0:01

So we're going to go on to a case of a

0:03

63 year old woman who had a recent diagnosis of

0:06

right breast cancer and metastatic disease

0:09

in her right axillary lymph node, and our MRI

0:12

was performed to evaluate extent of disease.

0:15

So here's our T1-weighted image.

0:18

On this patient, T1-weighted.

0:23

Just going through this from

0:28

top to bottom, you can see there's

0:30

a lot going on on that right side.

0:32

She has a very large mass, and we're going to

0:35

look at the contrast-enhanced study as well.

0:37

She also has large lymph nodes.

0:41

It's a little bit hard to get all of the

0:43

information from this T1 non-fat-saturated

0:47

image, but you can see skin thickening.

0:50

There's a lot, a lot going on here.

0:53

So I'm going to move to the post-contrast sub.

0:59

So...

1:02

One of the reasons to do this MRI is just

1:07

to see what's happening with this right

1:09

breast and also to screen the left breast.

1:12

So, in the right breast, we have

1:14

a large, diffusely enhancing mass.

1:18

It has some central areas that don't

1:19

enhance very much, probably because

1:22

they're necrotic, but that's a very

1:26

large mass involving the majority of the

1:29

central and upper part of the breast.

1:32

We can see that in certain portions,

1:35

the mass extends directly into the

1:37

skin, and the skin is also enhancing.

1:41

So, that whole thing...

1:43

Front part of the skin, the anterior

1:45

and lateral skin is enhancing.

1:50

And we can also see

1:54

in the axilla, there are

1:56

some very large lymph nodes.

1:58

One of those had been biopsied and

2:00

found to have metastatic disease,

2:02

which is not surprising, but

2:05

very large confluent lymph nodes.

2:10

There's more lymph nodes,

2:15

you know, even the lower

2:17

axillary lymph node is involved.

2:23

The other thing that we're

2:24

looking at is pectoralis

2:27

muscle involvement.

2:28

And you can see that the pectoralis

2:29

muscle is diffusely enlarged,

2:31

it has large masses within it.

2:33

Part of this looks like it's direct

2:36

extension from this mass in the breast,

2:39

but there are several masses involving

2:41

the pectoralis muscle and enlarging

2:43

it. We'll see those as we scroll through.

2:46

So, pectoralis muscle involvement.

2:50

The other thing that we look at in

2:51

a large mass like this is what's

2:54

happening with the internal mammary

2:57

lymph nodes.

2:59

And on the normal side, we see an

3:01

internal mammary artery and vein.

3:04

And on the affected side, we actually see

3:07

some large masses that are in that same area

3:10

with the internal mammary artery and vein.

3:13

So this is a large lymph node there.

3:17

And as we scroll through, she has another

3:22

one down lower, but internal mammary artery

3:27

and vein and internal mammary adenopathy.

3:35

We always want to check in a patient

3:38

like this who has a very large cancer,

3:42

we've checked skin involvement, which is

3:45

present pectoralis involvement present.

3:48

Axillary nodes internal mammary nodes.

3:51

And then we're also wondering if this

3:54

patient has more distant metastatic disease.

3:59

And one of the things that we noticed was that

4:04

she did seem to have some pleural enhancing

4:08

pleural nodularity here anteriorly, and we were

4:13

concerned about metastatic disease to the lungs.

4:21

I think on some of the sequences there,

4:22

there were actually some lesions that were

4:26

visible in the lung and in the liver.

4:31

And then one more thing to look at were any

4:37

bony lesions. If there's anything visible in

4:40

the sternum, which is here centrally, or ribs.

4:45

And we did have this lesion.

4:50

So this is a rib with a metastatic lesion.

4:55

There's a fracture that's a pathologic fracture,

4:57

and there's enhancement around the rib.

5:02

So we've got a rib lesion.

5:04

You can see the fracture there.

5:10

And we're also, you know, we're checking the

5:12

other side, but that's not a primary concern

5:16

in this patient who has such extensive disease.

5:19

But on the left breast, we do

5:22

see some foci of enhancement.

5:26

There's actually some linear non-

5:28

mass enhancement in the lower breast.

5:32

Right here.

5:33

You know, we might be concerned about

5:35

that if there weren't so many other

5:39

areas of interest here and also

5:44

interesting in this patient.

5:48

This is the stir image,

5:54

and it shows us some of

5:56

these masses in the lung

6:02

and then in the liver.

6:04

There were several masses.

6:07

First noticed on STIR images, but then when

6:13

we went, we went to the post-contrast images,

6:18

these actually were filling in with contrast.

6:20

So they were enhancing masses, and on

6:23

subsequent imaging with PET CT, these

6:28

were suspicious for metastatic lesions.

6:32

So this patient has a lot of the

6:36

associated findings that we're

6:38

looking for, kind of all in one patient.