequence by looking at the MIPs.

0:18

Um, you know, sometimes, you can,

0:21

you've pretty much read the entire

0:22

study by the time you've looked at the MIPs.

0:24

They're great for looking for

0:25

background for income enhancement.

0:28

They're great for looking for symmetry.

0:30

And in this case, if you look at the

0:32

MIPs, you can very clearly identify

0:36

that this got very asymmetric nipple

0:38

enhancement and some sort of flattening.

0:40

But probably thickening of that nipple

0:43

and then that she has segmental non-mass

0:46

enhancement in the right breast, pretty

0:48

much nothing in the left breast at all.

0:50

Now, a lot of this is sub-threshold so it's not,

0:54

you know, it's pretty low-grade enhancement.

0:56

Now let's look at the, uh,

0:59

subtractions, hopefully.

1:02

So here's that really

1:03

asymmetric nipple enhancement.

1:04

And nipple enhancement is tough because

1:06

there's quite a wide variability in the

1:11

degree of nipple enhancement in patients,

1:13

particularly in younger patients.

1:15

But it should be pretty symmetrical.

1:17

Um, it would, unless the patient's had

1:19

radiation treatment on the other breast.

1:21

So this is clearly asymmetrical.

1:23

And then here we're seeing that.

1:29

Segmental, plumped, non-mass enhancement.

1:32

Um, segmental enhancement is always the most

1:36

concerning for malignancy, followed by linear.

1:39

Um, and this was DCIS.

1:42

Now, the fact that it is kinetics, the sub-

1:44

threshold should not stop you calling it.

1:48

Um, I don't find the kinetics very reliable

1:50

for DCIS, particularly if it's low grade.

1:54

Um, This is a classic case of Paget disease.

1:58

Um, I withheld the history because otherwise

2:01

it would have been pretty obvious, but she

2:03

presented with, um, an eczematous right

2:07

nipple and had a skin biopsy of that prior

2:10

to having the MR done and she was sent for

2:13

MR for staging; her mammogram was negative.

2:16

Um, so sort of a nice case there. So look

2:18

carefully at the nipples, look for symmetry.

2:22

When you have a patient who has, like

2:25

that last case that we saw where they had

2:28

extensive non-mass enhancement, always look

2:30

very carefully to see if that goes up into

2:32

the nipple because it's going to make a

2:34

significant change to the surgical management.

Report

HISTORY: 79 year old lady, history withheld.

Summary of prior imaging

Mammography: Normal
Ultrasound: Normal
Breast MRI: NA

FINDINGS

Quality control issues: ☒None ☐Poor/lack contrast bolus ☐Poor fat suppression ☐Susceptibility ☐Movement ☐Other

Background Parenchymal Enhancement: Minimal
Amount of Fibroglandular Tissue: Heterogenous glandular tissue

LEFT BREAST

Narrative:
Associated findings LEFT breast: X NONE ☐Nipple retraction, ☐Nipple involvement, ☐Skin retraction, ☐Skin thickening, ☐Skin invasion-direct, ☐Skin invasion-inflammatory, ☐Pectoral muscle invasion, ☐Chest wall invasion, ☐ Architectural distortion

Non-enhancing findings LEFT breast: ☐High ductal signal pre contrast T1, ☐Cyst(s), ☐Hematoma/seroma, ☐Post therapy skin/trabecular thickening, ☐Non-enhancing mass, ☐Architectural distortion, ☐Signal void from clips

Fat containing lesions LEFT: ☐Fat necrosis, ☐Hamartoma, ☐Post-operative seroma/hematoma with fat

Lymph nodes LEFT: ☒Normal axillary, ☐Abnormal axillary, ☐ Abnormal internal mammary

RIGHT BREAST

Narrative: 6cm segmental sub threshold non-mass enhancement in the lateral right breast extending to the nipple with right nipple enhancement and thickening. 1.5 cm cyst RUIQ.

Right breast lesion 1
Lesion type: Non-mass enhancement
6 cm. Upper outer Quadrant. 9:00 Radian. 0-6 cm from the nipple

Non mass enhancement: Distribution: Segmental, Internal enhancement: Clumped, Kinetics: -subthreshold

BI-RADS:4: Suspicious abnormality – Biopsy should be considered

Associated findings RIGHT breast: ☐Nipple retraction, ☒Nipple involvement, ☐Skin retraction, ☐Skin thickening, ☐Skin invasion-direct, ☐Skin invasion-inflammatory, ☐Pectoral muscle invasion, ☐Chest wall invasion, ☐ Architectural distortion

Non-enhancing findings RIGHT breast: ☐High ductal signal pre contrast T1, ☒Cyst(s), ☐Hematoma/seroma, ☐Post therapy skin/trabecular thickening, ☐Non-enhancing mass, ☐Architectural distortion, ☐Signal void from clips

Fat containing lesions RIGHT: ☐Fat necrosis, ☐Hamartoma, ☐Post-operative seroma/hematoma with fat

Lymph nodes RIGHT: ☒Normal axillary, ☐Abnormal axillary, ☐ Abnormal internal mammary

Extramammary findings: None

SUMMARY: Segmental clumped enhancement in the right breast highly suspicious for DCIS. Asymmetric right nipple enhancement suspicious for nipple involvement.

LEFT breast BI-RADS:1: Negative

RIGHT BI-RADS:4: Suspicious abnormality – Biopsy should be considered

RECOMMENDATIONS: MRI guided biopsy of right breast lesion 1

Case Discussion

Faculty

Petra J Lewis, MBBS

Professor of Radiology and OBGYN

Dartmouth-Hitchcock Medical Center & Geisel School of Medicine at Dartmouth

Sheryl G. Jordan, MD

Professor, Department of Radiology

University of North Carolina School of Medicine

Ryan W. Woods, MD, MPH

Assistant Professor of Radiology

University of Wisconsin School of Medicine and Public Health

Practice Cases

Worklist 1

Practice Cases

Worklist 2

Practice Cases

Worklist 3

Practice Cases

Worklist 4

Practice Cases

Worklist 5

Wk 4, Case 5 - Review