0:00

This was a 78-year-old woman.

0:02

Uh, we do know that she has, uh,

0:05

lynch syndrome, and she presented for

0:07

staging of a known left breast cancer.

0:10

So my institution is a tertiary cancer

0:13

center, so we see a lot of cancer staging.

0:16

Uh, so a lot of the cases that I have

0:17

already have known breast cancer.

0:21

In this case, it was invasive lobular

0:22

cancer, ER/PR-, HER2+.

0:26

And she also has a history of chronic lymphocytic

0:29

leukemia, which is currently in remission.

0:33

So this is her low-energy images, a little

0:38

prominent lymph nodes, especially on the left.

0:42

That's her chronic CLL.

0:44

Other than that, uh, well, we see

0:46

a, a clip in the, uh, uh, in

0:49

known cancer right here.

0:52

And these are the recombined images.

0:55

So this is a pretty much an ideal situation

0:58

that we expect to see with the recombined images

1:01

of contrast mammography when we have a minimal

1:05

background parenchymal enhancement and, uh, high

1:09

conspicuity solitary mass in the left breast.

1:14

So we do know that this is an invasive lobular cancer.

1:18

What we do need to deal often, uh, with

1:21

when we contrast-enhanced mammography

1:23

is a little, um, incidental findings.

1:27

Like in this case, on the right, uh, you can

1:31

see a little, uh, area of maybe focal, uh,

1:34

enhancement, even though it's only on one view.

1:38

It was not seen on the lateral

1:41

medial recombined images.

1:43

So remember that you can do, uh, additional

1:45

views, uh, with CEM. You can do lateral, uh, views.

1:49

You can do spot compression views if you want.

1:53

So in this particular case, uh, there

1:55

was nothing on the craniocaudal view.

1:57

Uh, the area disappeared on the lateral view.

2:01

There was nothing really on the tomosynthesis.

2:03

So this is something that we dismissed

2:06

as a background parenchymal enhancement.

2:09

You will see that quite a lot if you do,

2:12

uh,

2:12

CEM, and that could be judgmental in some cases.

2:16

One-view asymmetries do need to be addressed,

2:19

and there is a percent of cancers in

2:22

those. In this case, although we were pretty

2:24

confident that there was, uh, nothing there,

2:26

so we dismissed that as a BPE.

2:29

And on the left, so this is an ultrasound, and

2:33

interesting point here is that on ultrasound,

2:36

you see this, uh, rather irregular mass with, uh,

2:40

microlobulated margins, little

2:42

angular margins, pretty irregular.

2:44

However, on a CEM, it looks a bit more circumscribed,

2:48

not circumscribed, of course, but, um, much more

2:51

circumscribed than, uh, on the ultrasound images.

2:54

So, ultrasound image appearance.

2:57

Uh.

2:57

This is a DBT image.

2:59

So if you compare the morphology, the DBT slice

3:02

seems to be, uh, corresponding to the ultrasound,

3:06

uh, the best in terms of the morphology of it.

3:09

And, uh, CEM gives us this

3:11

more circumscribed round appearance of this mass.

3:15

Again, more circumscribed.

3:16

I don't mean that these are circumscribed

3:18

margins, they obviously are not, but, uh, it's,

3:21

uh, more so than the DBT or, uh, ultrasound.

3:25

So, so these are, uh, lower energy images

3:27

that compare to lower energy images.

3:29

Of course, on lower energy,

3:30

we don't see margins at all.

3:32

So, DBT on the top,

3:34

and low energy on the bottom, just to, to see

3:37

that, uh, low energy, uh, images in this case

3:40

do not give us much information on the margins.

3:44

The woman went for a segmental mastectomy, and it was

3:47

confirmed that it was invasive lobular carcinoma,

3:50

grade two, uh, 1.5 centimeter maximum.

3:55

So this is a PACS, uh, presentation of the case with

3:58

the known, uh, left, uh, invasive lobular cancer.

4:02

These are four low-energy images on the top, craniocaudal

4:06

on the bottom, mediolateral oblique. So,

4:08

you see that, uh, the known cancer in

4:10

the left presents as a focal asymmetry

4:13

with, uh, with a clip in place.

4:15

And when we are doing the recombined images,

4:19

so we see that, uh, high-conspicuity, irregular

4:22

enhancing mass in the left upper outer breast.

4:25

That's the known cancer.

4:26

And I, what I wanted to show you

4:29

is thinking about this, uh, little,

4:31

maybe enhancing one-view asymmetry.

4:34

Questionable one-view enhancing asymmetry in the

4:37

right lower breast on mediolateral oblique projection.

4:40

This is a lower energy image.

4:43

This is that possible one-view asymmetry.

4:47

We happen to have a DBT.

4:50

And we also did a, a lateral image.

4:52

So lateral image demonstrates something that's

4:54

definitely vessel with some overlapping,

4:57

uh, background parenchymal enhancement.

4:59

And this is for, uh, DBT.

5:03

And again, just— we'll watch this area right here.

5:09

It seems like it's just overlapping

5:11

tissues and nothing there.

5:12

So that's what, uh, gave us confidence

5:15

dismissing that area as an artifact in the

5:18

background parenchymal enhancement, and she has a

5:21

clip there on the right from a prior benign biopsy.