MRI Case Review

Technical Aspects of Breast MRI

I'm just gonna show a mixture of cases.

Just a reminder. In your MR technique, obviously when you do your scanning, you'd never want any gaps between your slices. You always want at least contiguous slices or some people overlap slices.

Why would you do that? Overlapping can increase your signal to noise a little bit. So some sites might do, let's say a 1.6 millimeter slice thickness, or let's say a two millimeter every one millimeter. So their overlap, things like that.

Assessing MRS Quality

What's a good way to assess an MRS quality, particularly, we get a lot of outside scans. We're kind of stuck evaluating, and they load 'em on packs, and it doesn't always work that well.

One place is to look at the MIP images and you can just get a good global assessment of the quality of the scan. Here you can actually see, it looks like you can see the gaps. There might be little gaps between the slices. And the other aspect is look at the vessels. They're very notchy. So this doesn't have a high quality, high resolution picture here.

Does it? Now compare that to this scan where, look how smooth the vessels are. So this is a much, it's a higher quality. So the MIP image is a good kind of starting point to look and assess the global quality of a scan. And this is, looks very good detail on this.

Another thing people talk about their acquisition is, do you do iso volumetric scanning or non iso volumetric scanning? And what does that relate to? That relates to your voxel.

So if you have, let's say, an in plain resolution, here's a sagittal scan of one millimeter, but your slice thickness is three millimeters. Your voxels rectangular is not square. So when you reformat it to look at it in another projection, it's gonna be a little less lower quality. It's gonna blur a little bit because you don't have a perfect square.

So be a little careful when you, when you analyze the finding, when it's reconstructed in a different plane, when you're not iso volumetric.

Now this is a scan, a axial scan where it is a square of oxil and you can see it maintains the detail much better from the reconstruction. So this is the original, this is just reconstructed in a different, in the sagittal plane to the axial. So if you can, I mean, ideally if you could get a one by one by one, it's a nice resolution, without taking too much scanner time.

Case Reviews

Coil Error in Screening Patient

Alright, so I'm just gonna throw some technical, a case review beginning with some technical aspects of Mr what, so this is a post contrast subtracted image of a patient who's a screening.

Mr what, what happened here? Is she a mastectomy? Did she have a mastectomy on this side? Well, there's a little bit of an outline of the breast there. So unfortunately the error here was that they had the right coil turned off. You can select the coil right and left. And this was a place just starting out and they didn't realize they had only the one side. Fortunately they had the correct coil turned on 'cause that was the side that the cancer was.

If that happens, you're pretty much stuck repeating the scan. It doesn't happen a lot, but you recognize when there might be some problem with one coil on one side versus the other.

No Evidence of Contrast Injection

Here's the case. 49-year-old annual screening. Alright, here's on your left is the pre contrast sagal image of the left breast post contrast and the subtraction. What do you think about what happened with this scan?

Right, the, we don't see evidence of contrast. So that's one thing that you always wanna evaluate on your scan. And here's the pre-post. It doesn't really look like a difference between the pre and the post and the sub subtraction should always have contrast in the heart.

If you do not see contrast in the heart on the subtracted image, there's been an error in your protocol, in your scanning.

And so I'm gonna point these various aspects out. It's not a big deal, but it's a little more, with a mammogram, you pull up a screening mammogram within about two seconds, you decide, okay, it's either under overexposed or the positioning's bad mr. You know, it takes a little bit more time to analyze and, but you just need to remember to assess the quality of your scan that you're reading right up front.

For whatever reason, usually, the, if it infiltrated, the tech will know there'll be a note because the patient knows, or the technologist knows that the contrast didn't go in. Occasionally they may just forget to, to inject, and in their mind they've injected and you don't have any history of it. So occasionally you'll, you'll be the one to notice there was a problem.

Okay? So evaluate the heart lymph nodes vessels for evidence of contrast injection, 49-year-old annual screening. So on your left is the pre contrast on the right. Uh, the middle is the post contrast on the right subtraction. So what do you think happened here? What, what's the technical problem here?

So You see, this is your normal, and I point this out because you want to, if you read breast Mr, get an idea of what a normal pre contrast gradient T one looks like. And here's your a fat suppressed. So here, the, the fat should be kind of a dark gray, but you should have signal from gland T one signal from gland, right?

And here's the post, what happened? It got the suppression, got mist tuned, the fat is now no longer suppressed, and you've started to suppress gland. And that's why on the subtracted, the gland has dropped out because it was brighter on the pre than on the post. And so now it drops to zero when you subtract.

So let's look at this a little more closely. Here's another example. When you see an MR where there's just nothing in the breast, be a little cautious if there's been some error. This is just stone cold negative, right? It looks like there's contrast, but something just is missing in the breast. There's no gland, there's no vessels, there's nothing.

So let's look at what happened. If you, normally when you fat suppress, the water and fat are separated by 224 hertz and occasionally when they, they get the wrong peak and they suppress, water, which is part of your gland. And so here's what that image looked like, not subtracted. You can see that there's some type of saturation of the breast tissue.

So the, they've mist tuned the fat suppression. And here is what a normal, you want to know what a normal, normal fat suppressed. T one looks like you should have fat as a darker gray, but the gland should still have signals. So in this case, you're pretty much stuck having to repeat the study. It's a technically inadequate study, okay? It doesn't happen all that often, but occasionally you'll see that.

Post-Lumpectomy Changes and Fat Necrosis

Here's a patient just to show you an example of a woman who's had a prior lumpectomy. It's their first, first scan after lumpectomy in this area. And what do you think about this area? Is that suspicious for cancer or not?

Well, you're starting out at a new, baseline because the patient had a recent, had a prior lumpectomy and now you have is this just normal post-surgical change? So getting used to what normal fat necrosis you want to use your pre contrast non-fat suppressed image.

We tend to do in our sequences is obviously a localizer. Then we tend to do our, you do T two weighted image and then you can do a non-fat suppressed pre contrast. If you wanna shorten and not do two series, you could do a non-fat suppressed T two.

A lot of centers in, most places in Europe tend not to do fat suppressed T twos, but we like to have 'em separated. And here's your shows that there's fat perfectly in that area and that's just classic fat necrosis.

One question comes up, if you have a patient who had a lumpectomy and the margins were close or positive, should you, how long should you wait to do the MR looking for that extra disease? And I don't think there's really a need to wait other than whenever the patient can tolerate it because scar is gonna enhance for a long time.

What you really need to get used to is distinguishing normal post-surgical change from what? Look what is suspicious and you don't really have to wait. Waiting isn't gonna help you out because the things are gonna enhance for quite a while. And I'll have an example later.

You know, normal post-surgical change is either classic fat necrosis like this or you see a seroma with a smooth rim around it and some cloudy kinda low level enhancement around it. But you shouldn't see clumped mass like, or eccentric kind of mass like enhancement around the cavity that would be suspicious, for residual disease.

In this case, the fat is right in the center and that enhancement is usually around the fat, in this kind of, symmetrical pattern. Okay? So that's just a classic benign fat necrosis.

Enhancing Lesion as Hemorrhagic Cyst

Here's a 55-year-old high risk screening. Here's your post contrast. Not in fat suppressed, but this is a little enhancing four or five millimeter. Is it rim enhancing? Here's a previous surgery, there's some, fluid. Here's the T two. This doesn't really have a central T two signal.

So you might think that could be a cyst, a chronic cyst with a little, T two, but that's not bright. What, what sequence might you look at next? So the other thing to look at is look at the pre contrast T one. Occasionally you'll have proteinaceous or hemorrhagic fluid inside a, a little cyst.

So in instead of calling this a little rim enhancing mass, it's actually got a bright, little area of T one signal. So it's a little pro nastious or hemorrhagic cyst. So remember not just to correlate with your T two images, but also your pre contrast T one, which may show things like proteinaceous fluid in the ducks, et cetera.

Motion Artifact

Okay? Here's a 52-year-old female with a known right breast cancer. Uh, this one I just, you know what's wrong with this pattern here? It's a subtracted axial image. It's just major motion, it's gross motion. And this patient actually not only, moved, but she, she moved significantly up and down in the scanner so that the slice is no longer aligned.

Here's just an example of subtracted showing significant motion. So you have to rely, unfortunately sometimes on the, unsu subtracted images.

Extra-Mammary Findings: Lung Carcinoma

Okay? Here's the 70-year-old history of breast cancer annual screening. Now, I, I don't have the video for this, but the, when you scroll through the breast, I just bring this up because a lot of people who've embarked on breast, Mr you know, at some centers have been the dedicated breast imagers and they haven't done cross-sectional imaging for a long time.

Most 90 plus percent of mammography in this country isn't done by my people like myself who just do breast imaging. It's, it's general radiologists are doing everything and they tend to be much better obviously at detecting something like this. But this was actually on the year before. It was obviously smaller, it wasn't as obvious as this, but you know, you can get phase noise. You don't want to call everything in this area a mass, but this was clearly, this is an unknown primary lung carcinoma.

So just the caveat is, I tend to read the breast, look at the breast and then at the end of the case I scroll through the delayed axle and I'll look at the localizer and look at those extra mammary findings because you know, some people who just do breast imaging tend to just focus on the breast, but you need to look for extra mammary findings, at the end of your scan.

So evaluate the long, liver mediastinum, et cetera. I tend to leave that to the end of the study.

Contrast Injected Too Soon

Alright, here's the 60-year-old BRCA two positive annual screening. So here's the, these are axial post contrast images, subtracted images. This is the one minute post, 2, 3, 4, and five minute post contrast images. Okay? What happened with this? What went wrong with this study?

Now we remember we said the rule, you always wanna see contrast in the heart on your subtracted image. Well, there is evidence, it looks like there's contrast. So it's not that they didn't get contrast. What happened with the contrast injection.

Remember these are subtracted, they gave contrast too soon, they accidentally injected before the pre. So now that there's contrast on the pre contrast image, when you subtract it, you lose the heart. And so let's look at the, here's another example. No contrast on the subtracted axial image. There's no contrast in the heart.

So here's the pre, here's the post problem. Was they accidentally injected, before the pre, and now you're pretty much done. I mean, you gotta repeat the study another day because just because it's bright on your, post contrast doesn't mean it's enhancing. It could have been bright on the pre, but now you have no way of knowing. It doesn't happen all that often. Usually the patient will say something or the technologist will say something, but occasionally it happens.

So contrast injection, prior to the, the pre contrast study and you basically need to repeat it.

Windowing T2 Images

Uh, 48-year-old annual screening. Okay, so here's another, technical aspects of breast. Mr what would you, this lesion here, this is a sagittal T two weighted image of the right breast. How many people would call that bright on T two?

Right? And I just bring this up because I think this is something that's not talked about or taught that much, but a lot of times from when you acquire to when it's pushed over to packs, the window level of the T two may not be the greatest. And in this particular case, remember that T two signal, when you call it bright or not, is in relationship to the gland.

And these cysts, it seems a little oversaturated, a little over bloom. So here it is, it windowed a little differently. So here you want on your T two, so occasionally need to window and level your, your T two a little bit.

You want vessels and cyst to be bright but not over bloomed or saturated. So now it's not really that bright on T two, is it, it's almost the same as gland, maybe a little bit brighter. And here it was on the, it was enhancing, but it really truly isn't real bright on T two.

Another place when you see a mass and enhancing mass, you may need to window and level because if it's over bloomed, you won't see the internal details of a mass. You won't see the non enhancing septations of the rim enhancement.

Okay? So just sometimes you need to double check your window and level setting that you don't have vessels and cysts that are oversaturated. So you don't really have a true assessment of the T two signal of a lesion.

Erythema and Granulomatous Mastitis vs. Inflammatory Carcinoma

Um, okay, so here's a case of, a patient with some type of erythema questionable infection. So here's just a slice. I don't have the video for this, but here's a slice through there. Here we have this kind of non mass put these multiple kind of matted rim enhancing masses.

Now, so this, this area is enhancing, it's a post contrast scan. How many people think this is suspicious for cancer? Nobody. How many think it's benign? So I, you know, in this history you, it could be very easily, just infection and that's what this turned out to be.

The history was important because this patient was, came from South America and had already a biopsy proven diagnosis of granulomas mastitis. So this is a picture that would fit. There's really not a well-developed abscess cavity that you could drain. You can't drain these individual. It's, you know, so there's nothing really, in terms of a cavity that would be, considered an abscess or drainable abscess. But this pattern fits the granulomatous mastitis.

But I've seen this exact same. Now, what if you have the history, it's a patient whose status post lumpectomy and radiation therapy and she's got this, can you exclude inflammatory carcinoma? And the answer is no. I've seen inflammatory carcinomas look just like this.

And the only way really is for them to do a biopsy. Now you need to be careful. I'm always careful in my reports in that if I see, something that, you know, it may be it fits with their cellulitis or inflammatory, infectious process, I generally put in my reports that imaging cannot distinguish infection from inflammatory carcinoma.

Because occasionally what will happen is they'll give the patient some antibiotics that actually, even though it's inflammatory carcinoma will get better for a few months. And then a month or two later they finally, it rears its ugly head again and they get biopsied and now it's six months later and they sue everybody who they've seen in the past six months.

So you need to be, fairly careful in letting the clinicians know that it's really a clinical distinction between infection and inflammatory carcinoma.

But I've had similar cases look, look the same and one's inflammatory and one's, infectious. Can you do all the sound? I'm sorry. Would you do ultrasound? I don't think ultrasound's gonna show you the same thing. The question was can you do ultrasound? I mean the ultrasound's gonna show you skin thickening, trabecular edema, and these kind of cystic spaces.

Well, I mean we see these here. I mean, you would see the same thing, these kind of cystic spaces, but I don't think you can really distinguish the two. I don't think the ultrasound's really gonna be enough to distinguish it any further.

Chest Wall Recurrence

Um, okay, so let's look at another patient. 57-year-old prior lumpectomy annual screening. Let's just look at this. So this is a post contrast, axial image. She's had a prior lumpectomy and, and radiation therapy on the left. Alright, let's go to the next sequence. Uh, this may be the subtracted sequence here.

Okay, so did anybody see the finding? So I, you know, obviously you're not at the workstation, but this is a, a good example of some findings that you would normally see. So we see post-surgical change on the left, the breast is smaller and she's had radiation therapy. So we'll see, it's common to see kind of a background pattern on the non-radiating side.

Can see these scattered foci, they all look similar. None of them really stand out. So that's kind of a normal pattern. But the left side is devoid of that background pattern because of the radiation therapy. But did anybody see the finding at the end here, the chest wall recurrence?

So this is just another caveat. I threw this in there. To show you that, you know, in addition to analyzing the breast at the very end, I tend to look through and in ca patients with a known cancer, you wanna look at common spots for occurrence, the internal mammary, node chain, chest wall, axillary region, those types of things.

And uh, this was actually on the year prior mr it was on the last slice. It was pretty subtle. Then she had a follow-up MR for some reason six months prior to this. And it didn't go up high enough, it wasn't included and then it was detected on this, okay, here's got a CT scan and a PET scan showing that chest wall recurrence.

Suspicious Non-Mass Enhancement in BRCA Patient

Okay? Um, here's a BRCA positive 44-year-old annual screening. Let's just look through this. Let's see what other skin, here's the color overlay and let's see, what else do we have? Here's a delayed axial. So it's a little higher resolution. Okay, so everybody, I'm sure everybody saw the finding.

What do we have? It's a BRCA two screening, a BRCA two positive patient for screening. And we see this area that's in the upper inner left breast. How would you describe that? The non mass clumped. It may even have some branching. So it's branching clump, non mass enhancement.

What birads would you give that? How many people would give it a four? Would anybody give it a five? Okay. And I, this is one where, and I bring this case up. Let's just look at some key images. There's, this is totally a unique finding. She doesn't have any other areas like this. It's a unique finding.

And I bring this up because most people think in BIRADS five, mr, it's the classic speculated mass, but there is a non mass equivalent to byres five. And that would be this. I mean, this is highly suspicious. This would be similar if on a mammogram and this patient's mammogram was negative. But if you had linear branching microcalcifications and you do a stereo, are you gonna, are you gonna follow that? No.

So this is one of the cases where I would think you would use a byres five. Did you need the color? I mean, look at this, branching clump, ductal enhancement. Do you need the kinetics for something like this? No. Right? I just threw it in there so you could see it. But you know, that's, I probably look at the kinetics maybe 30% of the time.

If it's a totally negative mr, do you really need, what do you need the kinetics for? If it's, a, a suspicious finding like this, you're not gonna use the kinetics to not biopsy it. So the kinetics, I don't think really changed your management on this particular case.

So what happened on this case is she actually came from a system that didn't do mr. So we did it, we did it when we were in San Diego. We did the MRS for this hospital, but she went back to the hospital for second look ultrasound because she had to go back there since they offered that service, they did a second look ultrasound, they found some dilated ducts, they did an ultrasound core biopsy, I think a 14 gauge. They got duct ectasia.

And then they called us up and said, you know, is that okay? And we said, you know, you know, this is too suspicious, plus we're not a hundred percent sure you're in the right area because you went off to some other hospital. And so they sent her back. We did a quick scan to see where their clip was and sure enough, the clip was in the middle of this area and we said, you know, your clip's there, but you know, we're a little concerned about under sampling and you know, to me it's discordant.

So we recommended a surgical biopsy. You could have opted to do an MR biopsy at this point, but I think it needed to come out anyway. So we opted for a surgical biopsy. Well, the surgeon at that hospital called and said, why are we having to do this surgery? There's no a tipia or LCIS.

And I basically said, you know, you can have under sampling with the core biopsy and this is a highly suspicious finding. And so they, he was pretty much irritated with that. And then I asked, have you, have you even seen the mr? He hadn't even looked at the MR and uh, didn't have an idea of the level of suspicion.

So three weeks later, the patient called me and said, thank you for pushing for the biopsy. It was this BRCA patient and it turned out to be high grade DCS with microinvasion.

So this is just a cla it doesn't get more classic of a really, of a non mass, suspicious non mass area of enhancement. Here's other areas. So even more suspicious, I mean that's the segment you know, is when you get this large segmental area, highly suspicious for carcinoma. Here's another segmental distribution of linear enhancement.

Normal Background Patterns

Okay? Uh, 56-year-old prior right lumpectomy post-surgical, mr. So this is just a screening MRI threw this case in here just to give you an example. Let's do that one more time. Uh, here's the left breast. All right, let's go back to the other side, right? Breast, I, Okay, well I threw this in here just to keep everybody honest a little bit.

It's a normal, this is normal background, marked background pral pattern and um, it looked very symmetric. Both sides had these areas of kind of glassy enhancement. And you do see this, fairly common. This, this kind of a cortical pattern of enhancement where you see a little more enhancement around the periphery of the breast here and here. And that's just a normal peripheral enhancement pattern. Nothing really stands out as unique to this pattern. So that's just the BIRADS two.

Okay, here's another one prior, right? Lumpectomy annual screening. So you had a previous annual screening, previous lumpectomy and this is just a annual screening, no complaints. Okay, we'll do that one more, more time. Some lymph nodes in the axilla there. Those were normal few little foci. Okay, anybody see the abnormality? Just, And yeah,

Abnormal Internal Mammary Node

and this is an example where I find it a little easier to look for, internal mammary nodes on the axial images. So you gotta be, you know, a little bit aware and keep a lookout for them when you're sadly acquiring. And here, here it is abnormal.

So she was seven years post lumpectomy and there was this abnormal, this was new. The fellow reading the case actually picked this up. You know this when they get, like, this is a patient with multicentric disease in the medial left breast.

Normal patients, there've been different papers showing in, you know, 20 to 30% of patients. In normal patients you'll see some little two, three millimeter flat internal mammary nodes. It's when they start pushing five millimeters and get rounded. And, here's an example. It's over a centimeter. This is a presumptive diagnosis. You don't really need to do any biopsy.

And this would change management and that they might include this in the radiation field, but, clearly that's a grossly abnormal internal mammary node. Here's the T two can use that too to decide if it's node. This one, the patient had had a prior lumpectomy seven years ago and they wanted to know if this was the same biology as her original tumor.

So we actually did a FNA under, ultrasound guidance of the, of that node, that we found on second look ultrasound. And you know, you just need to be a little careful and come parallel and keep kind of the sternum. You always wanna see your needle tip while you're real time while you're scanning. So you're not near the lung of the heart.

But in, if you go to flat projection, if you go past the lesion, you've got the, the sternum is kind of a backstop to hit, keep you from hitting other structures. So another place to always look for, is in patients with a known cancer history of cancer is internal memory nodes.

Enhancing Mass with Suspicious Kinetics

Alright, let's try to get through as many cases as possible. Here's a 68-year-old high risk screening. So we have this little mass here, it's a post contrast. This was enhancing. Here's a closeup of that area. So it's pretty oval and smooth.

I'm not sure if we really see any internal features that well, here's the T two, so it's bright on T two and here's the kinetics. How many people would biopsy this? How many people would follow it?

Well, so this is a case where you might be thinking probably benign. I mean, this is your analysis. You see it's fairly oval and smooth. It's bright on T two, but the kinetics in this particular case, fiber adenoma really shouldn't have washout.

So this is a case where that finding alone would change from a probably benign to, to doing a birads four and doing a biopsy. The, the logic behind approaching these incidental, enhancing masses is number one. Number one, they're, morphologies. It's smooth. This is fairly smooth. Is it bright on T two? And does it have benign kinetics?

Well, this is bright on T two, but it doesn't have benign kinetics. The real tricky part becomes if you see a circumscribed smooth mass, it's not bright on T two and it, but it does, it has benign kinetics. That's kind of, that's the gray zone. And I tend to, if it looks really smooth and benign, even if it doesn't have a bright T two, if it's got benign kinetics, and no other kind of suspicious things, that's that I would put, put that in a follow-up category.

But this is a case where you were thinking fibroadenoma and then the kinetics changed your mind. Also the delayed axial, you know, you, if you look at a lesion in different planes, this shows it's got a little bit of a, a kind of an irregular margin here. It's a little angulated or that you might have missed on the sagittal.

So if you can try to look at a lesion in two planes, that might help you, see suspicious features that you won't see on one plane. Now that turned out to be a papillary carcinoma.

Follow-Up After MR Biopsy: Missed Target

Um, here's another case. 52-year-old prior benign, right MR guided biopsy. So she had an MR biopsy six months ago and this is the follow up to that benign MR guided biopsy. Here's the original, what prompted the MR biopsy, this non mass linear enhancement along the lateral aspect of the right breast.

Here's a image from the MR biopsy. Here's a sagittal image showing that kind of clumped segmental enhancement. We, we do a post biopsy mammogram. Here's the post biopsy mammogram after the MR biopsy. We tend not to do once we place the clip, I don't repeat an MR sequence after that just 'cause I find the clip hard to see after you have the biopsy site changes.

But we do send the patients down to a MA to do a mammogram just to document the clip site. Alright, so here's the mr, you're reading this is six month follow up. What birads are you gonna give this for this case? Another bi, another BIRADS three. Follow it again in a year.

What's wrong with this case? It doesn't look like they hit the right spot. Here's the cavity, the hematoma, here's the suspicious non mass enhancement over the lateral aspect of the right breast. This is a higher up slice and it's not, it's a little bit medial.

So if we go back and look at the MR biopsy, look at this post biopsy mammogram. Where's the clip? This wasn't picked up at the time of the post biopsy mammogram, but the clip in the biopsy site changes are way medial. So they somehow got, you know, the biggest error, error in MR biopsy To me it's not the X and Y, it's the Z.

You tend to target with the ator in and it pushes the breast away. And so you think you're at the lesion. But then when you put the pro take the plastic operator that's that's blunt and you put the probe in, that's sharp, the breast tends to relax down the, the needle and now you've gotten a little bit too automatically I think Mr biopsies, your depth is a little bit too deep, in, in some situations.

So this, and just because your clip is off doesn't necessarily mean, you know, we all know that you deploy, deploy a clip sometimes and because the breast is in compression, then when you, it accordions when you release the compression, the clip can be off and you might have biopsied the right area, but you'd like to see biopsy changes.

And in this case, we should have seen some biopsy changes out lateral, but all of the biopsy site changes in the clip are medial. So in this particular case, we recommended that that, that this be biopsied, she opted for an MR localization rather than a re an MR biopsy. MR got localization. This, this came back extensive DCIS.

So this is just an example of be, be careful on your follow ups and your MR targeting to make sure you really accurately sample the lesion.

Post-Surgical Changes with Close Margins

Uh, here's a patient with a 70-year-old female lumpectomy with close margins. She's recommended to your center with outside films that's recommended an MR biopsy. Oh, sorry, that's not this case. Let's back up. So this is, just a patient with close margins, recent lumpectomy and so close margins. Recent lumpectomy looking for residual disease, right?

So I put this in here, just this is your classic post-surgical change, right? A little cloudy, low level enhancement and maybe a thin wall of enhancement around the cavity. But there's really no mass like or clumped enhancement at in any area. So in this particular case, this looks pretty much like benign post-surgical changes.

Now in the report we say, you know, post-surgical changes, no evidence of gross disease, but we say that, you know, however, management should be based on the pathology because MR can't exclude some microscopic disease, through, through this, surgical change. Okay? But that's a classic normal post. It's a pretty large cavity, right? But that's a normal post biopsy change.

Targeting During MR Biopsy

Alright, here's, let's finish on this case here. It's, a 49-year-old with suspicious linear non mass enhancement that was scheduled for an MR biopsy. It's from an outside mr. Here's the outside MR for this little linear enhancement. And now you're doing the MR biopsy. Here's the targeting scan and you're, you know, At the scanner deciding whether to do the biopsy.

So here it is now, not as impressive, right? So how many people would abort the biopsy and do six month follow up? How many people would proceed with the biopsy? And so you wanna remember not to use your targeting MR scans as a diagnostic mr the quality isn't as good.

Usually you want to try to have the same resolution and slice thickness, but the breast is in compression and things like that. So my rule is if there's any semblance, like if I can see any semblance of the lesion, I'll go ahead and proceed with the biopsy. In this case it's turned out to be DCIS.

If it's truly not there, you might do some delayed scans and also release compression a little bit to really confirm that it's not there. And if it's truly gone, maybe it was just some hormone related enhancement. We always do a six month follow up Mr. After our aborted MR Biopsies just to keep an eye on things.

Chest Wall Involvement

Um, this is just to show, you know, how do you decide if there's chest wall involvement here? The, the tumor's against the muscle, but there's really no infiltrative in involvement. So, you know, maybe there's some microscopic involvement, but there's no gross involvement of the muscle.

Mm-hmm. It's good to look at it in two planes. This axial image shows that there's no infiltrative enhancement of the muscle itself. It just abuts the chest wall.

TRAM Reconstruction Fat Necrosis

Um, here's just an example of a classic patient with, who's had T tram reconstruction. This is classic fat necrosis from a tram and it was symmetric and bilateral kind of this bubbly appearance of fat necrosis.

Normal Patterns and BIRADS 3

Um, I think that should be it here. Let's just see what this case is. This is just a normal pattern of scattered foci. We've, I've shown you some normals. You know, here was the case from the Birads three lecture of what do you do when you see a little bit more concentration of foci in one area, but they're not particularly linear in in distribution.

This is something that we've put into a birads category three and followed it up. There's, they all look similar. Kind of a scattered distribution, just more concentrated in one particular part of the breast. And, here's another example. Here's a background pattern more concentrated with some non mass enhancement in one part of the breast.

That's something that you would probably want a biopsy 'cause it's, it's quite outside the, the distribution. And here's one with bilateral non mass enhancement that's got a benign pattern since it's bilateral and it looks similar.

Calcifications Leading to Papillomatosis and DCIS

Um, last case here, we'll just end this is, a patient with a mammogram who had these calcifications. They're very, innocuous looking. Their course macro kind of calcifications, but they're concentrated in one area of the breast and they've increased a little bit from one year to the, from the several years back. Not dramatically, but slightly.

So some, I think you can always keep yourself outta trouble if you use the mark Homer approach, which I adopted early on in my training. And that's kind of the Sesame Street approach to mammography. Is there one area of the breast that looks different than the rest, which means there's something different going on in that area of the breast.

Obviously if it's a classic ant mini benign thing like milk or calcium or rim enhancing oil or rim calcifying oil cysts, I mean outside of the classic, you know, don't touch benign lesions. If it's something that you just don't know really what it is, but it's only in one part of the breast, you should probably be thinking biopsy.

Well, here's these calcifications. They're over in just one segment of the breast look pretty benign. In this particular case, what you want to think of is papillomas, right? When you have these course like kinda lava like calcifications in a distribution in one part of the breast.

And so we did an MR showed that distribution of enhancement, that kind of seg segmental distribution. And we actually found these little areas here it is on, mip. We actually found this on, second look ultrasound where we found these, we were expecting to look for some ducts with filling defects. And sure enough we did those were underwent ultrasound, core biopsy and, came back Papillomatosis and DCIS.

So, you know, think, you know, Mr in this case was more of a problem solving to show the extent, but the mammogram, was the tipping point that started us to think there was something going on in that area.