0:00

So now we're gonna look at recalls, which is,

0:02

um, an area that I really love using it

0:04

for, especially for architectural distortion.

0:07

So this was a really amazing case.

0:10

A colleague of mine, um, recalled this patient

0:13

for exceptionally subtle distortion that was

0:15

marked here by the yellow arrows on TOMO.

0:17

Really subtle.

0:19

We brought her back for contrast-

0:20

enhanced mammo.

0:22

Why do I like it?

0:23

Well, if it's subtle distortion— right.

0:26

We know that distortion is subjective sometimes, right?

0:28

So somebody can think that there's something there,

0:30

and I can look at it and say, I don't see it at all.

0:33

And then there's another group,

0:34

which is very obvious distortion.

0:36

We all know that there's something going on.

0:38

So for those subtle distortions, we always

0:40

have this balance of, well, what do we

0:42

do if our diagnostic imaging is negative?

0:45

Then do we still go for a biopsy

0:47

for the initially identified, you know, there's...

0:50

There's so much question about

0:52

what the next step should be.

0:53

So the contrast mammogram helps us decide.

0:56

It gives more information to help triage.

0:58

Is this something to worry about or not?

1:02

And then on the flip side, if it's one

1:03

of those obvious areas of architectural

1:05

distortion, it really helps for staging.

1:07

So this is an example of subtle distortion.

1:09

Is this real?

1:09

Is it not real?

1:11

We bring her back and look at that.

1:12

These are the recombined images, which show

1:14

a large area of segmental enhancement.

1:17

And this was absolutely real.

1:20

Um, there's no question about it.

1:21

This was an invasive lobular cancer, and we could

1:25

tell that there was something to worry about

1:27

in seconds—minutes, I should say.

1:28

The exam takes minutes.

1:31

So the next example is recall for calcifications,

1:34

and I already mentioned that you're gonna act on

1:38

calcifications that are suspicious regardless of

1:41

whether there's enhancement or not.

1:43

So, the presence or absence of enhancement is

1:44

50 00:01:46,800 --> 00:01:50,700 only helpful if it's larger than the area of

1:50

calcifications, and it would impact your management.

1:53

This patient had a very large area of calcifications

1:55

throughout the central upper part of her left breast.

1:58

You can see these calcifications here.

2:00

They're pleomorphic, right?

2:02

These are coming out.

2:03

They were biopsied.

2:04

They're malignant.

2:05

We do a recombined image.

2:07

We see that there's associated enhancement,

2:09

so like what's the point of this?

2:11

Well, it's helped us know that there's no

2:13

enhancement in the lower part of the breast.

2:16

Right?

2:16

We can see that the enhancement and at least the disease

2:20

is isolated to this area of calcifications, and it's

2:22

also given us information about the right breast.

2:25

So when you consider

2:27

evaluating con— or using contrast

2:29

mammo for calcifications,

2:30

it's really to say, what, how is this going to help me?

2:33

I'm already worried about the calcifications.

2:35

I'm going to look— I have to look for something more.

2:37

And if that additional information

2:39

will help me, then it's worth doing.

2:41

This was DCIS.

2:44

This was a recall for a possible

2:46

mass, so there was the possible mass.

2:48

You can see it better, um,

2:49

in the upper outer left breast.

2:50

You can see it better on the MLO view.

2:53

When we do the recombined images, you can

2:55

see that there's this very discrete mass.

2:56

I mean, look at that.

2:57

This is a woman who has dense breast tissue.

3:00

Hard to differentiate anything, right?

3:03

If there's a subtle mass located within the dense

3:05

breast tissue. And then we do the recombined images,

3:08

and all of the normal breast tissue goes away, and we

3:11

see the mass, we see the size of it, we see the extent

3:13

of it, and we can look at the contralateral breast and

3:15

say, okay, this is really what we're talking about.

3:18

This one small area.

3:21

So now let's look at the data,

3:23

um, for architectural distortion.

3:24

Again, this is an area that I really love.

3:26

Patel and colleagues published the first

3:28

study on this in 2017, and they said that,

3:31

um, enhancement was associated with 30,

3:36

I'm sorry, with 29 of the 30 cancers.

3:40

So there was one cancer in their study

3:43

that was not clearly associated with enhancement, but

3:46

that person had marked background parenchymal enhancement.

3:49

So it's difficult to know if it really wasn't

3:51

associated with enhancement or it just wasn't

3:53

perceived to be associated with enhancement.

3:56

In 2021, there was another study done on architectural

3:59

distortion and said that if there was no enhancement,

4:02

you do not have to worry about this thing.

4:04

So between these two, the real take-

4:07

home is if there is no enhancement

4:11

in a patient who has no background parenchymal enhancement,

4:14

or very little background parenchymal enhancement,

4:16

the likelihood that that is cancer is very, very low.

4:19

Once somebody has a lot of background parenchymal

4:21

enhancement where it can impact your perception,

4:24

your identification of abnormal enhancement,

4:26

you wanna be a little bit, uh, more cautious.

4:30

We're looking at calcifications.

4:31

Most invasive breast cancers enhance,

4:34

but there are some invasive or DCIS, uh,

4:37

invasive cancers or DCIS that may not enhance.

4:39

This is similar to MRI.

4:41

And so we want to evaluate calcifications

4:43

with suspicious—suspicious

4:45

morphology regardless of enhancement.

4:48

And I talked already a little bit about, uh, when

4:51

to use contrast-enhanced mammo for these cases.

4:55

Next, we'll talk about masses.

4:57

Um...

4:58

Masses that are associated with enhancement are more

5:01

likely to be malignant. If a mass has no—if you have

5:05

a mass on a low-energy exam and there's no associated

5:08

enhancement, the negative predictive value is very high,

5:10

and that's no different than if you see a mass on a 2D

5:13

mammogram and you do an MRI and you see no enhancement.

5:17

That's—the likelihood that that

5:18

is a cancer is essentially zero.

5:20

I mean, there is no—it's, it's the negative

5:22

predictive value of an absence of enhancement

5:25

for a mass is very, very, very high.