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This is a 77-year-old woman, uh, with a

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history of right breast, uh, DCIS, high

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grade DCIS, uh, diagnosed and treated

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in 2006. She underwent segmental

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mastectomy and radiation.

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And since that treatment, uh, she gradually developed

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more and more calcifications in the right breast.

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She had several stereotactic biopsies, and this is her

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low energy images. So you can see that she has, uh

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some global asymmetry

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uh, in the right outer breast. There are a

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couple of biopsy clips from the prior biopsies.

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That's what the arrows are pointing to.

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And this is the area of calcifications

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that continue to evolve or continue.

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So there is developing calcifications

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in that area, amorphous calcifications,

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but definitely more than before.

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So we can see that on the left, it's 2022.

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On the right is 2019, and you can see that

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there's more density than there used to be.

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And calcifications continue to increase, but

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it's a difficult case because we know that

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we already biopsied twice and these scars can

1:07

evolve and they can get dense, and post-radiation

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changes can play into it, and fat necrosis,

1:13

calcifications can continue to develop.

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But we were concerned enough about them,

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and we did actually a CEM on her.

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This is her—

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We combine images of CEM, and here's

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definitely we see that there is a problem.

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It's very asymmetric enhancement on the

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right, segmental distribution enhancement.

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Uh, probably even some masses,

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maybe, at least in my mind,

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there's one mass in the subareolar breast.

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So if anything, I would be concentrating on this

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40 00:01:45,555 --> 00:01:49,935 particular area to find my most functionally

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suspicious target for a biopsy. On the left,

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it's a mild, uh, background enhancement, pretty

1:58

uniform throughout the breast, so dismissed that

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as a background and concentrated on the right.

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This is her, uh, MRI.

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She just happened to have an MRI.

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We did not really order it to

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work up our CEM, uh, findings.

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She came with it from our site facility, and we'd see

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that it's a very similar presentation on this, uh,

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maximum intensity projection post-contrast image.

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It's the same shape and size of non-mass

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enhancement and maybe a mass, maybe a mass here

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on the T1 post-contrast recombined image.

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And on sagittal image, it's the same

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kind of, uh, appearance.

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So when I went to do her ultrasound,

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I had, uh, this area in mind as my most

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likely area of potentially cancer.

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So if anything, I would like to biopsy that.

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So this is her ultrasound.

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She had a subareolar mass around nine o'clock.

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So knowing that there is an enhancement,

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I called it a mass.

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It's actually, uh, in the radial view, you can see

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that it extends into the outer breast at 10 o'clock.

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So these were my two targets:

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nine o'clock subareolar and 10 o'clock. I biopsied

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them both with ultrasound-guided biopsy, uh,

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placed a ribbon clip into the, uh, subareolar

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and the coil clip into the 10 o'clock one.

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And there was also a suspicious lymph node in the

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level 1 axilla with diffuse cortical thickening.

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These are my post-procedure images, and you

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can see that the clips—so this is the ribbon

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clip on the subareolar mass, which does correspond

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to the enhancing mass on the recombined image.

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This is the second clip, this is a coil clip.

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It also corresponds to the area of enhancement and

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the same, but, uh, of course these are lateral post-

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biopsy images.

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So the, um, it's not quite the same positioning, but

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I was pretty satisfied with the location of the clips.

4:07

And what it ended up being is a retroareolar mass at

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nine o'clock, five centimeters from the nipple.

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It was invasive ductal cancer,

4:14

grade 2. The second mass at 10 o'clock—

4:16

it was breast tissue with dense breast stromal

4:19

fibrosis, and the lymph node was metastatic carcinoma.

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But definitely,

4:25

I, I was thinking that the subareolar mass was the most

4:28

cancerous one, and that's what showed us the cancer.

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So this is a kind of a CEM-directed ultrasound-

4:35

guided biopsy, and, uh, she underwent total

4:39

mastectomy after neoadjuvant chemotherapy.

4:42

Responded very well, and there was no residual cancer.