0:00

The next case is a 52-year-old woman, uh,

0:03

who presented to, uh, us for a consultation.

0:07

Uh, she had a biopsy at an outside

0:09

facility, and she wanted second opinion.

0:14

So this is her, uh, low-energy images, heterogeneous

0:17

dense breast, and, uh, clip in place may be

0:23

associated, focal asymmetry — hard to tell.

0:27

She also has a, a mammographic mass in the

0:30

right breast, oval mass with obscured margins.

0:34

And these are her recombined images,

0:38

and we definitely see the clip on the left.

0:43

We don't see much in terms of the enhancement —

0:47

maybe slight

0:48

on the MLO, although we do have to be

0:51

careful, we know that this, uh, woman just

0:54

recently had a biopsy, and recent post-biopsy

0:57

changes can show as some, uh, enhancement.

1:00

So this is her, uh, recent biopsy site.

1:04

Uh, and really nothing on the right

1:06

in the area of that mammographic mass.

1:10

Maybe we can kind of make out some blue,

1:14

brain enhancement of eclipse

1:17

sign, but not very definite.

1:20

So when we did a slightly delayed lateral

1:23

recombined image, you know that there's already

1:25

some degree of enhancement in the area of

1:29

her post-procedure change — a post-biopsy.

1:31

So now we can see that there is a finding.

1:35

So originally, actually, the, uh, woman

1:38

presented with a palpable mass in the breast.

1:41

And when an ultrasound was done, there was a 1.2 cm

1:44

irregular hypoechoic mass at 3 o'clock.

1:48

She also had a right breast ultrasound, and we

1:51

saw a cyst at 12 o'clock of the right breast, and

1:55

we saw a circumscribed oval mass at 10 o'clock.

2:00

So there has been, uh, some literature, uh,

2:04

specifically from UPMC, and they, uh, described

2:07

that if there is an oval mass with no enhancement,

2:11

uh, in all likelihood, this is something benign.

2:15

And, uh, you can see that there's nothing really, uh,

2:18

of that size to correspond to the 3 o'clock mass.

2:21

Really nothing, uh, enhancing in the area

2:24

of cyst, uh, at 12 o'clock as expected.

2:28

So, uh, because it's an oval

2:30

mass, we could be pretty confident.

2:34

Uh, it's so circumscribed and looks, uh, very

2:37

benign, uh, on ultrasound and non-enhancing.

2:41

And so the chances are that this

2:42

is just a benign fibroadenoma.

2:45

Just so happened that, uh, this woman had, uh, prior

2:48

ultrasound, so it was a stable, benign fibroadenoma.

2:52

So it's a really true negative, uh, contrast-

2:55

enhanced mammogram, specifically con-, uh, true

2:58

negative, uh, recombined mammogram for benign mass.

3:04

I wanted to also point out, uh, you might

3:07

notice in the, uh, left axilla on the MLO view,

3:13

there is a, a linear, like, like a white

3:16

aligned with little white dots around it.

3:19

If you take a close look at the images

3:22

that are available to you, and on the

3:24

corresponding lower-energy images, there is

3:27

not much of that at all or nothing at all.

3:30

So this turned out to be a splash

3:34

artifact, but it wasn't really on the

3:36

working surface of the, uh, paddle or

3:39

of the plate because we wiped it multiple times.

3:42

So— and, and actually we saw it on, uh,

3:44

all four corners on multiple images.

3:47

So multiple projections.

3:48

So be careful.

3:49

It can be inside of the paddle.

3:52

Sometimes you just need to reach out to

3:54

the vendor if you see that persistently.

3:56

But the point is that the calcifications,

4:00

for example, don't show as white little—

4:04

dots.

4:04

You see that there's calcifications right

4:06

here and we don't see them as white dots.

4:09

Really, the, uh, recombined images of CEM

4:12

don't usually have that good of a resolution

4:14

to demonstrate such small findings.

4:17

So if you have this dotted white appearance,

4:20

it's possible that this is an artifact — that

4:24

specifically contrast splash artifacts. And

4:27

if you just wipe the surfaces,

4:29

you should be able to get rid of it.

4:31

And if not, then you need to contact your vendor.

4:35

And, uh, this is another case that

4:37

shows incidental cutaneous hemangiomas.

4:40

So there is one in the left upper outer breast

4:43

on both MLO and CC view, right here on the right

4:47

lateral breast and the craniocaudal view.

4:50

So basically this case, uh,

4:52

was, uh, meant to show that

4:56

cancers not always brightly enhanced.

4:59

They're not always very conspicuous.

5:02

You've seen some—a case of highly

5:04

conspicuous mass of invasive lobular cancer.

5:08

Invasive lobular cancers actually do not

5:10

necessarily, uh, brightly enhance, but they can.

5:13

But some cancers enhance very faintly, so just

5:16

because it faintly enhances, you cannot dismiss it.

5:20

So, and in this case, it was, uh, invasive mucinous—

5:24

and mucinous cancers are known to, to have

5:27

less of an enhancement on recombined images.

5:30

It was a, a low-grade mucinous cancer,

5:33

nine millimeter on pathology.