Interactive Transcript
0:02
Hello, and welcome to Case Crunch Rapid Case
0:05
Review for the Core Exam, hosted by Medality.
0:08
In this rapid-fire format, faculty will show
0:10
key images along with a multiple-choice
0:12
question, and you'll respond with your
0:14
best answer via the live polling feature.
0:17
After a quick answer explanation,
0:19
it's on to the next case.
0:21
You'll be able to access the recording of today's
0:23
case review and previous case reviews by creating
0:25
a free account using the link provided in the chat.
0:29
Today, we are honored to welcome Dr. Robyn
0:31
Roth for a Breast MRI Board Prep Case Review.
0:34
Dr. Roth completed her radiology residency
0:37
and women's imaging fellowship at the Hospital
0:39
of the University of Pennsylvania in 2014.
0:42
She specializes in breast and abdominal
0:44
imaging at Cooper University, where she also
0:46
serves as Women's Imaging Fellowship Director.
0:49
Over 15,000 of her closest friends
0:51
call her @BoobyDoc,
0:53
@theboobiedocs is her popular social media account that
0:55
discusses breast cancer in a fun and educational way.
0:59
So, give her a follow on all social platforms.
1:02
Questions will be covered at the end if time allows.
1:05
Please remember to use the Q&A
1:06
feature to submit your questions.
1:08
With that, we are ready to begin
1:10
today's board review. Dr. Roth,
1:12
please take it from here.
1:14
Thank you so much for having me, and um, I'm very excited
1:18
to be presenting my board review for you tonight.
1:22
So, I call this the Best of the
1:24
Breast MRI Board Review.
1:26
Um, you gave me such a great intro,
1:28
I don't need to say much more,
1:30
um, other than give me a follow at The Booby Docs.
1:34
Um, and I just wanna hear a little bit about
1:36
you, who is here tonight for the board review.
1:40
So, are you a resident who's studying for the Core?
1:43
Are you an attending or, um,
1:44
a practicing physician radiologist?
1:47
Are you just here for the cases or something else?
1:58
Okay. So most of you are here as a resident
2:01
studying for the board, which
2:02
I'm happy because this is gonna help you for that,
2:04
and a lot of attendings as well.
2:07
So, we're gonna start with a 35-year-old
2:10
female presenting with a
2:11
palpable area of concern in the left breast.
2:14
So, when you hear a question like this, I want you to
2:16
think in your mind: Is this a diagnostic or is this a
2:19
screening case? That will kind of help you choose, uh,
2:22
what BI-RADS is appropriate for the—for your answer.
2:26
So, a 35-year-old presents with a palpable area of concern.
2:29
We're gonna start with a mammogram.
2:30
You can see that she has extremely dense breast
2:32
tissue or heterogeneously dense breast tissue.
2:35
She has a palpable area of concern
2:37
in her left lower inner quadrant.
2:39
Um, nothing jumps out on the mammogram.
2:42
So, the next step would be an ultrasound.
2:47
So, on ultrasound, we see this hypoechoic mass.
2:51
There's not a great image, but I would say that
2:53
there might be some mild internal vascularity,
2:56
um, in the area of concern, and the
2:58
appropriate BI-RADS would then be...
3:10
Give it a minute to respond.
3:15
So, was it BI-RADS 2
3:16
benign; 3, probably benign; 4,
3:18
needs a biopsy; or 0, needs an MRI?
3:25
So, most people said a BI-RAD... Actually, most people said
3:28
BI-RADS 4, which is actually the correct answer, and I
3:31
like to tell my residents that if someone has a palpable
3:34
area of concern, you take that a little bit seriously.
3:37
Either it's a new or increasing mass.
3:40
I think if it was not palpable, you could definitely
3:43
get away with a BI-RADS 3, but because it is
3:45
palpable, then you'd probably want to do the biopsy.
3:48
And in this case, um, it demonstrated
3:51
invasive ductal carcinoma.
3:53
So, once we have a diagnosis of cancer, the next
3:57
step in many cases is gonna be a breast MRI.
4:01
And here's her breast MRI. We have the T1
4:04
non-fat sat on the top left, and then we
4:06
have the, um, the T2 in the middle, then
4:10
the T1 pre-contrast with fat subtraction.
4:13
And then you're gonna see three
4:14
consecutive dynamic images.
4:16
The T1, they're all separated by 90 seconds.
4:19
So the, the first subtraction, the second, and the third.
4:23
Um, and you could see abnormal
4:25
enhancement in the left breast.
4:27
So based on the MRI appearance,
4:30
the finding is concerning for: A. Multifocal
4:33
cancer, B. Multicentric cancer, C. Bilateral
4:38
cancer, or D. Contralateral cancer.
4:44
So, it's certainly larger than we saw in
4:46
ultrasound, which is often the case, especially
4:48
in people that have dense breast tissue.
4:50
So based on this, I'm glad that—yeah, so most
4:54
people did say multicentric, which is a correct
4:56
answer because it's involving more than one quadrant.
5:00
So, based on this appearance, what is
5:03
the most likely next step in treatment?
5:05
So, this is taking you a little bit further—
5:07
whether you know how breast cancer is managed.
5:10
So, Lumpectomy would be A; B. Mastectomy, C. Neoadjuvant
5:15
chemotherapy, or D. Sentinel lymph node biopsy.
5:21
Okay.
5:29
So most people said mastectomy, and I'm
5:31
glad—you know, actually, in this, in this
5:33
case, I think it can go one of two ways.
5:36
Certainly, lumpectomy is not the right
5:38
choice. Um, mastectomy or neoadjuvant care—
5:41
chemotherapy is usually how cancers
5:44
that are multicentric are handled.
5:46
Um.
5:47
In this case, they would wanna shrink the
5:49
cancer before they do the mastectomy to improve
5:53
outcomes, and that's what they did here.
5:55
So on the left, you can see the staging
5:57
MRI. It's involving more than one quadrant.
6:00
After the chemotherapy, you can see that it's nearly
6:02
resolved, and now that will give her better—
6:07
A lot of times, they will give chemotherapy to shrink
6:10
the disease, and they're looking for a complete
6:12
pathologic response when they go to surgery.
6:14
And that has better outcomes, um, down the road.
6:18
So these are the things that
6:19
we look for in practice.
6:21
Um, I don't think mastectomy is the wrong choice,
6:24
depending on the pathology, but a lot of times,
6:27
especially in a young 35-year-old, they're gonna
6:29
wanna shrink it first and then take her to, um, surgery.
6:34
So multicentric involves more than one quadrant.
6:36
Multifocal is two areas that involve one
6:39
quadrant. Bilateral, obviously, you would see
6:42
it in both breasts, and contralateral
6:44
doesn't really make sense in this case
6:46
'cause you know it's in the left breast.
6:48
Um, and in this case, she went on
6:51
to have neoadjuvant chemotherapy.
6:52
Though I think mastectomy would be
6:54
a reasonable choice, um, even though,
6:56
especially in this 35-year-old, neoadjuvant
6:58
chemotherapy is more likely what would happen.
7:01
Um, this basically just talks about what I
7:05
just mentioned, so we're gonna keep on moving.
7:08
So, which is the most suspicious kinetic curve?
7:10
Is it type one?
7:12
Type two, three, or four?
7:14
And this is asking you if you understand kinetic curves.
7:18
Um, I don't know if you could see the curve.
7:21
I think the question might be blocking it,
7:22
but we're gonna just go off of what you know,
7:24
based on the type one, two, or three curves.
7:29
Oops, sorry.
7:30
Leave that back for the answer.
7:33
So that is a type, um...
7:36
Three curve.
7:37
Sorry.
7:37
Let me go back.
7:39
Um, now, what is the most suspicious imaging feature?
7:43
Yes.
7:43
In that case, it was rapid uptake
7:45
and then washout, which is the type
7:47
three curve that is the most suspicious.
7:49
Now, what is the most suspicious imaging feature?
7:51
Is it kinetics?
7:52
Is it morphology?
7:54
Is it the presence of T2 hyperintensity,
7:56
or the presence of STIR signal?
8:07
So, morphology. Good.
8:09
So that definitely trumps, um, kinetics.
8:11
You know, kinetics are an important thing, especially
8:13
if you're trying to prove that something's benign.
8:15
Like, it has more progressive enhancement,
8:17
it's T2 hyperintense, but certainly,
8:20
morphology trumps everything.
8:21
So if you have an irregular, spiculated mass
8:23
with benign kinetics, who really cares?
8:26
All right, so moving on.
8:27
So, what is the appropriate BI-RADS
8:29
descriptor for the curve shown below?
8:34
Is it non-enhancing?
8:35
Is it gradually progressive, rapidly progressive
8:38
with plateau, or rapidly progressive with washout?
8:46
Oops.
8:51
Good. So, rapidly progressive with washout.
8:54
That is the correct answer.
8:55
That is a suspicious kinetic curve.
8:58
And based on that, what would be the appropriate BI-RADS?
9:01
Would it be BI-RADS 2, 3, 4, or 6?
9:06
Gave you a little bit of a hint there.
9:14
Alright, let's see what we got.
9:18
So, BI-RADS 4.
9:19
Good.
9:19
So, that's suspicious.
9:20
Notice—actually,
9:23
so some people did put six, and I guess
9:25
in thinking about the question, that's not
9:27
unreasonable because we know she does have cancer.
9:30
But if you saw something that, you know, represented
9:33
a curve like that, then I guess the—what I'm
9:35
leading you to—is that this is suspicious.
9:37
Notice how I didn't put a BI-RADS 5 up
9:39
there because that would be confusing.
9:42
Um.
9:43
So, but ultimately, you need to biopsy it.
9:47
When should a premenopausal female be scheduled
9:50
for an MRI to minimize background enhancement?
9:53
And obviously, this is a perfect world—um,
9:56
thinking that they can get in whenever they want.
9:58
So is it one to six days after completion
10:00
of their menstrual cycle, days 7 to
10:02
12, 13 to 15, 21 to 25, or where background
10:06
enhancement is independent of the menstrual cycle?
10:11
Good.
10:11
7 to 12 days.
10:12
Everyone got that right?
10:13
Good job.
10:16
Next, which of the following
10:18
is not an indication for breast MRI?
10:21
So is it newly diagnosed invasive
10:23
lobular cancer, chest wall radiation?
10:26
I think it's 10 years ago.
10:27
I don't know if you guys—are you guys seeing
10:29
this blocking the, um, slideshow, or are
10:33
you able to see under that—the whole thing?
10:36
We can see it.
10:37
That's just on your, you can see.
10:38
Yeah.
10:39
Okay.
10:39
Um, lifetime breast cancer, about 15%.
10:42
According to the Gale model or concern for
10:44
implant rupture, which is not an indication.
10:50
Okay, good.
10:51
So I'm glad that there was some discrepancies.
10:54
So actually all of those are, um, indications for breast
10:58
MRI except a lifetime risk of breast cancer of 15%.
10:02
Usually, we recommend a breast MRI over
11:05
20% lifetime risk of breast cancer.
11:08
Um, the other ones are definitely
11:09
indications for breast MRI. Good.
11:14
Okay, we're gonna move to the next, next case.
11:17
So I'm kind of, um, I'm kind of grouping them
11:20
together the way that I think things are covered.
11:22
And, um, on the boards, you'll kind of note that if
11:26
you get one, if you get a question wrong, it might
11:28
lead you down the wrong path, which is why I'm, in
11:31
most cases, I'm gonna not give you the answer right
11:33
away to see if you're gonna fall down the wrong path.
11:36
So, like we said, type three
11:37
is the most suspicious curve.
11:39
It has rapid uptake and then wash out.
11:41
Um, type two is, um.
11:44
Medium uptake and then plateau and then slow.
11:46
Progressive washout, I mean, sorry, sorry.
11:49
Slow progressive enhancement is usually benign,
11:53
but again, morphology trumps everything.
11:56
Um, this is an example of rapidly
11:59
progressive with washout, which is
12:00
suspicious, which is why it's a BI-RADS four.
12:03
Um, type one curves are typically benign.
12:06
Type two and three, when they have washout
12:09
or plateau even, that's considered suspicious.
12:12
Um, and type three is the most suspicious,
12:14
strongly suggestive of malignancy.
12:17
'Cause we know that cancers have a lot of vascularity,
12:19
so they tend to wash in and wash out fast.
12:22
So we, we talked, you guys all got this, right?
12:25
So day seven to 12 is when, um, is when.
12:28
Background enhancement's the least.
12:31
Um, we talked about lifetime risk of breast
12:33
cancer greater than 20% as a breast MRI.
12:36
Um, so most breast MRI, it's going to vary
12:39
based on where you, on your institution, but.
12:43
Almost all breast MRIs are gonna have a T1,
12:45
A T2 with fat sub, with fat saturation.
12:48
So that water's bright and most
12:50
benign things are T2 bright.
12:52
And then you're gonna have an axial
12:53
T1 pre contrast with fat set.
12:56
Um, and then you're gonna get
12:57
post contrast dynamic imaging.
13:00
At our institution, we image every 90 seconds.
13:02
We typically do three subtraction images.
13:05
The first subtraction image is the most important.
13:08
My attending Mitch Schnall, who invented breast,
13:11
MRI, said that no self-respecting breast cancer
13:14
will not show up on the first subtraction image.
13:17
So if you had to pick one, um, you definitely
13:20
wanna look at the sub, and this is, and then often
13:23
they'll get, usually get a sagittal delayed image.
13:26
Um, based on that information, the abbreviated
13:29
breast MRI is a protocol that a lot of places are
13:32
now using as a screening for people that are dense
13:35
breast cancer, that have dense breast tissue and
13:37
are like at intermediate, um, risk for breast MRI.
13:40
It's.
13:41
Much cheaper and much quicker than a full breast MRI.
13:44
It takes about 15 minutes rather than 45 minutes,
13:47
and basically you're just getting the scout.
13:49
You're getting a T2 so you could see if things are
13:52
bright, you're getting a T1, one ran, one subtraction.
13:56
Image.
13:57
So the first sub, like I
13:59
said, that's the most important.
14:01
Sorry, you're getting a pre and a post.
14:03
Uh, the first sub, most people, most
14:05
places charge under $299 outta pocket.
14:08
It's highly sensitive and specific.
14:11
Um, and it's a great screening tool that I think
14:13
we're gonna see more and more places offer.
14:16
So again, we talked about indications for breast MRI.
14:19
I like to think of it as like high risk
14:21
risk screening versus the diagnostic.
14:23
So screening is if you are high risk for breast cancer
14:26
based on your lifetime risk, or if you have known.
14:28
Genetic mutations such as BRCA or if you
14:31
have high-risk lesions such as LCIS or LADH.
14:35
Also, if you had chest wall radiation as a child, you're at risk for developing
14:38
breast cancer about 10 years later.
14:40
So we typically start breast MRI screening once.
14:43
Somebody is 10 years, um, post-chest wall
14:47
radiation, but we don't usually start breast
14:51
MRI screening before the age of 25.
14:53
Um, so even if you're BRCA, we don't
14:56
typically start, um, before age 25, and then
14:58
we start adding a mammogram on at age 30.
15:05
Um, also staging is a big one.
15:07
Staging of newly diagnosed
15:09
breast cancer, especially if it's invasive,
15:10
lobular, and it's more likely to be bilateral.
15:13
And, um, cancer isn't also multifocal.
15:17
And then also after you've had breast cancer,
15:19
especially if you have dense breast tissue, we might
15:21
do this for surveillance in premenopausal women.
15:24
Also response to, um.
15:27
I guess response to therapy.
15:29
So if you're getting neoadjuvant chemotherapy,
15:31
like our last patient, to see if it's responding,
15:34
um, diagnostic, it's not really breast.
15:37
MRI is not typically intended for
15:39
breast, um, as a diagnostic study.
15:42
So let's say you work 'em up with
15:43
mammogram and ultrasound and you're,
15:46
you're undecided.
15:47
It's not really meant to be the tiebreaker, though.
15:49
I see it a lot used in practice.
15:51
You're really supposed to come up with your own BI-RADS
15:53
based on what you see on mammogram and ultrasound
15:55
and um, and, you know, breast and MRI in some cases.
16:00
But if you're, if you see something on
16:01
mammogram and not on ultrasound, then you
16:03
might wanna biopsy under stereotactic biopsy.
16:06
So it's not really used in the diagnostic setting.
16:10
Also for implant integrity.
16:12
Um, we typically use this for, um,
16:14
we use this breast MRI for silicone.
16:17
Um, and you definitely wanna get a STIR sequence.
16:21
If you're looking for, um, implant rupture.
16:24
So moving on to the next case.
16:26
A 73-year-old female presents with, uh, who has
16:28
silicone breast implants presents with pain.
16:31
What is the most appropriate first imaging test?
16:34
Are you gonna go to a mammogram
16:36
ultrasound, MRI, or none of the above?
16:39
First imaging test.
16:48
Good.
16:48
So emer.
16:50
Mammogram is definitely the first best imaging test.
16:54
Um, he'll eventually get an ultrasound
16:56
and maybe an MRI if you're suspicious.
17:00
Um, MRI is the most sensitive, but the
17:02
first line of testing would be a mammogram.
17:06
So what type of implants are, are these?
17:08
Are they retropectoral, saline, pre-pectoral, saline,
17:12
retropectoral, silicone, or pre-pectoral silicone.
17:25
Okay, I'm glad.
17:26
So these are actually.
17:29
Pre-pectoral silicone.
17:30
So I don't know if you can, you can't see my mouse, but
17:33
you can see that the pec, um, actually goes, you, it's
17:37
not going in front of the implant, so it's actually it.
17:41
The implant is in front of the pec, so that's
17:43
why it's a pre-pectoral silicone implant.
17:45
It's a silicone implant because
17:47
you can't really see through it.
17:48
So, um, saline, saline implants,
17:51
you can usually see the valve.
17:53
So in this case, it's a pre-pectoral silicone implant.
17:58
And ultrasound of the breasts in the area.
18:01
Pain shows, um, a, a snowstorm appearance compatible
18:06
with intracapsular rupture, a snowstorm appearance
18:10
compatible with extracapsular rupture, linguini
18:12
sign, compatible with intracapsular rupture or
18:15
linguini sign compatible with extracapsular rupture.
18:19
So what am I showing you on this ultrasound appearance?
18:24
Snowstorm appearance of extracapsular rupture.
18:27
That's correct.
18:29
Um, and what imaging tests can confirm that
18:32
we have in fact, extracapsular silicone
18:35
rupture, even though I think that the.
18:37
In this case, the ultrasound is diagnostic.
18:39
The MRI confirms, you can see that it has, um, some
18:44
T2 hyperintensity outside of the fibrous capsule.
18:47
You might see uptake in the lymph nodes.
18:49
All of that is telling you that it has extra
18:51
capsular rupture and something I didn't really
18:54
understand until I was an attending is that in.
18:57
If you see extracapsular rupture, that
18:59
means you also have intracapsular rupture.
19:02
So if you see extracapsular, you know that
19:04
there's intracapsular rupture as well, even
19:06
though it might not be as obvious on here.
19:09
Um, a referring clinician is concerned
19:12
about saline implant rupture.
19:14
What study should he order as an A-M-R-I-B mammogram?
19:20
C, ultrasound D?
19:22
None of the above.
19:28
Saline implant rupture.
19:37
Good.
19:37
So this one is split, but mammogram I. In this
19:41
case, I was actually going for none of the above
19:43
because if he's really concerned about saline
19:45
implant rupture, it's really a physical exam.
19:48
Um, even though that, you know, mammogram wouldn't
19:52
hurt, it would confirm that it's ruptured.
19:55
Often when patients have a saline implant
19:57
rupture, it's like a deflated balloon.
19:59
They know that it's ruptured.
20:01
So what sequence must be included to
20:03
assess for silicone implant rupture?
20:05
Is it T2 with fat suppression, stir
20:08
flare, or diffusion weighted imaging?
20:12
I think I gave you a hint on one of the earlier slides.
20:26
Okay, so actually it's gonna be, um, STIR because
20:31
silicone can be bright on T2, T, uh, fluid
20:35
and silicone can both be bright on T2,
20:38
so that would be difficult to ascertain.
20:41
But the stir will suppress the
20:42
water, but not the silicone.
20:44
So in this case, it's a stir.
20:47
What is the imaging finding
20:48
on this axial stir, um, image?
20:51
Is it A, an injured capsular rupture?
20:54
B, extracapsular rupture, C, normal
20:56
radial folds, or D, none of the above.
21:10
Good.
21:10
So the answer is actually a normal
21:12
radial fold, and we'll, we'll show you an
21:14
example of the opposite in the next case.
21:18
Um, the ultrasound imaging, the ultrasound findings
21:21
are suspicious for an intracapsular rupture.
21:25
B, extracapsular rupture.
21:27
C, intra and extracapsular rupture, or B-I-A-A-L-C-L.
21:33
I'm not gonna tell you what that stands
21:34
for just yet, but we'll get there.
21:37
But they could list it like that.
21:39
So I want you to be familiar with what that stands for.
21:45
Okay, good.
21:46
So the answer is actually correct.
21:48
It's intracapsular rupture, and we'll talk
21:50
about why that's actually the stepladder sign.
21:53
Um, what is the finding and
21:55
significance on this axial stir image?
21:59
Is it the linguini sign compatible
22:02
with an intracapsular rupture?
22:03
Linguini sign compatible with extracapsular
22:06
snowstorm appearance, intracapsular rupture, or
22:08
snowstorm appearance, extracapsular rupture.
22:11
So it's testing if you know the sign and what
22:12
the indication, what, what the implication is.
22:18
So in this case, that's correct.
22:20
It's the linguini sign of intracapsular rupture.
22:23
Um, and you could have intracapsular without
22:26
extracapsular rupture, but not the opposite.
22:28
So referring clinician concerned about
22:30
implant rupture, saline, implant rupture.
22:32
Actually, it's physical exam, but again, an MA
22:35
mammogram wouldn't hurt, but certainly not an MRI.
22:39
Um, sir, sequences we talked about.
22:42
These are normal radial folds, so you don't
22:45
see any silicone going in the, um, making
22:49
a noose with it, which I'm gonna show you,
22:51
um, on the, on one of the future slides.
22:54
And this is the stepladder sign on ultrasound
22:57
that's compatible with intracapsular rupture.
23:00
This is the linguini sign on MRI that
23:02
is indicative of intracapsular rupture.
23:05
So when talking about breast implants, we talk, when
23:08
we talk about the capsule, we're actually talking about
23:10
the fibrous capsule that actually develops over time.
23:15
Also, the saline, I mean, sorry, the silicone implant
23:18
will also have an external capsule that, um, that
23:21
is what ruptures when you have an intracapsular
23:23
rupture, but it doesn't go beyond the fibrous capsule.
23:25
Whereas in an extracapsular rupture, it goes beyond
23:28
the fibrous capsule, um, and into the tissue.
23:33
So on just a summary of all the findings,
23:36
so intracapsular rupture, you're gonna
23:38
see a keyhole or a new sign on MRI.
23:41
You might see a linguini sign, an ultrasound.
23:44
You're gonna see a stepladder
23:45
sign like we saw extracapsular.
23:47
You're gonna see silicone outside the implant and
23:49
may see in the lymph nodes on MRI and an ultrasound.
23:52
We're gonna see that snowstorm appearance like we saw.
23:56
And like I said, you must have
23:58
intracapsular rupture in order to have
23:59
extracapsular rupture, but not the opposite.
24:03
So these are three different findings
24:06
that I am showing you kind of adjacent
24:08
to each other so you can compare them.
24:10
Um, I just want you to take a look at this
24:12
and see if you can identify the differences.
24:15
Um, so on the left image we're gonna
24:18
see the keyhole or the noose sign.
24:20
We can see that the silicone goes within the folds
24:22
and it kind of makes like a little noose at the,
24:25
at the tip of it, as opposed to radial folds in the
24:27
middle, which are just flat pieces of the, um, implant.
24:33
Upon itself, but there's actually no fluid
24:36
outside of the implant as opposed to the
24:38
linguine sign where it kind of just looks
24:40
like noodles, uh, folded upon themselves.
24:43
That's a more dramatic appearance
24:44
of intracapsular rupture.
24:47
And again, here's a stepladder sign on ultrasound
24:49
that indicates, um, intracapsular rupture.
24:53
But of course, you know, MRI will confirm it.
24:55
And on the sagittal image we see, uh,
24:58
fluid outside of the implant capsule.
25:01
So, uh, that's outside of the, the fibrous capsule.
25:04
So that would be extracapsular rupture and
25:06
you might see in the lymph nodes as well.
25:09
Again, this is another case we could see
25:11
the linguini sign of intracapsular rupture.
25:13
And in this case, I think they have
25:15
extracapsular rupture as well.
25:17
Inferiorly.
25:18
Um, and on the right, and then on the left
25:22
you see that intracapsular noose, um, signs.
25:26
So that means that there's intracapsular rupture
25:28
on the left, and I think both on the right.
25:32
Okay, next case, a 47-year-old female
25:35
presents with, sorry, with silicone
25:37
implants, presents with left breast swelling.
25:39
What is the most definitive imaging test to
25:42
rule out a silicone implant complication?
25:45
Most definitive, is it mammogram,
25:47
ultrasound, MRI, or physical exam?
26:01
It is the most definitive imaging test.
26:03
You might see some findings on it
26:05
on ultrasound, but, um, or mammo.
26:07
But MRI definitely confirms that.
26:10
So in this case, this is a T1 on the top left, a T
26:14
1 post contrast on the top right with fat subtraction.
26:18
Um, I think that is a, a STIR image on the bottom left.
26:24
And then, um.
26:26
And then actually probably a STIR image
26:29
on the bottom right and the T2.
26:32
That's probably silicone suppression on the left.
26:34
Bottom left.
26:35
So what do you see on this image?
26:37
MRI shows an intracapsular rupture.
26:41
B, extracapsular rupture, breast cancer, or
26:45
peri-implant collection concerning low for lymphoma.
27:00
Okay, good.
27:01
So I understand why people think it might be an
27:03
implant complication, but in this case, it's actually
27:06
the peri-implant collection concerning for lymphoma.
27:10
Um, what type of implant is
27:12
most susceptible to lymphoma?
27:14
Is it retropectoral?
27:15
I. Saline, smooth silicone, or textured silicone.
27:30
A few more seconds to answer my light a little bit.
27:36
Okay, good.
27:36
So textured silicone is the correct answer.
27:39
Um, retropectoral really doesn't make sense
27:43
because that's just where it's located.
27:45
It actually doesn't have any implication
27:46
for, um, for implant complication.
27:51
Ultrasound confirms a peri-implant collection,
27:54
which was subsequently targeted for FNA.
27:56
It's a little hard to see the difference between
27:59
this peri-implant collection, which is like
28:01
low-level internal echoes versus the implant,
28:03
which is a little deeper, and that's just black.
28:06
Um, and this was aspirated and it confirms
28:09
breast implant-associated lymphoma.
28:11
So BI.
28:12
A LCL stands for breast implant-associated,
28:15
um, I think it's large cell lymphoma, but
28:18
it's a type of non-Hodgkin's lymphoma.
28:20
The patients usually present with, um, breast
28:23
swelling they may present with as a mass or pain.
28:26
Um, imaging will usually show a peri-implant
28:29
collection, a peri-implant collection.
28:32
It's a little hard to tell if that's an
28:33
extracapsular or intracapsular, but it's
28:36
usually contained within the capsule.
28:38
But you can see that it has mass
28:39
effect on the actual implant.
28:41
Like in our case, highest association with
28:43
textured silicone implants, which have
28:45
now, um, been recalled from the market.
28:48
So most people that have textured silicone
28:51
implants are getting them taken out.
28:54
So they don't have this, um, problem.
28:58
So 43-year-old presents for baseline mammogram.
29:02
Um, so again, remember when you're reading a
29:04
question, ask yourself, is this a screening
29:06
or is this a diagnostic case that will
29:08
help you choose the appropriate BI-RADS?
29:10
So baseline mammogram, um, her breast density
29:14
can best be described as, is it fatty,
29:17
scattered heterogeneously, or extremely dense?
29:29
Good.
29:30
So in this case, it's extremely dense.
29:32
I know that breast, you know, breast
29:33
density is subjective, but she's certainly
29:36
over 75% breast dense breast tissue and
29:39
going back, um, to her actual mammogram.
29:43
You know, does something jump out at you automatically?
29:46
Maybe not, but I think that
29:47
the 3D images would be helpful.
29:50
She was, um, on the 3D images, we saw
29:53
an area of architectural distortion,
29:56
maybe a prominent left axillary lymph node.
29:58
Um, she had a circumscribed mass
30:00
in the right upper outer breast.
30:01
So what BI-RADS would we want to give her in this case?
30:07
So is it a BI-RADS 3, 4, 5, or 0?
30:19
Baseline mammogram.
30:25
Good.
30:25
So BI-RADS 0 is the correct answer because remember
30:27
she was, this is her baseline screening exam.
30:30
We see some findings, we have to call her back.
30:32
So that's a BI-RADS zero.
30:34
And you know, typically when you call someone
30:36
back, especially for architectural distortion,
30:38
you're gonna do, um, you know, maybe some
30:41
spot compression images, you might, um.
30:44
You know, get a true lateral or LM view.
30:48
Um, certainly you're gonna wanna do an ultrasound.
30:51
Um, but in this case we actually
30:53
did something different.
30:54
So this is what her diagnostic call back looks like.
30:59
So what imaging test is this?
31:01
Is this an MRI?
31:02
Is this a contrast-enhanced mammogram?
31:05
Is this tomosynthesis or is
31:06
this molecular breast imaging?
31:14
Many of you may not have seen
31:15
this test before, but you will.
31:19
Um, I hope, I'm not sure if they're gonna ask
31:21
this on the boards, but this is an example
31:23
of a contrast mammogram, which is something
31:25
I never saw in fellowship and now I use it
31:27
in practice all the time and it's definitely
31:29
gaining traction at the Society of Breast Imaging.
31:31
This year it was a hot topic and it's, I think in
31:35
a lot of ways it's gonna replace MRI in many cases.
31:39
Um.
31:40
So this is a contrast-enhanced mammogram.
31:42
The findings are suspicious for,
31:44
is it A unifocal breast cancer?
31:47
B, bilateral multifocal cancer,
31:50
or C, bilateral multicentric?
31:56
Little tough, but I think you guys can do it.
32:07
Okay, good.
32:08
So, multi, multi bilateral multicentric.
32:10
So you see the non-mass enhancement
32:13
in the left outer breast.
32:14
You also see it in the left inner breast.
32:16
Um, so that is definitely gonna be different quadrants.
32:19
And also on the right, um, you see it in irregular
32:23
SPD, mass in the right upper central breast.
32:25
I'm gonna go back really quickly because I think even.
32:28
On your best day, it might be hard to
32:31
catch this large right breast cancer that
32:34
is totally obscured in the central breast.
32:37
Um, and again, you know, we saw the architectural
32:40
distortion in the left outer, but we're
32:42
missing a lot, especially in the left medial.
32:44
So this really does show the effect of breast density
32:47
on, um, on, you know, our sensitivity with mammography.
32:54
So, um, this was the right breast.
32:56
Remember, we saw like an irregular speculated
32:58
mass in the right upper central breast that
33:00
we saw a corresponding ultrasound image.
33:02
We saw a few other enhancing masses.
33:04
This is what they look like on ultrasound,
33:06
so they're a little bit more circumscribed.
33:08
But certainly, you know, given the suspicious finding at
33:11
12 o'clock, you might wanna biopsy another one of them.
33:14
The right ended up being invasive ductal carcinoma, and.
33:17
DCIS (ductal carcinoma in situ) I will tell you that the others, the,
33:20
like the dominant masses on the right were
33:21
biopsied and it ends up being fibroadenomas.
33:24
Um, so those were all benign, but I
33:27
just wanted to, oh, you know what?
33:28
I don't have the left image for some reason.
33:31
But again, on the left she had an ultrasound.
33:34
We saw an ultrasound correlate for the
33:36
large area of non-mass enhancement, and that
33:39
ended up being an invasive lobular carcinoma.
33:42
And we didn't find an ultrasound
33:44
correlate for the medial, um, finding.
33:47
So she ended up getting breast MRI and the way I
33:49
oriented this, the contrast mammogram is on top.
33:52
I made it, I rotated it to look
33:55
like the, the MRI on the bottom.
33:57
So you can see that the contrast mammogram
33:59
kind of looks similar in a lot of ways, if
34:01
anything, and has less background enhancement.
34:04
Then the um.
34:06
Then the, um, MRI below, and actually I'm
34:11
realizing that the left breast, um, it's flipped.
34:14
It should be the more prominent non-mass enhancements
34:18
actually in the outer breast, not the inner breast.
34:20
Um, so that makes more sense.
34:22
But you can see she's got extensive bilateral cancer.
34:26
The thing that you can't see on the
34:27
contrast mammogram that you can see on
34:29
the breast MRI is the lymphadenopathy.
34:31
Um, you can see she's got bilateral lymphadenopathy,
34:34
MRI, but like the contrast mammogram, the
34:35
field of view is not posterior enough.
34:38
So I'm gonna go quickly over contrast mammogram.
34:41
I don't know that they're gonna ever ask
34:42
you this on the boards, but they could.
34:44
Um, contrast mammogram is like a
34:47
3D mammogram and an MRI had a baby.
34:50
And it gives you, uh, physiologic
34:53
information similar to breast MRI.
34:55
It basically combines, uh, mammogram with contrast
34:58
administration giving a physiologic component.
35:01
It gets dual energy images so it gets a
35:04
high and low dose image at the same time.
35:06
Um, during the single breath hold and then they
35:09
get the subtraction images immediately and you
35:11
can review with the patient in the real time.
35:13
It's received FDA clearance in 2011.
35:16
We've been using it in practice since 2012.
35:18
Um, it basically is a regular mammogram
35:21
machine that has update, has undergone some
35:23
equipment upgrades, and you basically give.
35:27
Aided contrast material similar to
35:30
CT, the dose is pretty similar.
35:31
It's all based on weight.
35:33
It's about 75 to a hundred ccs.
35:35
You're basically gonna inject the patient, wait
35:38
two minutes, and then you're gonna start getting,
35:41
um, routine images of the, um, of the breast.
35:45
You always wanna start with the
35:47
side you're most worried about.
35:49
So in her case, we started with the left
35:50
'cause we were most worried about the left.
35:52
And you're gonna 'cause Right?
35:53
'cause we wanna mimic.
35:55
Physiologic components.
35:56
So cancers tend to wash in and wash out.
35:59
So you wanna get that early, um, uh,
36:02
mammogram picture on the affected side,
36:04
the side you're most worried about.
36:05
And then you switch to the other side and you
36:07
come back to the side of interest at the end.
36:10
You have 10 minutes to get all the images.
36:12
You can get spot compression in that time.
36:14
Um, you can get magnification after the fact,
36:17
but it will give you, it has the added benefit
36:20
of showing you calcifications that MRI does not.
36:24
Um, like I said, we have 10 minutes to obtain the
36:26
images and you can get spot compressions and typically
36:29
the radiologist reviews the results with the patient.
36:31
So it's pretty quick.
36:33
You can do an ultrasound to target
36:34
any abnormal areas of enhancement.
36:36
So just so you're familiar with contrast mammography,
36:39
um, just so you can see an example, this is.
36:43
You could see this person has extremely dense breast
36:45
tissue, and then when you give them the contrast
36:47
and do the subtraction images, it's beautiful.
36:49
There's minimal background enhancement and you can
36:52
tell if something is normal or abnormal in this case.
36:55
So the radiation dose of contrast mammography
36:58
is about 1.2 times a regular standard mammogram.
37:02
It's getting a little bit, hopefully it's
37:04
getting lower so we can make it similar to a
37:06
regular mammogram. As an MRI, it has no radiation.
37:09
Um, all the cost is a diagnostic mammogram
37:12
plus contrast as opposed to MRI, which
37:15
is about 10 times more expensive.
37:17
It usually takes less than 10 minutes to acquire the images,
37:19
as opposed to MRI, which is,
37:21
you know, 15 to 40 minutes depending on if it's
37:24
more likely, like 40 minutes to pull a breast.
37:27
MRI, and it has a, um, has a decreased
37:30
false positive callback rate with less
37:32
background enhancement compared to MRI.
37:35
Um, I, in my experience, have lower background than MRI.
37:39
So just an overview on contrast mammography
37:43
75-year-old female presenting with
37:44
a palpable lump in the left breast.
37:46
Remember, when you're reading these questions, ask
37:48
yourself, is this a screener or is this a diagnostic
37:51
that will help you decide what the next BI-RADS will be?
37:54
So this is her mammogram.
37:57
And I will tell you these images were
37:59
obtained at Penn, and actually at Penn we, um.
38:03
I don't know why it was different than every other
38:05
place I've heard of, but they showed it, um,
38:09
the right on the right and the left on the left.
38:11
So she has a palpable lump in her left breast,
38:13
but that looks like it's in the right breast
38:15
on this, but you can see that it says left CC.
38:18
So next step
38:21
would be an ultrasound.
38:23
Um, so what is the appropriate by, in this
38:26
case you can see, um, circumscribed mass.
38:29
It's myx.
38:31
Cystic and solid.
38:32
Is this a BI-RADS 0, 2, 3, or 4?
38:38
75-year-old female with a palpable area of concern.
38:41
Third.
38:48
Good BI-RADS 4.
38:49
That is correct.
38:50
Um, I do see some people pick 2 or 3.
38:52
So remember I told you if something's palpable,
38:55
I always take it more seriously.
38:56
I think you're better off to biopsy it because invasive,
38:59
um, triple-negative cancers can grow circumscribed.
39:02
Lots of things can grow circumscribed.
39:04
Doesn't always mean it's benign.
39:06
So all the following are circumscribed cancers except
39:11
mucinous, medullary, papillary, tubular, or invasive
39:15
ductal cancer, which is not well circumscribed.
39:31
So I'm glad that people are all
39:33
over the board in this case.
39:34
Actually, tubular is the answer.
39:36
Tubulars tend to be slow-growing, irregular SPD masses.
39:40
They may grow slowly over time.
39:43
Invasive ductal is actually the most common type of
39:47
well-circumscribed cancer, just because all things
39:51
considered it's the most common, triple-negative and
39:54
aggressive breast cancers tend to not break through the
39:58
pair, uh, the, um, Cooper's ligaments, they
40:00
don't get irregular like the other ones do.
40:03
So invasive ductal can be very well circumscribed,
40:07
um, especially if it's aggressive.
40:09
So in this case, um, we could see that she has this
40:13
enhanced, she had an MRI because this was now staging.
40:16
We could see that, um, you see on the pre
40:19
contrast it is circumscribed and you could
40:21
see that it has some signal intensity.
40:23
It also is on the T1 post.
40:26
Um.
40:27
High T1.
40:29
Um, actually the, um, on the subtraction image,
40:32
it takes away a lot of the, uh, enhancements.
40:36
Um, so based on the MRI appearance, the findings
40:40
are suspicious or are they most likely mucinous,
40:44
medullary, papillary, tubular, and invasive ductal.
40:49
Um, I'll tell you, the T1 pre is the
40:53
answer there is gonna give you the answer.
41:05
Okay, good.
41:06
I'm glad people are all over the place on this one.
41:08
So remember in T1, um, what is hyperintense on T1?
41:12
It's usually hemorrhage or it's blood or protein.
41:16
So, and mucin is a big one.
41:18
So mucin will be right on T1, and
41:21
that's what this was in this case.
41:22
You can see she had moderately invasive.
41:25
Invasive, moderately differentiated
41:27
mucinous ductal carcinoma.
41:28
So mucinous is actually a subtype of invasive ductal
41:31
cancer, which is why that, um, is also considered,
41:35
you know, invasive ductal is the most common.
41:38
Um, oh, we, we talked about invasive, that tubulars tend
41:43
to be irregular spiculated masses that are slow growing.
41:47
Um, okay, so 53-year-old, I think
41:51
this might be the last case.
41:52
53-year-old with history of left breast cancer.
41:55
Status post bilateral mastectomy
41:56
presents with skin thickening.
42:01
What is the most appropriate first imaging test?
42:01
Is it mammogram?
42:02
Ultrasound, MRI, or contrast mammogram?
42:07
Bilateral mastectomy with skin thickening.
42:10
So.
42:17
So in these cases, actually we typically
42:19
start with an ultrasound first, especially if
42:21
someone's had a bilateral mastectomy.
42:24
Sometimes they have reconstruction, um, and
42:27
in some cases they might do a mammogram first.
42:29
But usually we start with an ultrasound.
42:32
Um, and of course, I don't have those images,
42:35
but this is what her MRI looked like.
42:38
Um.
42:40
So I'll give you a second to look at these
42:42
images and, um, so the findings in the skin are
42:48
suspicious for, is it Paget's disease, infection,
42:52
inflammatory breast cancer, or radiation changes?
43:09
Okay, so, um, about 50% of people said
43:13
radiation changes, we're gonna get to this.
43:16
Um, which would be the best biopsy
43:18
to confirm the suspected findings?
43:22
So is it ultrasound, biopsy, MRI,
43:24
biopsy, punch biopsy, or surgical biopsy?
43:27
And this is one of those cases where I'm not telling
43:29
you the answer before I ask you the next question.
43:34
So perhaps you chose the wrong answer
43:36
before; this is your time to make up for
43:38
it or fall down deeper down the hole.
43:42
Okay.
43:43
So in this case, um, lung biopsy is the most
43:48
common answer and that would be correct.
43:51
These findings are more than just radiation changes.
43:54
So she has, on the left, she has
43:55
some multiple enhancing masses.
43:57
You see some enhancement of the skin.
44:00
Skin thickening.
44:01
On the left, you see lots of, you know,
44:03
masses throughout the left breast.
44:04
This is more than just radiation changes, which
44:06
you might just have on the right, but this
44:08
looks more like inflammatory breast cancer.
44:11
You would confirm that with a punch biopsy.
44:14
Um, I.
44:16
This is what her CT looked like.
44:17
You could see that she's got the skin thickening.
44:19
And it was an, um, you could see on the
44:21
punch biopsy it showed invasive cancer
44:24
consistent with recurrent mamillary cancer.
44:27
So on physical exam, um, inflammatory
44:29
breast cancer can look like mastitis.
44:31
So it often, um, they might fail
44:34
a trial of antibiotics.
44:36
They're gonna have that classic peau d'orange.
44:38
Orange.
44:39
It's gonna look like the skin of an
44:40
orange because the breast is so inflamed.
44:43
Um.
44:44
And what you're gonna wanna confirm
44:47
that with a punch biopsy, and the biopsy will
44:49
show tumor emboli and dermal lymphatics.
44:52
They might ask you that you're looking for
44:53
the words tumor emboli and dermal lymphatics.
44:56
That's pathognomonic for, um,
44:58
inflammatory breast cancer.
45:00
It's locally advanced.
45:01
It usually does present fairly quickly.
45:03
They might say that it happened overnight,
45:05
and in a lot of cases that's true.
45:07
Um, these patients are often.
45:10
Almost always treated with neoadjuvant
45:12
chemotherapy first to shrink it.
45:14
Um, it's gonna be at least stage 3B
45:16
cancer because it's involving the skin.
45:19
And somehow we got to all the questions.
45:22
So I hope I answered all your questions.
45:25
I'm gonna leave a few minutes left for, um, any
45:29
questions if you have any, but you could always
45:31
feel free to reach out to me at the Booby Docs.
45:34
Um, across, I'm most active on Instagram,
45:36
but all social media platforms.
45:38
Also, my email address is Rothrobin@cooperhealth.edu.
45:42
But I will tell you, I'm getting wrist surgery
45:43
tomorrow, so I will be out of the office for two weeks.
45:46
Um, so Instagram is definitely better.
45:50
So I hope you found this helpful and
45:52
good luck on your boards, Dr. Raw.
45:55
Thank you so much.
45:56
That was great.
45:57
I can't believe we got through 30 that fast.
45:58
That's incredible.
46:00
Me too.
46:01
Um, there are a couple of questions coming in through that.
46:03
Let's do it.
46:03
That Q and A feature, I don't know if you can pop
46:05
that open or if you want me to read those to you.
46:08
You know what, I think I can.
46:09
Let's see.
46:11
So, um, do you do contrast mammogram
46:15
in the follow-up of malignant cancer?
46:17
Um, malignant mass on.
46:19
Um, neoadjuvant chemo, uh, chemotherapy.
46:22
So that's a good question.
46:23
I think it's a good, um, follow-up test,
46:26
but usually, we like to know what it looks
46:27
like on contrast mammogram beforehand.
46:30
So sometimes they'll do contrast mammogram
46:32
for staging, and then it's a great test
46:34
to st uh, follow up its response.
46:36
I think it can be hard if you get an MRI.
46:39
Then you follow it up with contrast mammogram
46:41
because you're comparing two different modalities.
46:43
So we typically like to keep it consistent, but
46:45
certainly if you can prove that it enhances on
46:47
contrast mammogram, then it's a great way to follow it.
46:50
Following neoadjuvant cancer, I, okay.
46:53
In the multicentric bilateral cancer
46:55
case, you normally biopsy all the masses.
46:58
That's a great question.
46:59
So a lot of times it depends
47:01
on the patient and the surgeon.
47:02
So most surgeons will look at that and be
47:05
like, it's multicentric invasive cancer.
47:08
There's no need to biopsy it.
47:09
You're gonna get mastectomy.
47:11
And some cases, they do like us to biopsy more
47:13
than one area to prove that it is multicentric.
47:17
Um, and also maybe you want to
47:19
prove that it's the same type of breast
47:21
cancer involving the whole breast.
47:23
So sometimes you'll have, you
47:24
know, HER2-negative tumor.
47:25
So you might have an invasive ductal carcinoma with
47:28
that’s ER-positive, PR-positive, and HER2
47:30
negative in one quadrant, and then
47:33
triple-negative in the medial quadrant.
47:36
So it is, I typically, I, I typically
47:39
say if breast conservation therapy is
47:41
being pursued, consider tissue sampling
47:44
of a distant lesion.
47:46
Um, but again, some surgeons
47:48
will say, you know, it's enough.
47:49
We don't need to do that.
47:51
But it's a great question and good.
47:53
Can you please describe Paget's disease?
47:55
Yes, I can.
47:55
So, Paget's disease is, um, cancer
47:59
that's involving the nipple.
48:00
So you're gonna see eczema.
48:02
This changes, it's more of a
48:03
clinical exam finding oftentimes.
48:05
They will have, um, kind of Paget's
48:08
looking nipple on clinical exam.
48:10
You do the mammogram and the
48:11
ultrasound, it all looks fine.
48:13
So they might do a, you know,
48:14
biopsy based on how it looks.
48:16
They might do a punch biopsy or
48:17
they might do something deeper.
48:19
Um.
48:20
They might do a surgical biopsy as
48:23
opposed to inflammatory breast cancer,
48:24
which is more involving the skin.
48:26
It doesn't need to be involving the nipple.
48:27
It can involve the nipple, but it's
48:29
definitely a different disease process.
48:32
Um, and that's the one that you're gonna
48:33
see, the tumor emboli and the dermal
48:35
lymphatics, like that's the key there.
48:39
Um.
48:40
Any other questions?
48:42
If not, um, I will leave it back to you guys, but
48:47
you did really great and I think that you are very
48:50
prepared for the boards, especially after this lecture.
48:54
Thank you so much for the
48:55
opportunity to lecture you tonight.
48:58
Thank you so much, Dr. Roth, for providing
49:00
this lecture and for helping all our learners
49:02
who are getting ready to take the test.
49:03
This is.
49:05
Helpful and awesome.
49:06
Appreciate you being here.
49:07
Okay.
49:07
Of course, anytime.
49:09
Thank you.
49:09
And thank you so much for
49:10
everyone else for participating.
49:12
Um, you will be able to access the recording of
49:14
this replay and other replays, uh, case reviews,
49:17
um, by creating a free MR online account.
49:20
Be sure to join us tomorrow, Tuesday, April 30th.
49:23
With Dr. Dan Patel, who will lead us in a rapid
49:26
review of vascular and interventional imaging cases.
49:29
You can register for that at the link
49:31
provided in the chat and follow us on social
49:33
media for updates on future case reviews.
49:36
Thanks again for learning with
49:37
us, and we will see you soon.
© 2025 Medality. All Rights Reserved.