Other Modalities & Technologies in Breast Imaging mp4
So. Tonight we're gonna learn a little bit about, other. Than mammogram. And ultrasounds. What other modalities. Can we. Use with breast imaging and we're also going to dive a little bit in the mammogram again. Important. To know this because in ultrasound. One. Of our primary jobs is following, up other studies, so we don't, just follow up mammograms, although that's by far the bulk of what we do but we also follow up a lot of other studies, and, unique. To ultrasound is, radiologists. There's, not always, a lot of one-on-one communication with, sonographer that, sometimes they kind of leave us to our own to. Kind of go do what we need to do and then come present, it to them so they put a lot more trust, into us and so, we really need to know what, we're doing so if we read a report we need to know what the report is talking, about so. That we can go figure out where to scan some. Places spoon-feed. You the information they say ghosts can hear this is what I want you to find but other places give you virtually nothing you have a report, and that's what you're you're, looking at so you've got it know, a little bit about what. To look at. So. We're gonna start, with mammogram, we're just gonna review a couple of things, first. First, of all we, learned about. Screening. Mammograms, versus diagnostic, mammogram, so screening, mammogram is when. A patient's, asymptomatic. We're. Not following up any other type of modality, and we're not following up a mammogram, and we're, just screening, that patient, and, we do these annually, for, disease. Diagnostic. Mammogram is answering, a question so we're, looking to see does the patient have symptoms. Or. Are we following up something, and a diagnostic, mammogram are, generally. Read by radiologists. Right. There while the patients in. In. The. Center and, anything. That needs to be done we try to get it done that day so if, they need ultrasound. Or if they need mammogram, pictures we try to power. Through all that in the same day and, then we also have a baseline, mammogram baseline, mammogram is either a patient's, very first mammogram, or, it's a mammogram after, there's been some sort of significant, change so. For. Instance if a patient has a mammogram and they were we are doing plain film mammograms, when a patient had a mammogram and now the patient's back ten years later and we now have digital, technique it's, really hard to compare plain film digital, technique so, if there's a significant, change in technology then, we'll consider this newer, mammogram, we took the kind of their new baseline, mammogram, or, if. A patient has a surgery, a breast reduction. You. Know some. Sort of lumpectomy, that type of stuff anything performed. When there's been a significant, change in the breast and what, constitutes, a baseline, mammogram means, that we don't have anything significant. To compare to so we always want to compare apples to apples but, if we have to start comparing apples to oranges that's. Really hard to do so, baseline, means we're either, doing the very first mammogram or we're starting, kind of again with a new, where. The patient is at that moment. In. Mammography, we use tape, markers, on the skin and these, mark, areas. Of interest, and. It's important, to know what these are because, most. Of our patients come from mammogram, with, these stickers on their skin and often. We're we need to take these stickers off and know why, we're taking that sticker off and why they marked that spot because sometimes it has to do with the reason for our exam. So, the first type of marker, and this is the one that really pertains, to ultrasound Texas, a BB marker so it's this little marker here and it's. A mark, a tape marker that's got a little metal dot in the center of it and we. Put this over an area of patient symptoms and by, we I mean the mammogram, techs so, if a patient has a lump or pain or something like that and what, it does is it mark that little metal dot shows up on the mammogram picture, so the radiologist. Can see where. On that mammogram, the patient's symptom, is. When. That patient comes to us then to have their ultrasound, they're still going to have that little BB marker on there and we.
Need To see where they mark, from the mammogram, sometimes, a patient you know the. BB marker will be over here and then the patient will point over here and you're thinking those. Don't even correlate, at all patients. Change their minds a lot so it's important, to always document. Where that BB marker was because, for some reason you know it got put there at the time that's probably where the patient was pointing, but. Also document, their new place that they're they're, putting on. Also. We, put on mole markers, they that's ones like this. And. Or. This one the ones with the holes in the center and, mammogram. Tucks place these over, a mole, that's on the skin and the, reason we want to do that is it, alerts. The radiologist. That there's a mole on the skin in that area moles. If they're not mark can look like a superficial, mass on the mammogram and we don't want to confuse a mole with a mass and. Then. We also can use a scar, marker that's these types here and, these. Are placed over, surgical. Scars that a patient has had in the past and. We want to do this because in the area of surgery that tissue is going to appear distorted, on the mammogram and we don't want to have. The radiologist think that there's new distortion, in an area when it's just an area where the patients had surgery. The, mammogram, techs and, then, those markers show, up on that, they. Show up on the mammogram image. When. We yep so, the patient gets to us they have all the stickers on and mammogram. Tech's are trained, you, know to have the patient keep those on because it's important that we know where things were marked. Nope. But the, most important, marker for us is that little BB marker where the patient symptoms are you know we take. That off we want to see where that was placed and we definitely want to document that area. All. Right cat, so this is um. Computer-aided, detection. We use this for both mammogram. And for, MRI studies, and it's. Basically, a computer. Reads. The mammograms, and reads, the, MRI studies, and it. Flags areas, of interest, for, the radiologist, to see. And. Why. We do this is it really, helps catch subtle, little things that sometimes fatigued. Radiologists. Or inexperienced radiologists, wouldn't see so, they say that this detects, cancer. Detection rates by 7 to 20 percent. The. Downfall, with it is computers, are not as good at problem-solving in.
Some, Aspects. As a radiologist, is so they sometimes, do, mark things that are not of concern so every. Thing, that a CAD machine, flags, the radiologist looks, at each one of those and determines is this a real finding, or not a real finding if. It's a real finding the radiologist, you know notes that on their report if, it's not a real finding they, dismiss, that that thing so this is something that is one of the you know newer, types of technologies, we have probably. In the last maybe, 15, years and this is really revolutionized. You. Know reading, stuff especially, for rural centers, that don't have radiologists. That are trained as well, in mammography as, some of the more populated, centers, this, can really help them. So. What can we see on a mammogram, we've, gone, over some of these before, we're, just gonna go through them one by one here, so. Mammographic. Density. Density. Has to do with how the, x-rays. Those mammogram, uses x-rays, are attenuated in the tissue so. An area, in the breast, tissue that really weakly, attenuates, those x-rays, low. Attenuation is what we call this this is gonna be dark on a mammogram, so black. Or gray and this is going to be our fat density. This is fat. Is black or gray we. Call this radiolucent. On a mammogram, we. Can also have I so dense this is equal density so. This means equal density to the glandular tissue. And. This. Is going to be radio, opaque, or kind of a whitish, color on a mammogram, like. A light white or. White. Lighter. Shape than, a really, high density, but, brighter. Than this fat density, and then we can also have high density high density mean this area is really, attenuating. X-rays, this, is going to be bright, white on a mammogram and this is what our calcifications. Are on a mammogram, as. A general, rule what, kept one thing that catches the, radiologists. Eyes they're looking for things that are increased indention density. Density. Can. Me be worrisome, on a mammogram so they pay attention to this and this, is a little different than how ultrasound, things when, we're comparing things in the breast echogenicity. We, compare, everything to the fact well, radiologists, are comparing, everything to the glandular tissue, on, a mammogram so it's a little bit different concept. So. With, not. Only do we look at how much that x-rays. You know attenuating, but we put, these into categories, so you, can have either a phat density, something, that's the same density as the fat you, can have a calcium density. This is our bright. White category like, calcifications. And pretty. Much everything else is what's called a water density on a mammogram, so water. Densities, are that are this. Equal. Density category. And pretty, much on a mammogram almost everything, falls into a water density category. Glandular. Tissue, Duss. Fluid. Such, as cysts, two solid. Masses. Cooper's. Ligaments, pectoralis, muscles, so, all, of these things are all water densities, so, we're, on ultrasound that's very easy, to distinguish.
Water, From, something that's not water on mammogram, it's, not because everything, shows up as white assist, shows up as white a cancer, shows up as white, solid. Mass shows up as white so, mammograms, good at detecting things but not so great at characterizing. Them so that's where ultrasound, comes in, so. What. We always like to think of on a mammogram is because. Glandular tissue is white and masses, are white it's, like looking for a snowman, in a snowstorm so, this is why breast density makes. It tough to read mammograms. So. One, of the things we look for is asymmetry so, this, is. Where. You have your breast. And. We look from the side and a mammogram. And. They're. Looking at the. Glandular tissue, that's in there and they want to see is the glandular tissue, from, side to side the same is it, the same from other parts of the breast if you have an area of glandular tissue, that's much wider or you. Know denser, on that mammogram, this is what we call asymmetry. And it can be in a small area, sometimes. It can be the whole breast. That's. Denser, so, these are things that, radiologists. Pay attention, to when. It's a large area meaning, the whole breast or a very large part of the breasts we call this global, asymmetry. And. It's, usually one breast that's asymmetric. To the other breast. Things. That can cause this sometimes. It's weight loss although weight loss usually, affects both breasts. Or. Sometimes, a change in hormone, use affects one breast more than the other breast or. Sometimes it's a lobular, cancer you know that cancer that grows in sheets, instead, of a ball and, lobular cancer can make one. Breast, just much denser. We. Also have focal, asymmetry, this is where you have just a small area, of asymmetry. Focal. Asymmetry, much of the time ends up being okay but what we always are looking for is this lobular, cancer one. Of the kind, of ways that it hides is making an area asymmetric. To the rest of the tissue, so. We are often, called an ultrasound to, evaluate, focal, asymmetries. If we see something like this that's denser, than anywhere else in any of the other breasts or. This breast then we want to see is there something hiding in that tissue that's making it denser and then. We have our most worrisome. Category, of asymmetry and this is developing, asymmetry. This, means I'm it's an area it's usually a focal, area most commonly and it, means that before. On previous, mammograms, this area was not there so this is something new that's happening and anything, new happening, on a mammogram or an, ultrasound for that matter is circumspect, so. They. Say the chance of malignancy, with a developing, asymmetry, is about 10 to 15% and this is usually that lobular, cancer so, we pay attention to this. But. There's, also other things that can cause either. Focal, asymmetry, or developing, asymmetry. We. Remember patch which. Is that kind. Of a regular, appearing, area, of tissue we see that commonly on ultrasounds, or mammogram. And, again. Sometimes weight, changes, or hormone levels kind of can have this happen, so, all sorts of things or sometimes there's a mass and it's hidden inside a patch of glandular tissue so these are all things that can happen so. Just, a couple of things to go through so here. Is a case, here. Is the, vocal. Asymmetry. And. On. This patient was actually feeling this area so here's. The little metal dot right here from. That little BB, sticker that, that patient is feeling so the radiologist, can see that that, patient, is actually what, she's feeling is corresponding. To that area and. It's. Not you know vocal. Density is not her vocal, asymmetry, is not always really. Apparent, on a mammogram to us but, sometimes. You kind of have to look for it sometimes. It's really obvious, sometimes it's more subtle so. When, we were, asked to evaluate this.
We. Know this is going to be up high. Near. The axilla. So. In this patient she didn't have a very large breast so. This. Is what we saw. Nope. It's this whole, area. So. We know it's hyper, ko ik. So. This whole area. Closed. We're, on the right track now. Accessory. Breast tissue, versus. Glandular, tissue, how do we tell the difference. So. Accessory, breast tissue is going to be attached to the skin and in. This case we've got some, fat, in between, them. Yeah. So, this, was actually we. Biopsied this area it actually came back pash and. This is one. Of those common things we happen. To see in the breast that happens this is where the stromal. Tissue overgrowth. That stromal, tissue and. It just looks like a patch of tissue that's very distinct, it looks different than other tissue around it it does look like glandular, tissue, but, usually it's kind of got a little bit of hypoechoic, little, areas in it more, than a normal glandular tissue would have so it's usually fairly distinct, on ultrasound now, sometimes you can have patch that's readily, visible on. A mammogram and you can't see anything on older sound sometimes, the ultrasound like this cooperates, and you can see it, so. That's one thing that we can find on an ultrasound when we go looking. For focal. Asymmetry. Or a developing. Asymmetry. We're. Gonna kind of make a list here so one. Of the findings so for a vocal. Or. Developing. Asymmetry. On. Ultrasound. One, thing we can find this patch. All. Right so here's our second. Case here, and. It's. All this white, stuff right in here back. Behind the nipple. So. You notice that this breast is primarily, fatty, a. Radiolucent. It's almost. All fat so, this area is very distinct. In a breast that's almost all fat, so. We were asked to evaluate this. Area. And. This is what we saw. Okay. Why. Yep. Does have a little bit of shadowing good catch not. Anna Koch though it's actually got echoes in it so it's hypoechoic. Uh-huh. So. Why. Would, I think this is not a pepper level. Rate, hyper. Vascularity. Is the hallmark, of, it and this has no blood flow in it, right. Also. Another possibility so I showed. This to our radiology, or a radiologist. And I said I have no idea I don't, know what this is I've never seen anything like this and I. Said it doesn't have any flow in it I said. It maybe is a duct it's right by the nipple, I said, but. It. Just doesn't quite look like adopt, so, I said, and there's all this hyper coat, stuff around it I said. To me it looks like a really weird. Patch of glandular tissue, I said but I have no idea and, she says why I have no idea either I said, well that's not good. So. We biopsied it, any, guesses. Pash. Yep. So. So. Pashtun. Be anywhere, in the breast tissue so the only time we we. Worry, about things close to the skin is that's our accessory, breast tissue that's a stuff way up in the Exile that's, extra.
Apart From that a glory tailspin, so a patch can be anywhere in the breast and the, one thing to keep in mind about pash it, can look like anything, I have seen almost, anechoic. Pash I have seen pash, that looks like this now so, we. Always talk about the many faces of pash the, hard thing about passions. Early, don't find it until we biopsy, something because it. Masquerades, as other things. Right. So, so. Right. So. Pseudo. And yomet is stromal. Hyperplasia, so big, long word it basically means the stroma of the breast that is over. Growing and how. We see, it on ultrasound, usually, is it looks like a patch of tissue that just looks abnormal it, just doesn't quite look yeah. It's. So very common um it usually doesn't have flow in it most commonly although, you're not everything, follows the rules and it really can look like anything on older sounds so, often, these focal, asymmetries, turn out to be this patch, oh. For. Our number two answer, here we're going to just say, normal. Island, so W&L, within, normal limits you, guys need to know that for your Medical Careers. Tissue. Camp. Right. Right. Great. Yep. Probably, in this case this. Is most commonly, when we say, it's. Usually just a patch of glandular tissue it's off by itself and it just looks, distinct. It looks different than all the other glandular tissue in this case is just cuz I had a little bit of hypoechoic, spaces, in it so. Yeah, oh. Within. Normal, limits so. You will see that in every, field, of ultrasound. Everywhere. That's how the doctors, talk so. Very important to know those. Three little letters. So. For. Focal, asymmetry. Basically. There's. Three outcomes, if. We're asked to evaluate it, we. Either find something. Like actually. I'm sorry there's four outcomes. So. We either find patch, which. Is probably the most common. Secondly. Most common we just find a patch of just normal glandular, tissue, kind of off all by itself but doesn't end up being patch. I also. Sometimes, we find nothing you. Can't find anything that's distinct, and, sometimes, we find a mass that's hidden in tissue so, you might have a patch, of glandular tissue that's got something, in it so that's when, we see either. A developing, or focal, asymmetry, those are the. Forth outcomes. That that, we're going to have on ultrasound. All. Right so our next thing is distortion. Distortion. Is, when the tissues, getting pulled, or tethered. Worried. About distortion, because cancers, pull, or tether the tissue in. How. They define, this specifically. It's an area of radiating. Speculations. But no central, mass, so. Cancer. Would. Have a center, to it and then, speculations. And the, center is the mass of the cancer. Distortion. Just has the speculations. But there's no center, to it there's nothing definable, in that, center. So. When, we see distortion.
There's Really four, causes of distortion. Sometimes, it's a surgical, scar that's. Why we place those scar markers, on the skin because, we want to make sure the area, that had surgery, in it is not mistaken. For distortion, on a mammogram. Sometimes. Cancer causes, this. Or. Sometimes it's a radial, Skaar, remember Radio. Scars are kind of our transitional. Lesion this is the thing that can. Have cancer is associated with it radial, scars when you know the fat loses its blood supply kind, of scars down or fibrosis, in the area and creates this area of distortion. Also. You can have something called superimposition. This, is a mammographic, artifact, this means that that everything's, kind of overlapping, on top of itself it's mimicking, the appearance of distortion, but it's not true Distortion. Most. Of the time distortion. Is a 3d. Mammographic. Finding, and it's, not something that's seen on ultrasound. Only. When it really looks distinct. On a mammogram do they halt ultrasound, or the rest to see if we can find something. But, sometimes we find nothing. So. I, don't. Have a specific case for you of mammographic. Distortion. The reason for that is even though we see it gosh, almost every day, evergreen. Is. Because, it's a 3d finding I don't, have a way to show 3d. Images, and without 3d images you just can't appreciate distortion. It's very subtle so, my. Good friend that internet here showed, me some things I could show you guys so it, you, know the tissue just looks, kind. Of you know speculated. There's a regular, things coming off in this case it's all of this stuff here. In. Normal, tissue the tissues gonna be in lines it's gonna follow an order, you know organized. Path with. Distortion, either. The, outside, of the tissue starts, to get tethered, or pulled in by this distortion, or, within the tissue it starts to get pulled in and these, lines of tissue get distorted, they. Also call this architectural.
Distortion, Because the architecture, of the breasts these lines. Are, no longer organized, they start to to. Get an organized so it kind of looks like a spider, without, the body. So. These are cases where. We were asked, to go evaluate. Distortion. So here's the first case so. What are your thoughts on this area and here's the area that we're looking at right here. Good. Good. Taller. And wide mm-hmm. Yep. Scott, definitely got, irregular. Margins. So. What is our first thought when we see something like this I, do. See it love it. So. Exactly, so, we. Actually biopsied. This case and this, actually came back a radial, scar. So. Sometimes. Radial scars an IDC can have a very similar appearance and, they both can have vascularity, on ultrasound and, it's usually this kind of subtle it's, you know not a huge, you, know well-defined, mass. Yep. Just like you cancer so, they mimic cancers all right. That's. A sebaceous, cyst. Radial. Scar is like a tethering. Or fibrosis. Of the tissue so it appears, a shadowing. On ultrasounds yeah. Yep. Then it's going to be a surgical scar. Yep. So then you're gonna see actual, scar, yep, yeah. Okay, so here's case two where we are asked to evaluate. Distortion. Sort, around yeah, although. Kind of I would say taller than wide yeah yeah. So. When we see something like this what's our thought. Macey, and this one actually came back IDC. So. When we are called the value 8 distortion, this. Is what we're gonna see on an ultrasound. Most. Common, nothing. Times. 100. We're. Asked to evaluate distortion, I would say 75% I'm I see nothing, 25%. Of the time I find something but. The radiologists. Now if they know that's the odds why. Would they send me to go look at all. Because. So. Much easier, to biopsy something, with an ultrasound than it is with with, our 3d equipment. All. Right number two. Radial. Scar. Cancer. Those. Are pretty much our things every. Once in a while this. Has happened a couple of times and 12 years. Somehow. Because, it was a like, a tiny, scar, or the patient wasn't a good historian, I have, seen, a scar. Marker not placed on destroy over an area of Distortion and we. Were asked to look for something and we find a surgical, scar so, I that's incredibly. Rare mammogram. Checks are very good they, find this stuff but every once of all these scars are impossible to see and the patients they'll be like have you had any surgeries no so. They're not looking for a scar so patients. Are poor historian, so I guess the number four could be surgical scar but that's incredibly, rare and how, if I was evaluating distortion, how would I know it was a surgical, scar. It'd. Be on the skin so you'd see a thin white line and you'd, see it it coming, down from the skin it, would be you know that black wispy. Line. Yep. I. Had. A patient that forgot she had cancer. We. See everything, and. When I say we see everything we see everything. It's. Rare, for us not to see something yeah, I would say probably 90%, of time we can see a scar unless. It was an incredibly. Tiny surgery, with a incredibly. Skilled surgeon but yeah. Evergreen. Anywhere. But we do between four and five biopsies, every day and we have three texts, and we rotate who does it for the day so every, third day. Is. When I do. It. Yep. No. We, split it up yeah, so. Part of the day we're doing procedures and part of the day we're doing, yep.
So Yeah. But. We're also a very busy Breast Center I, mean most breast centers if there's an ultrasound tech sometimes your radiologist. Is your ultrasound tech because they don't even have one if most. Press centers have one scenographer we have three so we're, one of the largest in the state so, we. Cost. Cost. We're, expensive. Yeah. And and, there's there's. All it's. Hot and to, availability. It's, hard to find a scenographer this train and Brussels or something. Yes. And and when you get. Experience and breast ultrasound if, you get registered and breast ultrasound and have experience you are horrible anywhere, I we. Have people we. Have people come to us some, of the doctors from other sites come and they're like will you come work can I steal you from everything because, they, just, can't find good scenographer so a lot of these radiologists, are left to go scan by themselves, and they, don't want to do that. Good. Question and that, is a very, hot topic at Evergreen right now. To. Be continued, is what we'll say with that. We. Have been trying to get it approved but radiologists. Are creatures of habit they like things their way so it's tough sometimes to, move, through all the channels, that are way above us. Alright. So mass. Does. Anybody remember what, a mammographic, mass is. Yep. We've got to see it in two views, at. Least two views. When. We see something and it's something that's just well-defined, like you can, see it it's, not something that oh is, that something, or is it not something but it's something that's truly something. When. A radiologist, sees a massive memory room they characterize it so they try to look at the shape and the margins, and the density, of it, and. Then. Ultrasound. Is called to figure out what it is. So. Rule, number one, with a mass. It. Has to, be something. You. Cannot. Go to the radiologist, and say I do not see anything because they will send you right back into that room to find something a. Mass. Is something, on a mammogram that there is something there so we have to figure out what is it. So. Here's, our first case. Here. Is our mass. Right. In here. No. I'd say this mass is fairly circumscribed. Yeah I'm sometimes, I mean the hard thing with mammogram is things blend into the glandular tissue but this is a fairly circumscribes, mass on a mammogram so. We, were asked to find this on an ultrasound. Yeah. So tell me about the cysts. Excellent. So what kind of cyst is it, simplice. That's good so these are bread-and-butter, things on a on a mass a lot of times this is what we find. So. Number. One cysts, and it may be simple. Complicated, you. Might find something complex. So. It's this, area right in here and. It's right in here and sometimes it's hard to see stuff just because the glandular tissue, you. Know a butts. It is what I'll say. No. Not. Necessarily, I our. Water densities, and water density is glandular, tissue, fluid. All that stuff so it's going to be the same color as that glandular, tissue. It's. Probably the, maybe. There cuz you know it's yeah it's, pretty much the same as the glandular tissue, yeah. All. Right so here's our next mammographic. Mass I don't have to point this one out. So. What can what do you guys notice about this one. Good. Octopus. This is our octopus, what about, these. Margins. What. Color is what. Color is this on the mammogram. So. The, denser. Something, is on, the mammogram we, start to worry about it more. This. Is this, is whiter yep, yeah. So. Wider, is that, it's. Denser. Yep. Denser. Things are, more, worrisome. There's. Is all about. How. It relates to, the x-ray, attenuation not. How, the sound, wave attenuate, so they have different terms so this, would be. Radiolucent. Sorry. Radio opaque I'm mixing four terms radio. Baked yeah. The, patient, actually felt this so that's why this little dot, this is the BB marker good pickup yep. This was something that the patient had felt. Mm. I'm, sorry what. Mmm-hmm. Nope that's a that's an ultrasound, finding yeah, all. Right so here's our ultrasound. Posterior. Shadowing good what else, vascular. Eddie. You. Know sometimes with these it's hard to figure out when you have shadowing, where is the bottom of it you just. Try to guess. No. That's, just the fat. So. Are the margins nice. So. When I see something like this what's my first thought. Awesome. So. Number, two finding, for a mass on a mammogram cancer. Okay. So this. Is a tricky. One so, what, I want to say is the, reason I'm only showing you part of the breast here is, because this patient's, breasts were ginormous. Huge. Huge, huge I, still, remember this case because it made me sweat so.
Gigantic. Gigantic. Breasts, know when things are gigantic, is really, hard to find stuff, and this was a tiny something so this, was tiny and the patient was huge, so the patient the radiologist actually, called me into the the reader and said I want, you to go find this. Thank. You. This. Is G is some you know everybody's, different this patient just had, gigantic. Breasts. Right. Yeah so, and. This, is what we were looking for. Good. Pickup, it's got little calcifications. In it so that's how I would know if I was in the right thing this. Measured four millimeters. So. I was really hating, that radiologists. Yes. And her and I were going back and forth on where exactly is this because when breasts are so big they roll every which way and. Yeah. So. This. Is what we found on ultrasound. Four. Millimeters. No. Shadowing. So. This is a tricky, one on ultrasound when they're this little this is actually, a cyst. And, it's. Got a little calcification inside. Of it you. Can see the little calcification when. Sister this tiny sometimes, you don't see enhancement, so, it. Just it's too hard the machine just doesn't, pick it up but commonly, cysts. At one of the reasons we, get calcifications. In the breast is insists. So our, radiologist, is thinking this is either solid mass with calcifications, or assist with calcifications. Nope. This is something they just saw. Often. Often, often, we are called to evaluate things that are three to four millimeters so this is not unusual and in, a. Small breast no, problem, but in a big breasts. No. In this case we knew it was a cyst. So, and if and it, explained why it had calcifications. Because cysts often have a little they leading lay. Down calcifications. In them so, we. Reassess some. Sis, yet depends on some, cysts and sometimes. As they dry up they deposit, a little calcium in the pot in the breast sometimes you can see big cyst with calcifications. In them. So this is something we commonly see. No. It was actually and it's hard to tell them the pictures but real time you could see it was actually completely, anechoic, no echos in it, hard. To see on these pictures, just cuz it's blown up so much but ya, know this is a simple sister, with just a little calcaneal. So. Unfortunately. We, love to see those big you, don't masses, because they're easy to find but this is our bread and butter exam, this is what you know we're often called see um one, thing I'd like to point out to another, thing that we find is a mass is, a, lymph node. Sometimes. Lymph nodes can look like something, on a mammogram like a mass and. So. Sometimes we'll pick up a lymph node as well so that's. That's. Another possibility. Okay. So calcifications. So we learned before you can have big calcifications. Which are macro, calcifications. And you, can have small calcifications.
Which Are micro, calcifications. There's. A long, list of what causes calcifications. The. Ones we want to worry about are the ones the. DC, is that, you know the ductal. Carcinoma in situ that lays down those calcifications. That's, our first you know early, type of cancer, so that's what we're always on the hunt for so. When we see mammogram, calcifications. We, characterized. Them you know want. To look at their shape and pattern and size and all that stuff, one. Thing I want to point out is calcifications. Are a mammographic. Finding, this is one. Of the bread-and-butter things, at mammogram detects. Walter, sun has a very hard time seeing calcifications. We, seek health Civic ations when they're either large. And. Then we will like that last case you could see that calcification. And that was considered actually a macro, calcification. Believe it or not. You. Know we can see them and they often will have shadowing, behind them not always. Only. Time we see micro, calcifications is, if they're in something, with a dark background so, if you have a fibroadenoma. That's. Got little. Calcifications. In it fibroadenomas, are hypoechoic, and then we'll see those bright white calcifications. But. If you're just scanning through the tissue looking, for calcifications, you're just not going to see them. So. When. Since. Calcifications. Are a mammographic, finding, when. Would a radiologist, ask a older chantek to evaluate, calcifications. Microcalcifications. Yeah, because those the ones we really worry about. The. Answer is when they're extensive, so. Radiologists. Much prefer ultrasound, biopsy, over. Mammographic. Biopsy, it's just much easier. So. If there's really, extensive, calcifications. In area sometimes they try, us they think maybe we'll get lucky and, ultrasound. Will actually find something or, we're, looking for to see is there a mass, associated. With the calcification. So. Here's our calcifications. On our mammogram, they're. In this area here and in. This case they, were all different shapes, and sizes and, densities. Anybody. Remember what that means. We. Called them plea morphic, calcifications, so we worry about these anything's, that the. Breasts we like symmetry, so anything that's asymmetric, meaning it's not the same as another thing and. It's kind of hard to tell in this picture but they were all different, densities, different shapes different sizes. Maybe. A couple here and there and that's not unusual you might see a couple scatter here we worry about when they're in yeah. And. Like. A group, so. The. Radiologist, called in and said I want you to go see, if you can see anything in this area this, is a if, with.
The Naked eye without the magnification. On a mammogram if we can see calcifications. Just with our naked eye they're extensive. There are a lot of them, sometimes. Radiologists. Are looking at an area calcifications. It's like four or five calcifications. And you're never going to see them without their special magnification, tools so, if if we can see it with the naked eye we know it's extensive, the radiologist told me these are very suspicious, calcifications. They call them plea morphic, calcifications. So. I went, scanning, and this. Is what I saw. No. Movement. Vascularity. Good so I know what. Because, it's vascular. Solid. So that's my first clue what. Are all these little white dots in here. Calcifications. Yep and I can see them on the ultrasound because they're. You, know there's a mass in there so. When. We, can see a mass, with, calcifications. And it has vascularity, on ultrasound this, almost always turns out to be cancer, so. Especially. With that type of mammographic, appearance and in this case it was actually invasive ductal carcinoma. Nope. But not everything follows the rules. So. And and so I like this case because you could actually see the calyx and not. That on ultrasound that's not very common. Maybe. A hint. Not. Not a ton or. Maybe a hint of it mm-hmm. Okay. Limp, adenopathy, so this basically, means the radiologist. Sees a lymph node that they think is abnormal, either because it's denser, than it should be or, the size of it is something, that, they're worried about. Now. One thing we learned about abnormal, lymph nodes is that you, can have a big, lymph, node it can still be normal. As long as it has that fatty hilum, retained and it doesn't have any other abnormal, signs, so, when. We're called to evaluate, lymph adenopathy, sometimes, on older tongue we find normal, lymph nodes that are just big for whatever reason. Ultrasound. Is much better at, evaluating. A lymph node than a mammogram is so. Usually, what we'll catch a radiologist is that lymph node just looks big or it looks dense and they say hey will you go look at these lymph nodes. Lymph. Nodes can be abnormal, because they're reactive, meaning, they're reacting to. Something so. This. Is when they become. In appearance because, they're fighting off disease so. We see this with you know flu cold. Chronic. Illnesses, like lupus. Rheumatoid arthritis all, these types of things I've seen it with eczema. Also, after a patient has immunization. Shot. A, flu, shot and pneumonia shot those types of things the lymph nodes on one side of the body can become. Reactive. For. A little while afterwards, as the body fights, off all that stuff. Or. Lymph nodes can also be abnormal because they're cancerous now. Generally. Speaking a cancerous, node is going to be a lot, more ugly than a reactive lymph node the problem, is though lymph. Nodes don't like to follow the rules so, we generally consider that. Things that, are abnormal could be either reactive. Or cancerous, and they're all sampled. And. That tells us the sampling, tells us which. One it could possibly be. So. We remember our abnormal. Science so. Our. Focal, cortical, bulge which, is that lobule, a ssin we're. Looking for a round shape we're. Looking for hyper vascularity. We're. Looking for a thickened cortex, and we're looking for a loss of a fatty hilum. So. Here oh one. More point lymph, nodes can be either intra. Memory in the, breast tissue or. They, can be up in the exilic which are our axillary, lymph nodes so here's our first case this is our interim. Amory lymph anat lymph, adenopathy so, here is the little area that, we. Were asked to evaluate. Mm-hmm. Yep, and on women often have, you. Know couch serener. And. Hard. For us to see with our eyes but on. A mammogram, lymph. Nodes have. Auto. Ultrasound, - lymph nodes have a fatty Center, so they're their centers are more. Loose. It's they're more of a fat density, where their outside, is more wider, on, a mammogram, so, they have a darker, inside and a brighter outside not.
Always Sometimes on mammogram it's really hard to see that so, going, into this our radiologist, thought this was going to be a lymph node, I'm just based on its appearance but they told me to go find this and evaluate it. The. Inner part is kind, of and. Then, the outer part is just slightly brighter white but. I mean it's not very. Radiolucent. It's definitely. Increased, in density that a normal, lymph node would be so that's. What caught their eye, so. This is what we saw on ultrasound, so. What what does it look like to you guys. Good. Thickened, outer cortex, hyper. Vascularity. And what about the shape. Round. Shape so it's got three, out of the five things, that we don't like to see. So. When. We see something that looks like this we biopsy. It and our. Radiologist, actually thought oh this is probably just going to be a reactive. Lymph node even though the patient didn't have any. History. Of being ill or anything like that but sometimes you you don't even know that your body is fighting off something so sometimes you're not even ill and believe. It or not this actually came back invasive, lobular, carcinoma. Metastasis. So. And this, so this came back as a metastatic. Lymph node meaning somewhere, in her breasts that we haven't found yet is invasive. Lobular carcinoma. So, the radiologist. Went back and did many. Mammogram, pictures saw nothing. We, did many ultrasound, pictures we actually screened, her whole have breast with ultrasounds, which we never do found. Nothing and they. Thought where the heck is this invasive lobular carcinoma. Nope. It would be on this site because it metastasized. It's a lymph node and. So. We actually then went up higher in her eggs illa and evaluated, those lymph nodes and the, lymph nodes up in her and Mozilla we. Biopsy, a couple, of those that were also abnormal, and they also came back metastatic, invasive. Lobular carcinoma so. We did an MRI on this patient. Yep. We did an MRI and we found a four millimeter invasive, lobular carcinoma, that mammogram. Ultrasound. You. Know showed up great on that MRI. Not. Seeing it all I don't. You. Know what I found over the years with cancer is it does it's size doesn't matter if it's, gonna spread, it matters the histology it came back a grade three, out of three it's a really, aggressive cancer, so I've seen nine. Centimeter, cancers that have not spread to the lymph nodes and, sometimes. You see a four millimeter cancer, and you have abnormal notes so size doesn't really matter what, matters is what what type of cancer are you dealing with and how aggressive is, that cancer in this, case it was an incredibly, you. Know. Aggressive. Type cancer so it had our and also we. Don't really know how big that lobular, carcinoma is, you, know really because it spreads, out in sheets so it could be more in that breast on a cellular level that, we didn't even know. In. This case sometimes. Yes but in this case it was so small they said there's no way ultrasound, mobility listen we had already looked with ultrasound and found nothing so. The patient had an MRI guided, biopsy. Right. It's already metastasized oh. Yeah. The patient actually ended, up having chemotherapy. And radiation and, a mastectomy and patients, doing well now, yep. Uh. It. It. Depends. On a lot of factors and I'm not sure what her stage ended up being but I know I have seen her pack she's had a palpable lump this was like two years ago she's, had a palpable, lump sense and which was normal and she's actually, doing great. I'm, guessing, probably. Not a long time because it's a very aggressive, cancer and those usually tend to spread fast, so. Mm-hmm. Nope. So. She came, in for her screening, mammogram, and we saw this. Ono. Probably. Several. Months at least or, maybe, even a year yeah, I don't know exactly, but yeah it was aggressive I do know that so the aggressive things can spread fast. Okay. So, case, two, so. This is now axillary. Lymphadenopathy so, this patient here's 2013. Here's all the lymph nodes and here's. 2016. So. What, do you notice. That's. A eggs illa. De. Are bigger what. Else. Don't. Look at the breast size yeah, sometimes, it's just how magnified. I have it up on the screen yeah. You, know sometimes, it's just how, high, up they're able to get with a mammographic, picture, so sometimes we only see them kind of at the edge.
Yep. Yep. So when. We see something like this the radiologist, says go evaluate, the lymph nodes and we in this case bilaterally. Because they're both big. So. Here's the right, eggs illa. Around, what else. Yep. So definitely. A thickened cortex we're starting to lose. And. We're actually not. Really lobbying this is actually one lymph node this is a lymph node this is a lymph node here's, another lymph, node I mean they were everywhere. No. Not. Really, I mean not oh. Yeah. A little bit mhm yep. What. About vascularity. I'm. For vascular good. Here's. The left axilla. So. One. Thing to keep in mind if we have abnormal, lymph nodes in one breast we. Think about is there a cancer, spreading, to the breast but. If we have abnormal, lymph nodes in both eggs illa de. La rue thinking about. Good. So we biopsy, this and this came back lymphoma. Nope. Normal. Nope. These are normal. Normal. Normal normal and, these are abnormal. Yep. All. Right so. Go take a break and then we'll jump into MRI that. I'm, not sure I think they do chemotherapy for that but I'm not as familiar with lymphoma so. A. Not. Sure what they do for a lymphoma I'm not sure about the treatment for it so, don't. Know. So. What I want to say about MRI, is it, is absolutely the. Hardest subject, you will ever ever ever try to wrap your brain around so, I'm, not an MRI tech I've actually spent three years trying to wrap my brain a little bit more around MRI for this class I'm. Still not there so, what. You guys need to know about MRI, is on. The study guide and I wrote out on, all that colored stuff so if it's not in there you don't, need to know that so, I'm going to kind of take you through some of the big things so, most. Commonly. MRI. Which is a magnetic resonance. Imaging. Is called an M R so you'll, hear the radiologist, refer to it as an M R. But. It's also almost. Anything. How. Much. An. Area of tissue, and. This. Is an area. And. This is why. Also. Looks at the. Haven't even grown a mass yet, so. The patient, lays on their stomach on, a breast. Removal. On there's a little bit of compression on the breast so the patient doesn't move. Up. So. Basically. Your. Breast will. Look like a breast will, always be able to find the nipple and then. The tissue is going to be whatever. Area, stands, out within that center. Part of the breast here. Well. Actually, that's the way the, patterns. They, take different what they call sequences. For the breast. All. Computer-controlled. Right. Exactly. So, for. Purposes of us we want to be able to find the breath we, find the breast it's you know hanging, out there and usually they know. My. Stomach so you're hanging. Down so they look very pendulous. You know you can see them easily we, can always find the nipple and somewhere, in the middle is going to be the glandular tissue. You're. Always going to have an a for, anterior. So. Look at those. Orientations. You know my breasts you're looking at. This. MRI. Machine is a big, giant, magnet. So. What, that means is that, anything, metallic. Is. Strongly, attracted. To that, magnet, and. Not just this whole machine but they say the whole MRI, suite that. Whole room. Called. Coils, within, the MRI machine and the coils send out different Cygnus signals, all. Times, and all this complicated computer, stuff. When. It's tuned into an image. Every. Different. Part of the body has its own specific, type, of coil, which, sends out different signals so you can have a head coil, wails. Depending. On what your yeah. What. We have to remember about an MRI is. Magnet. Let. Me rephrase that big. Big. Magnet. Always. On. Always. Movies. Always always always this MRI machine. When. They turn it down, you prepared. Or something it's done for weeks because, that's how hard it is to turn it off and on so this minute, is on the. Unit over. 24. Hours a day. So. What we. Have. So. They, they figure this out. So. Stuff. Like this, so. The only thing that comes to mind in hospital working, Americans. Don't really like the. Patient. Suddenly stops breathing so, what do they usually, start bringing oxygen tanks. And all sorts of stuff do you know, start bringing, stuff like that to it very sweet. Little. Dangerous. Burger tough so, everything. About my bag you know MRI suite has to be. Stopped. So you have your normal code team and then you have your MRI code team everything. Is specific. For a bit Safran alright. So. We, always talking about MRI safety, so these. Are. Evergreen. Specifically. One. Of the cleaning people I guess both hands to the floor buffer, in order that section. Itself can imagine, it, could kill this person they're, wanting actually better performing. Well. And. In most apartments it's, looks like sealed, off to gain. You. Have to pass an MRI time they are treating, you so, because, they know how dangerous is. Something. If you take the breast board this is. Okay.
So MRI, looks at enhancement. Now we just learned on alignment. When, it, can be any color and, I literally mean any color on the. Doctor admissions, enhancement. One of their settings that makes it really easy to see is they turn it into color, so. That they can see the enhancement, really nicely so this is an area where the contrast. Is you know meeting in that area it's an uptake, of gadolinium, contrast. That, we call enhancement. And it, represents. An. Honour, MRI, enhancement. Can be colored. White. It can be great but it's an area that stands, out against the background of whatever color is here so. Enhancement. Is not more than become. So. When, we see enhancement, we really have to pay attention to. The enhancement. Just. Like everything else in the body we have to characterize it. So. When would we do an MRI, because. It's oversensitive. Been. Doing a lot of biopsies, so, we do these in patients, that have a high risk of breast cancer for. Screening. Purposes so, if you have a greater than 20 percent lifetime, risk of breast cancer. We. Do it when we stage, breast, cancer so. After you are diagnosed, with anemia of biopsy, we, then do an MRI. Ultrasound. A mammogram haven't picked up. And. We also use MRI to evaluate, breast movements, let's, put it far the, the best evaluation of an implant. Everyone. So all if there's something that's really difficult for, the mammogram we might order an MRI. Using, to evaluate how, a patient's, responding, to chemo movie, or cancer treatment, it's. Really, great at jumping. Between scar, tissue and recurrent, cancer. Enhancement. Some. It also can tell us whether, it just. Won't. Do. It in patients that are too young they, have a high risk of breast cancer but, they're too young to have a mammogram so, patients, less than 30 will use it as a screening tool for them. Now. When would we not doing MRI. Metal. Metal metal metal you. Know, some. Pacemakers. They. Are starting, to make MRI. Safe pacemakers. You. Can have clips, on it anyone, with, a brain or, somewhere. Insulin. Pumps, you know bullets, shrapnel. You, know anything that is metallic, if, a patient, is not sure. Can. Actually do an x-ray x-rays really good at picking up metal. Also. The patient has to be less than three pounds. To. Over. 300 pounds I can't fit into the MRI machine nine. Minutes. Ago, mr. Provo. Into. The machine. There. Are some. And. Then. Probably. One of the more common, reasons we, can't do it is portable, engine so this, clone dressed. Is. Processed, by the kidneys, so, if you have poor kidney function, they can actually send you into kidney failure don't. Want to play with patients, that, have poor candy fate function, so if there's a concern, with the chemo unless. There are certain levels they're looking for the, chance. To reach before it's safe to have an MRI. Most. Of the time we do a miraculous in the breasts although. With breast imaging implant, when we don't, open on dressed. So. This is the table that you lie on and these are the holes where your breasts, go into. And. Their. MRI coils, are down in, this, hole let's, send off the signals. From one of the computer. All. Right as a good test because it's very true you can bring things before, we won't, find him on other tests but it's bad, in that it picks up everything, so. That's why we really have to determine who should and shouldn't get an MRI. One. Of the pitfalls, of MRI is what, we call background. Enhancement. So, this is where instead. Of something, abnormal picking. Up the contrast. Normal. Breast tissue is, picking, up that contrast. Now. Why would normally, mustache you want, to pick up that contrast, and display this enhancement. Most. Commonly, it's due moon changes new breaths so. When. You get closer to your periods. Breast. Tissue goes crazy on your own so, instead, of having. A. And. You, know that's what we need to focus on. Suddenly. The whole breast.
They. Can do it. But. You. Know. We. Try yeah. Whenever. We can time it we, minimize, that background, enhancement. So, things. That do enhance on MRI the, nipple and areola can normally, enhance on the MRI sometimes. Also. If, you've had a. History, of radiation, therapy to the tissue this, can infect, enhancement. So. Radiation. Treatment decreases. Blood flow to the tissue so sometimes, in women that have had radiation between one breast and where I can be less sensitive. Because. It just doesn't pick up blood signals as well so. MRI. A great. Test but like, every test not, a perfect, test. We. Often do with the second, local treatment. This, is a study that follows, up in the MRI, and this means. Generally. These, patients, are patients that have already gone through mammogram, and ultrasound and, we didn't find anything and then they find something on MRI and then. They send them to understand, the scene now that we know exactly where it is and what shape it is in size can, hunters don't find it so, we call these second, look MRIs meaning we're taking another look to see if we can find an MRI finding. Of. Second. Look older sounds I would say at least 50, to 75% of them I find nothing, so. Maybe. Only about 25%, of the time actually finding, something so about 25%, see, that patient from an MRI guided biopsy which. Is more involved in the ultrasound biopsy. Absolutely. We, want to learn about it next, week. All. Right so how, do we care. We're. Get to that next week where. We will go there I promise, yes. Yeah. So um. How. Do we characterize enhancement. So there's two ways that we can characterize enhancement. So. The first one is the morphology. And. This basically, means what does it look like. So. The characteristics. Of it its appearance. And. The second way is the kinetics. And. This. Is how, fast. Does. The the contrast, travel. To. An area. We're. Getting there. So. We're gonna start with morphology. So this is they, have to characterize. What is the parents. Of the enhancement, so, they've made three, categories. The, first. Category is. A focus. Or fossa, second. Category, is a mass and, the, third, category is a non mass so all of these are the parents. Of what, enhancement, can look like to their eye so. The very first category of focus, this is a really. Tiny spot, of enhancement, it's less, than 5 millimeters it's. Too small to really capture and characterize, um it, could be benign or it could be malignant who knows because it's so little you can't really tell much about it but, you can see it as a distinct, spot on MRI. Our. Second, category means. That, the. With, this. Enhancement. There's actually, a mass, in, that area so, you have a mass which is you know we've learned a space occupying, lesion a mass, plus. They have enhancement, in the area of the mass, when. They see this just like on ultrasound we have to start characterizing so, the shapes the margins, and all of that stuff and they're, also going to characterize, what does the pattern of that enhancement. Do so. On. MRI. And. I want you guys to think of this separately, as an, ultrasound, but you have your mass and you, have your enhancement. Inside. That mass and they want to look at the pattern, of it so it, is it even. Within. The mass so, is it homogeneous, or heterogeneous.
Does. It kind of go around the rim they call this rim like, or. Is it right smack dab in the middle middle, central. Or, something. That they call, separations, on, a mass. So, for. Them it's, not actually, the characteristics. Of the map, so the, characteristics. Of wearing. This enhance, the brightness. Within. The mass so, when, these are talking about septation. About, pushing. It on enhancing. Background. And, lighting, up on top of that mass or septation. Non. Mass means, of. Having a mass that's, got enhancement. With it you, now just have enhancement. What. No mass. How. We distinguish. The. Size so. This. Enhancement. We can characterize this, and. So. Is this enhancement, look. Like it's an S shape of a duct. Enhancement. Is, it just in one area. Which. Would be focal. Is. It. Within, a just, a certain segment of the breast. Call. That you know segmental. So there's lots of different, cameras. Us to figure out what it is. So. Mass. Means. They. CMS. You. See both so, think of it as mass. And. Then you're very handsome, smack that on the top of it. So. MRI, picks up enhancement, but it also picks up Anatomy, so. You've got two things it does which, is why it's such a good test. So. This is our first category this is our faux sigh so it's. Basically, where the. Enhancement. Lights up in an area and, it's. Too small to really characterizing. So. That's what we know about a focus, it could be benign it could not be benign it's, just little. And. Then. We have our mass, so, a mass, means there's actually, a mass there, plus. You have enhancement, right smack dab over, the top of it and. I want to know what is that enhancement, doing, over the top of it is, the. Enhancement. You. Know homogeneous, heterogeneous is. It around the rim is it within the middle of the mass or, is. There sub tations, now, there's two types of sub tations, for MRIs, these. Are not septation. X' like we think of septation x' for. Us for us septation, x' or something that's actually within a mass these. Are acceptations. Of that enhancement. So. They, have dark except ations and this, means there's. Lines, within a mass that are actually part of a mass just like we think of with ultrasound and they don't enhance, they have no enhancement, on them or, you have enhancing. Internal, septation x' these. Are septation x' within a mass that do have enhancement, with them. Then. We have our non mass so when, they see enhancement. That's bigger than a full size so it's bigger than five millimeters but. There's no mass associated with us then we get a non mass and all these are terms. That. Describe what. They what the radiologist, looks at how they characterize that, so. I've, put, on your study guides what I want you to know what you don't need to know if it's not in your study guide you don't need to know it. So. This, is what they look like so. There's. A mass behind, this and here this whole areas enhancing. And it's. Very heterogeneous, the, enhancements, not smooth, and uniform like, this enhancement. So, you know homogeneous, and her genius sometimes. You have a mass and just the rim of it. Lights. Up and, then. This is where we have septation. So in this case you have septation x' and a mass but. There aren't enhancing, with the color. And. They're also looking at the shape so, you know all the same kind of things that we look at on, an ultrasound. Enhancement. Can also be you. Know long duck ductal, segments, this is when they worry about them or. Within a segment of the breast or within a region of the breast so all these are things that they're looking at. Now. The second, category is the kinetic pattern so. Kinetic, pattern, rather than looking at what does the enhancement, look like what is its appearance, now, we're looking at how fast is that contrast, traveling, to an area. Contrast. Travels, to cancers, much differently, speeds, than it travels to benign, things so. This is how they, determine, they. Have what they call a curve or a line, and this curve our line shows. How fast that contrast, is traveling. Over time, they'll. Be reading this into two phases. So, two phases the, first phase is the first two minutes.
After. They've injected the contrast so they inject, the contrast, and from the second thing dipped it until. They hit the tune it was, not a one. The. Second, phase is two, minutes plus, so. Whatever happens. So. The first two minutes that they inject contrast in the patients. Go. To, areas. Of the breast. This. Is how fast did it get there. And. This is how long does it stay there. And. This is all calculated. Out by a computer, into. A sort, of line, or graph. So, what, we call this this, first two minute phase here the first two minutes is, called the initial enhancement. Phase and the, second two minute is called the delayed, enhancement. Phase and, within. These categories we start to get different types of enhancement, so we're going to look at the graph so. What. What happens here's our initial, phase the first two minutes and here's our delayed phase, so things. That. Travel, slow. Or, at. A medium, pace, and, this is all measured out by numbers, that the radiologist know we don't need to know that but in the reports that will say slow, to medium. Things. Are benign things. Things. That are malignant, travel, very fast, in, the first two minutes. Cancers. Want to pick that contrast, up and they want to pick it up very quickly so fast, is bad medium. Of slow or benign findings, and then. For our second, phase here the delayed phase this is how long is the contrast going to stay there once it gets to the area it's going to in the breast tissue. Benign, things, have, a very persistent, thing, meaning. The. Contrast, gets there and then over time it just slowly. Rises. Over time the Kandra the amount of contrast, in that area we. Call this persistent. Enhancement, it's, staying, there and it's, gradually getting, bigger this, is a very benign pattern, of a, mass. Things. That, do either plateau or washout plateau means the, contrast, travels, to an area and then. It just hangs out there but it doesn't do anything does it increase in number it doesn't decrease in number just hangs out, this. Is a malignant, side and. Then. Things that travel. To an area and then over time the contrast starts decreasing, in, number this. Is called washout, this is a malignant sign. It. Stops, it grabs. It quickly, and then it doesn't want it anymore. I. Don't. Know exactly how, it works I just know it grabs, the contrast really fast and then it just doesn't. Care about it anymore. It. Spits it up. Okay. Right. Exactly. Okay, CT this is a cat scan this, is a study that uses, x-rays, to take really tiny thin slices, throughout the body, a CT. Is an anatomy, test so it shows us the anatomy. CT. Is terrible. At seeing breast, masses terrible. Terrible terrible so when. They see something, on a CT, it almost always ends up being something that we call in once again waiting and that, means that the patient had a CT, for whatever reason, they had maybe they're having abdominal pain or something and they, just happened, to stumble across a, breast mass, when. That happens, older, sound is called in and sometimes a mammogram is called in to assess, these areas, so. We, don't use CT, to screen the breast for disease because it's terrible it just doesn't. Really. Tell. How. Many times. So. It's not a fabulous. Tool unless we're dealing with something big. But, there are developing, new technology. And I've heard this is in the clinical trial space for, a 3d breast CT, so, we'll see how that goes I'm not quite sure about that, so. This is a normal CT so. Just like our MRI you're gonna have your labels. Anterior. The front of the body. Posterior. Is the back of the body patient's. Left side, patience right side so you always get that to orient yourself now, on a CT, the breasts are almost kind of off to the side and this is because the patient's laying on their back and when someone lays on their back where do the breasts here. They. Go off to the side. It's. Tough, yeah,