0:00

This last case is another woman

0:02

who's very dense, as you can see.

0:05

She's 68, and again, you know, we start with

0:11

just her localizer, and then we have the T2

0:14

here, and she's got a lot going on, you know,

0:19

very active breasts and extremely dense.

0:23

If we look down here at her pre-contrast T1,

0:28

you can actually see that she's got some debris.

0:32

Within her ducts, fluid bilaterally also almost

0:36

looks like she's got a mass in her anterior

0:39

left breast, but on her post-contrast, you

0:42

can see, you know, that's not enhancing again.

0:46

This is post-contrast.

0:47

We can see still the brightest material.

0:50

No change in its enhancement pattern

0:52

within the duct structures bilaterally, but

0:55

what I'd like to call your attention to

0:57

is in the superior breast right here is a very

1:03

small focal area of enhancement that appears

1:06

to bridge her glandular tissue different than

1:11

all the other sites, you know, the ductal

1:14

areas that didn't enhance and all of that.

1:16

And you can see right here in the

1:18

superior slightly lateral breast.

1:20

And now I'm going to show

1:21

you her subtraction image.

1:24

And again, it's the only dominant area enhancing.

1:28

It's a little irregular.

1:30

All that other activity or breasts

1:33

is not enhancing. That non enhancing mass actually was stable

1:35

32 00:01:37,279 --> 00:01:39,110 on her mammogram from years ago.

1:39

I'll show you her mammogram.

1:40

It's quite complex, but so we've got this

1:43

little focal area, and that was really,

1:46

really teeny and a complicated breast.

1:49

I'll show you now her mammogram.

1:51

Here's her mammogram again.

1:53

Very, very active.

1:54

This was on the anterior

1:57

aspects slightly medial to her nipple.

1:59

This is marking a skin lesion

2:01

that really had no significance.

2:04

Nothing pops out on her 2D mammogram.

2:07

I'll show you now her tomosynthesis study.

2:11

And again, very complicated nodular breasts.

2:15

We're looking for something out

2:17

in the posterior lateral breast.

2:20

On the left side, here's the tomosynthesis

2:23

of her left breast, and I think you can

2:25

actually see a very subtle area of distortion.

2:29

I hope you can see my area and

2:30

my arrow pointing to this site.

2:34

Laterally, that really does correspond to that MR

2:37

56 00:02:37,625 --> 00:02:39,875 finding pretty remarkable.

2:40

It was not as well seen on the MLO

2:42

59 00:02:43,005 --> 00:02:43,205

2:43

tomo image here, and we're moving

2:46

into the lateral breast here.

2:48

And there's a lot of complex tissue, but on that

2:52

CC view, I think you can see it.

2:55

It's in this area somewhere,

2:56

but very, very hard to discern.

2:59

Targeted ultrasound, of course,

3:01

was done looking for the area.

3:03

See, maybe on the CC Tomo images only and on the

3:06

MRI, and nothing was really seen to correlate.

3:09

There was a lot of shadowing and

3:11

irregular structures, but no focal area.

3:14

So she underwent an M.

3:15

R.

3:16

guided core biopsy.

3:17

And this was an invasive ductal

3:19

carcinoma of a tubular type.

3:21

So that often causes distortion.

3:23

It was about six millimeters in size, and

3:25

it also was associated with in the background,

3:28

parenchyma ALH, atypical lobular hyperplasia,

3:31

again, just a, you know, a risk lesion.

3:34

She did go on to have a sentinel node

3:36

biopsy, which of course was negative.

3:38

She had three nodes removed.

3:40

So it was very small.

3:41

Tubular carcinomas tend to be fairly low

3:44

grade, but again detected by the MRI.

3:46

One could have possibly tried a single view

3:50

using that CC subtle distortion, a tomo

3:54

guided core biopsy, but I think it's much

3:56

better seen on MR, and that was our preference.

3:58

Could not find the correlate by ultrasound.

4:01

So those are my cases.

4:03

I hope those showed you a little

4:04

bit about what we're using.

4:06

I think one of the interesting

4:07

things, as I said in my lecture about

4:09

the abbreviated MR is we're beginning to

4:11

see, as others have, that there may be some

4:14

improvement in specificity when you're only

4:16

looking for avidly rapidly enhancing lesions.

4:20

I think we need really, really big data

4:22

to compare that to full protocol in

4:23

MRI, but we're very excited about it.

4:26

And it's

4:27

something that we really offer at our site.

4:30

Now, people talk about contrast mammo.

4:32

That's also a good alternative.

4:33

We just happen to have access to our MR

4:35

units very close to our breast imaging

4:38

area and our diagnostic imaging area.

4:41

So, it's an easy thing for

4:42

the patients to move between.

4:44

Of course, contrast mammo is very, very good, gives

4:46

you, again, the physiologic imaging with contrast.

4:49

It doesn't image as far back, obviously, into the

4:51

chest wall, axilla, and things like that, but it's

4:54

certainly an alternative for contrast imaging and

4:57

increasing your sensitivity of cancer detection.