0:00

This is a 63-year-old woman with dense

0:03

breasts, uh, who presented for screening

0:05

within one of our research protocols.

0:09

So these are her low-energy images,

0:12

bilateral dense breasts, as expected.

0:15

A little suboptimal positioning on the cranial

0:18

caudal view with a nipple, not quite in profile.

0:22

Uh, so just remember that the quality

0:24

control for CM is very similar to, uh,

0:28

your regular mammography in terms of positioning. It's

0:31

still the same requirements, the same, uh, requirements

0:34

for the posterior nipple line, for the nipples

0:36

in profile, for the concave, uh, pectoral muscle.

0:41

Quant on MLO views.

0:43

So those are the same requirements because really a

0:48

contrast-enhanced mammography is still a mammography.

0:52

So low-energy images, we combine images.

0:56

Take a look at this area.

0:57

So it's a focal, pretty low conspicuity, non-mass

1:01

enhancement at two o'clock of the left breast.

1:05

Among, uh, the cases which I presented,

1:07

there is a case of artifactual axillary fat

1:11

enhancement, which almost looks like this.

1:14

So just remember that in this case, it's

1:16

asymmetric, it has some densities, uh,

1:20

on low-energy images associated with it.

1:24

And it's on two projections, so

1:26

it's a focal non-mass enhancement.

1:28

Definitely has to be taken seriously.

1:30

It's very asymmetric with the right side also.

1:33

So the background of minimal or mild

1:35

enhancement, and on this background, it is

1:39

pretty noticeable, even though it's still, uh,

1:41

low conspicuity, relatively low conspicuity.

1:45

These are side-by-side low

1:47

energy and recombined images.

1:49

So you see that there are some

1:50

asymmetries on low-energy images.

1:53

So there is some morphologic underlying correlate.

1:56

On DBT, there is a tiny little

2:00

probable architectural distortion.

2:03

So on the right, you can see a DBT slice. On the left,

2:07

uh, it's a recombined image. So if you happen

2:10

to have, or if you decide to do, uh, for

2:13

particular indications, uh, DBT and C under

2:16

the same compression, this is what you might see.

2:19

So you can see that it's exactly the same area,

2:21

little architectural distortion, but it was

2:24

so a low-conspicuity architectural distortion,

2:28

and we only could see it on one projection.

2:30

Really?

2:31

Uh, well, it was.

2:33

A questionable target for a DBT-guided biopsy.

2:38

So that's why we decided that, uh, we would prefer

2:41

to have a contrast-enhanced mammography on board, uh, for our

2:45

biopsy because we just weren't quite sure we would be

2:48

able to find that architectural distortion again on a

2:51

DBT-guided biopsy after we had a focal compression.

2:55

So, and this was a CM, we did a

2:58

CM-guided biopsy, you see, uh.

3:01

Multiple images of the a CM-guided

3:03

biopsy, a step-by-step approach.

3:06

Having a CM-guided biopsy, if you have a CM service,

3:10

is extremely helpful because if you don't have it, the

3:14

only way to address the findings, which are most

3:18

pronounced or only seen on recombined

3:21

images, is to do an MRI, an MRI-guided biopsy.

3:24

So having a CM-guided biopsy eliminates

3:27

those extra steps and helps tremendously.

3:30

So if, uh, at all possible, please try to,

3:34

uh, acquire a CM-guided biopsy, uh, device,

3:38

which is really just a modified upright

3:41

stereotactic unit.

3:42

And the technique of a CM-guided biopsy

3:44

is very similar to your, uh, stereotactic.

3:47

Uh, but you can use the DBT guidance

3:49

with that process also.

3:52

So, uh, here you see, uh, scout recombined image.

3:57

These are two angled views of targeting.

4:01

These are also recombined images.

4:03

This is the pre-fire image and post-fire images.

4:09

And at the end, we have our clip exactly

4:13

in the area, uh, of concern on the region.

4:16

We recombined images and on, uh, pathology for

4:20

this biopsy demonstrated invasive, moderately

4:23

differentiated ductal carcinoma with

4:25

invasive micropapillary pattern grade two.

4:29

So again, the, uh, just the lower

4:31

conspicuity does not exclude the cancer.

4:35

After that, she actually opted for a mastectomy

4:39

and it was, uh, invasive cancer plus A-D-C-I-S.

4:43

The residual was A-D-C-I-S grade two, 20 millimeters.

4:48

So the, uh, CM actually did not

4:50

see the 20 millimeter of disease.

4:52

Right.

4:52

You're not just, it's probably nine

4:54

millimeter or so focal asymmetry.

4:56

And it's not unusual because, uh, recombined images

5:00

do not necessarily demonstrate DIS very well.

5:05

So in this case, there was a bit of a

5:06

large extent of disease due to DIS.