0:00

For this one, I'm going to show you,

0:01

first of all, two images on PowerPoint.

0:06

And that's these two.

0:08

And the history on this lady is that she's a 46-year-old

0:14

high risk patient who has a personal history of breast cancer.

0:19

And so, let's just show you that for one moment.

0:24

And then I'm going to go across.

0:26

And this is right breast on the right here.

0:29

Let's go back and look at our images.

0:32

And what I have here on the left is a gadolinium-enhanced image.

0:37

What I've got here on the right,

0:38

which is sort of the most important image here, is a subtraction image.

0:42

And so, I'm just going to go through that.

0:56

Okay, let's see the quiz.

1:01

All right, let's see the answer to that.

1:04

So we've got normal variant, post radiation effect, and diffuse DCIS.

1:07

So that's kind of our differential.

1:09

So what we're looking at here is really,

1:11

and I think the MIPS are really the most of it.

1:16

I always start with looking at the gadolinium subtraction MIPS.

1:21

I find they sort of, you know,

1:23

in some patients, that's basically all you need to look at and you're done.

1:26

But they really are very helpful

1:27

at looking at globally symmetries between the two breasts.

1:30

And you can see here that her left breast

1:34

really has a very little background,

1:36

background parenchymal enhancement at all,

1:38

where the right breast has significantly more,

1:41

and probably classified as being moderate background parenchymal enhancement.

1:45

And in this case, the reason is that the left breast was previously irradiated.

1:51

And when that's happened, once the acute post-radiation changes have gone,

1:55

that tends to quell down, the background of parenchymal enhancement.

2:00

But these can be challenging.

2:01

You've got to correlate it very carefully with the history.

2:05

You also need to look for a history

2:06

of hormone replacement therapy,

2:08

and hormone replacement therapy.

2:11

Not hormone replacement therapy,

2:13

hormone suppressant therapy,

2:16

with one of the estrogen antagonists

2:21

such as Tamoxifen or oxidase inhibitors.

2:26

The reason you need to know about those is

2:28

they will suppress this background parenchymal enhancement.

2:31

But when you come off them, you can have a flare-up.

2:35

And so, you can have a patient who, one year, has fairly low background activity

2:40

and then the next year, you've suddenly got diffuse activity.

2:43

And obviously, your question is always,

2:45

in these patients, you know,

2:46

could this be diffuse DCIS?

2:49

In this patient, we felt that these foci was scattered enough.

2:54

They all look very similar,

2:56

but we were happy just calling that asymmetric background enhancement.

3:00

But I can tell you that we have been caught out.

3:03

Just as an incidental finding in this lady,

3:05

kind of coming back to our first case,

3:08

she does have bilateral inverted nipples,

3:10

which you're seeing here on the right.

3:19

And then, just there,

3:21

you saw it on the left.

3:22

So just another example of bilateral nipple enhancement.