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This case is a 62-year-old woman, uh, who presented

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for the evaluation of left nipple discharge.

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She had it for years.

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Uh, it was clear for many years, uh, but she

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did have one episode of, of bloody discharge.

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So that, uh, alarmed her and, uh, she came to us.

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So you can see that she has a

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heterogeneously dense breasts.

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It's a pretty symmetric pattern.

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Uh, these are lower energy images,

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the equivalent of FFDM, full-field digital mammography.

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And, uh, these are, uh, recombined images

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of, uh, contrast-enhanced mammography.

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So, again, you can go back and forth and on.

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You can see, uh, how the anatomy overlaps and

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how, um, some morphologic findings might be

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matching the, uh, recombined imaging findings.

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For example, this

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little mass of lymph node.

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You can see that there is an enhancement right there.

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Just to explain the full story behind this,

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uh, she did, uh, undergo bilateral ultrasound.

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Uh, we found either cyst or cystic

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duct, uh, dilatation within the left

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hip and right under the left nipple.

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And, uh,

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maybe, possibly, uh, underlying

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hypoechoic mass right next to it.

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Uh, because of course, because her, uh, nipple

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discharge is potentially a concerning symptom.

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So we took it seriously and we were working it out.

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She happened to have breast MRI, and this is a post

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contrast T1 MIP, maximum intensity projection

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image, which gives you an overview of the overall

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background parenchymal enhancement on MRI and the

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uh, tissue pattern, and notice how similar it is.

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So this, uh, pattern of contrast-enhanced mammography.

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So this patchy appearance, which we would

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call probably at least moderate or maybe even

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marked, uh, background parenchymal enhancement.

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So on this right MLO is probably even marked,

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so marked to moderate background parenchymal enhancement,

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and just like breast density for mammography,

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background parenchymal enhancement can be limiting

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for contrast-enhanced mammography.

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So the more prominent, uh, background

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parenchymal enhancement, the less likely it

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is that you will find little enhancing masses.

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So moderate to, uh, marked

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background enhancement in this case.

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So, uh, just like on, uh, contrast

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mammography, which does not really find any

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focal findings, but rather this, uh,

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moderate to marked background enhancement.

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The same we see with, uh, breast MRI.

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Nothing really focal.

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Just a lot of background. On some

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individual, uh, sequences of MRI,

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so you see that she did have, uh, one single duct

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with some T1 non-contrast high signal in it.

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So it's either blood or maybe

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proteinaceous fluid right here.

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Nothing really concerning in that area.

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Nothing focal on, uh, post-contrast subtracted

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T1 MRI image and we do see that cystic, uh,

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T2 bright, uh, lesion within the left nipple.

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So basically, this is to show the correlation

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between, uh, contrast mammography and MRI

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and that MRI wasn't really much more helpful

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in, uh, figuring out the patient's symptoms.

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So this is persist.

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We did end up doing an ultrasound-guided biopsy

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of that little possible, uh, subareolar, uh, mass.

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And it was a benign, uh, finding no malignant

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cells, uh, benign proliferative ductal lesion

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in the background of, uh, proteinaceous debris.

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So in this case, uh, it was a true

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negative, uh, a bit challenging

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CM, of course, because of the

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background parenchymal enhancement.

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But one of the reasons for demonstrating

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this case is that MRI might not be helpful.

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Let's say you are stuck, uh, doing some, uh, CM

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cases and you think that MRI might solve your issues.

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Not always does, or not, not even often does because,

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uh, it, it might have just the same pattern and

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the same issues as contrast-enhanced mammography.

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And here's an example of how you can use your

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contrast-enhanced mammography, especially the lower

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energy part of it in relation to the prior image.

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So let's say this is your baseline

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contrast-enhanced mammography, and you

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see some mass, it's an enhancing mass.

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But you just happen to have a, a previous mammogram

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available to you, and you see that, that mass,

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even though you, you didn't know that it was

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enhancing before, but it was there. As soon as

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the morphologic and underlying lesion is there,

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it— we can consider it benign and stable.

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So— and I will show you, uh, how I would approach,

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uh, this case with the left nipple discharge on PACS.

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And again, you have, uh, you

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might have your own display.

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But here we can see the, uh, so the top there,

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uh, bilateral craniocaudal low energy images of

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contrast-enhanced mammography. On the bottom,

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uh, bilateral— mediolateral oblique, low

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energy images of contrast-enhanced mammography.

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You can, uh, work with your PACS and

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make sure that your low energy images

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and, uh, recombined images overlap.

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And you can see is that, uh, in this

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case, it's, uh, moderate to marked

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background parenchymal enhancement.

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It's not as smooth as we saw in the first case.

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Definitely a lot of, um, background happening.

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So you might notice a little something that might

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look like non-mass enhancement in the outer breast,

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uh, on the left.

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But then, uh, we did additional views

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and we looked at the mediolateral

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projections and there is really nothing.

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Uh, we also did an ultrasound later and

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we did not find anything in that region,

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so we concluded that this is, uh, just her

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background parenchymal enhancement, and

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this might be difficult in these cases.

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Again, just like with dense breast, when

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you are limited in terms of what you can see

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through the breast density, you can be limited

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what you can see is through the marked

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background parenchymal enhancement.

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Uh, so this is a case where we did have

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DBT, the digital breast tomosynthesis.

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And just like with low energy and recombined images,

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you can toggle with your DBT, so you can actually see

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exactly of what's, uh, under your enhancing findings.

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So just like in this case, in the outer breast, we see

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it's the classic lymph nodes with, uh, fatty hila.

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And if you bring back your recombined image,

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you will see that there is a little bit of enhancement

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there, and there is a mass on the low energy images.

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In our PACS, we have buttons we can toggle through.

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Uh, remember you can do basically, uh, any

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additional views except for magnification views.

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With contrast, you can do spot compression,

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contrast views, uh, you can do lateral views.

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So in this case, we were trying to figure

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out what's going on behind that nipple

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and did not really see anything new,

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uh, or suspicious from her prior images.

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This is an example when we did spot

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tomosynthesis on that, uh, case.

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And this is an MLO, uh, view.

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Notice how you do not really see the

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pectoralis very well on recombined images.

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You do see enhancing lymph nodes.

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But again, the beauty of it is that you

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can cross-correlate with the low energy

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images under the same compression.

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And this was a, uh, a lateral image.

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So, uh, this was a basically negative, uh,

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study with, uh, moderate to marked background

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parenchymal enhancement, uh, no pathology.

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The woman, uh, saw this lady for another

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year and, uh, she's still okay.

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So she did not develop any cancer.

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So we consider it's a true negative one study.