0:02

Hello, and welcome to Case Crunch Rapid Case

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Review for the Core Exam, hosted by Medality.

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In this rapid-fire format, faculty will show

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key images along with a multiple-choice

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question, and you'll respond with your

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best answer via the live polling feature.

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After a quick answer explanation,

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it's on to the next case.

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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.