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This 48-year-old woman presented to

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us for right breast cancer staging.

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We do know that she has an invasive lobular

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carcinoma of the right breast, which

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was diagnosed at an outside facility.

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Um, she has dense breasts, and she already

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came to us with two clips in the right breast.

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So.

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Looking at her low energy images, we can probably,

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uh, suspect a couple of at least focal asymmetries.

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There are calcifications with those focal asymmetries,

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but when we do contrast mammography, we can see that

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the extent is actually quite a bit larger, especially

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in the craniocaudal in the transverse plane.

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When we have, uh, two sites of cancer, we

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obviously become much more suspicious about

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any additional finding in that breast.

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So, uh, we would not be dismissing these, uh,

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little lower conspicuity and smaller findings as a

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background parenchymal enhancement, especially when

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we have minimal background enhancement on the left.

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So it's, the whole appearance is very asymmetric.

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In this case.

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We also had the benefit of, uh.

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Having both a contrast-enhanced mammography and DBT.

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So, but what it shows here, we were focused on the

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extent of disease in a transverse plane at this point.

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So let's say if this is the only extent of

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disease we are aware of, some women might actually

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still ask for breast conservation and, uh.

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It might even be possible

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with some surgical approaches.

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However, when we know, when we suspect the extent

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of disease is that much larger, at least in our

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institution, we are trying to confirm pathologically

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that this is, let's say this most medial extent and

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the most lateral extent are part of this pathology.

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So we tried to find those most medial and

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most lateral lesions of the extent of disease.

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So on this image, so the most medial

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enhancing mass of this whole area of

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multiple masses and non-mass enhancement.

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When we are doing a DBT, it actually looks like

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there might be a little mass on the right.

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There is a DBT slice at a

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different level, and it probably

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correlates to this most lateral enhancing,

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uh, mass on the craniocaudal view.

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So DBT can be helpful to actually

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find the underlying correlates.

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Then we went for an ultrasound.

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And when we go for ultrasound, we, uh, have

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a completely different, uh, approach in mind.

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We know that wherever we can see even small

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lesions, medial or lateral, uh, less likely to be

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fibrocystic changes and more likely to be a part

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of the whole extent of disease because you wouldn't

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expect fibrocystic changes to actually enhance.

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So in this case, we saw this, uh, large

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conglomerate of masses at 12 o'clock, and that

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was a part of the previously biopsied pathology.

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These are all components of

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that conglomerate of masses.

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We saw another one at one o'clock, but also

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going more medial, so this is a very small.

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But looking, uh, closely at

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it, it's quite an irregular mass.

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And knowing again, our recombined images

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that we should be finding some extent

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of disease kind of lesions in that area.

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We decided to biopsy this one, and

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going actually towards the lateral

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aspect of the breast around 10 o'clock,

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we saw these little masses, and without knowing

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that there is something enhancing, it might be

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probably easier to dismiss it as a fibrocystic

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change, but we did know that there is something

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enhancing, so we do have to take it seriously.

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And we decided to biopsy this

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as well with ultrasound guidance.

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So on the left, these are our

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new biopsy clips.

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These are the pre-existing — these are new biopsy clips.

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Obviously, right after the biopsy, the

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positioning is a little off, but it's still pretty

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close to the extent of disease in the transverse

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plane we expected to find. And these are our new

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clips on the lateral view, and we did know that the

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disease is mostly spread in the transverse views,

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but they're not very far from the shadow here.

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Again, uh, pay attention to some little, uh,

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cutaneous, uh, cherry hemangioma, like in this case.

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So you already know that they're oval,

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they're enhancing, they have little

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dark rims of surrounding air.

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Uh, so those are benign cutaneous cherry hemangiomas.

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The patient ended up having a right mastectomy,

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and it was invasive lobular cancer, at

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least 10 centimeter in greatest dimension.

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She also had a left mastectomy — prophylactic

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mastectomy — and there was no cancer there.

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Just lobular neoplasia, confirming

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our true negative CM on the left.