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So our next case is a 42 year old woman

0:03

with a recent diagnosis of right breast cancer, which was initially discovered

0:08

on a baseline screening mammogram as a right retroareolar mass.

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And that mass was biopsied and found to be

0:17

an invasive ductal carcinoma, which was kind of a surprise.

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And she had fairly dense breasts on mammography.

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The size of the tumor was a little bit

0:29

unclear based on the mammogram and ultrasound.

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So MRI was requested for evaluation of extent of disease.

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So here's the patient's MIP,

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which really shows a lot going on here in the right breast.

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So the area behind the nipple that had been biopsied was just this mass.

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But you can see that there's a lot more going on in the right breast.

0:56

There's some non mass enhancement.

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There may be other masses.

0:59

There's a suggestion of a lymph node here in the axilla,

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and she has a fair amount of background parenchymal enhancement as well.

1:09

So we'll go ahead and look at this a little bit more closely.

1:13

We'll pull in our T1 and our post contrast sub,

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and you can see that this patient has a lot of fibroglandular tissue,

1:24

and on a mammogram, that would manifest as breast tissue density.

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So she does have heterogeneously dense to dense breasts on mammography,

1:34

and that was making it difficult to interpret her mammogram.

1:41

But on her MRI, you can see that even in places with denser tissue or more

1:49

fibroglandular tissue, she doesn't really enhance very much.

1:54

But then on the right breast, she has a lot of enhancement.

1:59

So the area that was biopsied was this mass.

2:03

So that's an invasive ductal carcinoma.

2:05

But then she had

2:08

sort of this surprising amount of non mass enhancement in the lateral right breast,

2:16

kind of extending from front to back, and then another mass or masses posteriorly.

2:27

Most of her issue is here in the central

2:30

breast to upper breast, but it does extend lower as well.

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And there are a few other masses

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in the medial breast as well here, anteriorly and posteriorly.

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And she also has multiple large lymph nodes

2:49

in the right axilla that are enhancing, several large lymph nodes.

2:58

So we looked at this with our source images as well, T1,

3:04

pre and post contrast, and you can see the same findings,

3:14

particularly these large axillary lymph nodes.

3:17

So we read this as a BI-RADS 4, because what we wanted to do was biopsy or

3:26

do a second look ultrasound and biopsy of one of those right axillary lymph nodes.

3:31

And there was some discussion before

3:35

reading this, as to whether she would need anything else done in the breast

3:41

on the right. All of this enhancement was suspicious

3:46

on the right kind of BI-RADS 4/5, almost certainly cancer.

3:54

We elected not to do additional biopsies in the right breast because it was felt

3:58

that this would probably be needing to be a mastectomy.

4:01

And we went ahead and did a biopsy, ultrasound guided biopsy of a lymph node

4:09

in the right axilla, and that showed metastatic disease.

4:14

So this was BI-RADS 4.

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And, you know,

4:19

I think in some of these cases, there's a fine line between BI-RADS 4 and 5.

4:23

This is almost certainly going to be a cancer.

4:28

So BI-RADS 4 or 5 would be appropriate here.