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This is a case of an 81-year-old woman,

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uh, who presented to our institution

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for left breast cancer staging.

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It was an invasive ductal cancer, grade

0:09

two, ER/P positive, HER2 equivocal.

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These are her all low energy images, fatty or

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scattered triradiate glandular densities on the left, uh,

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focal asymmetry, maybe a little mass with the clip.

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On the right.

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It's hard to see here, but, uh, you will

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have a benefit of magnifying that area.

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There are.

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There is an area of regional micro

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calcifications, so here they are.

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However, looking at the, uh, contrast-

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enhanced mammography at the combined images

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of the contrast-enhanced mammography,

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we don't see any asymmetry at all on the right.

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So in the area of those calcifications,

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there is no enhancement at all.

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Although we do see low to moderate conspicuity

0:56

mass on the left, and that's the known cancer.

1:00

When we do an ultrasound.

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So we see it as expected in the

1:03

regular mass with the clip in place.

1:06

So this is an MRI—breast MRI—and

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she happened to have an MRI also.

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And on the right we see the left

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enhancing cancer on the, uh, maximal

1:18

intensity projection image on the left.

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So this is her enhancing cancer.

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On the right we see, uh, one

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duct with the T1 hyperintense material in it.

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So it's either blood or it's, uh, protein-

1:34

tenaceous material, but it doesn't really

1:36

enhance because this is actually a MIP of a post-

1:39

contrast image, and this is a T1 shine through.

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You see that on pre-contrast image, it's also bright.

1:46

Apart from that enhancing duct, the MRI

1:49

didn't really show us any pathology either.

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So the point of me bringing up

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the MRI here is that neither

1:56

CEM nor MRI showed any focal pathology

2:00

in the area of concern—in the area of

2:02

those mammographic microcalcifications.

2:05

However, as Dr. Phillips pointed out, CEM is a combined

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exam, and the suspicious findings on low energy images

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are enough to do a biopsy and to do further workup,

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even if there is no enhancement on recombined images.

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So we did do a stereotactic-guided biopsy

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of the right, uh, microcalcifications,

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and it was DCIS, intermediate grade.

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On surgical pathology, she had a segmental

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mastectomy, which confirmed grade 2

2:38

DCIS of 5 millimeter in diameter.

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So it actually was not as big

2:43

as the area of calcifications.

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But the point is, uh, that especially with

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the calcifications, if the calcifications

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are suspicious enough, even if they don't

2:52

enhance, they have to be biopsied.