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This is an 84-year-old woman recalled

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from her screening mammogram for

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right breast microcalcifications.

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We just happen to have a research study for that.

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It's not necessarily an indication you would

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be, uh, routinely doing your CEM of four unless

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that's what you decide in your practice.

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But, uh, this was a research case.

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These are her low energy images,

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scattered fibroglandular densities.

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This is the area of calcifications when you,

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uh, take a closer look at the images available

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to you, you will be able to see them better.

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Here is the extent of the calcifications and

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when we look at, uh, her recombined images.

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So on the background of minimal enhancements,

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especially take a look at the left breast.

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So minimal enhancement, not much going on there.

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Somewhat asymmetric enhancement on the right, so

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it's, it's pretty inconspicuous, but comparing

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right and left, which is extremely important

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in CEM, just like an MRI, you can see that there

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is some asymmetry there and it just happened to

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correspond to the area of microcalcifications.

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So this case actually demonstrates some struggles.

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And so whenever you start doing CEM, not every case

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is a straightforward, uh, high conspicuity mass.

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You start seeing stuff like this.

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And in this case, both the presence of, uh,

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suspicious microcalcifications and the asymmetric

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non-mass enhancement make us suspicious.

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So we need to biopsy.

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At first we did just a stereotactic

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biopsy of microcalcifications.

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So it's, uh, was it 10 o'clock, one centimeter from the

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nipple, and we got focal atypical ductal hyperplasia

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only involving one terminal duct-lobular unit,

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which is a very small, uh, focus of ADH and some

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separate ducts with coarse calcifications on necrosis.

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This pathology was considered discordant,

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so we decided to use a CEM this time.

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So we went back to our images and we're looking

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at what is the most conspicuous, or what is the

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most prominent or suspicious enhancement there,

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and decided that probably the craniocaudal view

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demonstrates more targetable and

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more discrete, uh, areas of enhancement.

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So probably this medial breast,

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is probably this lateral.

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So these are the areas which seemed

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like most prominent and most enhancing.

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So if we are to get cancer, the thinking was

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that it probably would be in these areas.

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So we went actually for a CEM-guided biopsy.

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This is, uh, uh, site one, two to three

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o'clock, three centimeter from the nipple.

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It's on the top.

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It's a scout.

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This is a scout, uh, recombined

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image and the scout low energy image.

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So in low energy image, you see some

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calcifications, but on the recombined image,

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there is some non-mass enhancement with it.

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So at this point, you can either

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see, okay, so enhancement kind of corresponds

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to that calcification, so I can use it as a

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target, or you can continue using your recombined

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images as the target, which we did on this.

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In this case, it's pretty low

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conspicuity, and we knew that it would be.

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So on these paired images, we see a low

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conspicuity non-mass enhancement, which

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is still targetable on a CEM-guided biopsy.

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And here, uh, we actually got

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DCIS, intermediate nuclear grade.

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Now we have to think about the extent of disease and

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what's happening with the, uh, most lateral, um, area.

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This was one of our earlier, uh,

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biopsies, and at that point the thinking

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was that the contrast is washing out.

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So we only have 10, 15 minutes to do the CEM-

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guided biopsy before the contrast forces out.

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Since then, that, uh, has been disputed,

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and the contrast seems to stay longer.

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But in this case, we did not attempt

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the second biopsy as a CEM biopsy because

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it was done during the same injection.

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So we did what we call CEM-

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directed stereotactic biopsy.

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So we saw where the calcifications are corresponding

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to that, uh, lateral area of enhancement, and we ended

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up doing a serial biopsy of that and just got, um...

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A CPNC.

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So that was a benign biopsy, and this

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is what we ended up, uh, having at

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the end in terms of our biopsy sites.

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So the, um, most lateral clip is the, uh,

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original serial biopsy of calcifications.

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You see, there's no enhancement at all to correspond

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to that on CEM. This is a benign biopsy, but it does

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correspond to the area of non-mass enhancement.

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So we think that we biopsy that area well,

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and this is our DCIS, again, corresponds to

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the most conspicuous area of enhancement.

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So she went for segmental mastectomy,

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and it was actually extensive DCIS,

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six centimeter in greatest dimension.

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So the point of this case is that

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sometimes the, uh, findings can be subtle.

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Look for asymmetry and in calcifications when

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you have, uh, a large area of calcifications

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and you're just not sure which is the most

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representative area of calcifications and unsure

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about your concordance, CEM is something that can be

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potentially considered to find the most functionally

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suspicious area and use that as your biopsy target.