 So today I'm going to be talking on Contrast Enhanced Breast MRI, a case-based review. So before I go to my cases that we all on the same page, I'd like to just tell you a little bit about the descriptors what we use on MRI. So when you see a Contrast Enhanced MRI, you either call it the lesion of focus or you call it a mass or you call it a non-mass enhancement. So what is a focus? This is any lesion which is less than 5mm and you cannot define the morphology. Mass on the other hand has convex margins and you can see it in all the planes and you can see it even on the plane scan. So anything which is not a focus or a mass is a non-mass enhancement. So when you're talking about a mass, we need to tell about the shape and the margins. The shape can be oval, round or irregular. I think the names themselves are very self-explanatory. And the margins can be either circumscribed or non-circumstribe. Non-circumstribe is further divided into irregular or speculated just like mammography. Then we look at the enhancement pattern. So this is unique to MRI. So the enhancement of masses can be either homogeneous, heterogeneous, real enhancement or dark internal septations. So if you have a homogeneous enhancement, thick of a benign lesion, if it's heterogeneous, think of a malignant lesion. Rim enhancement, you can see both in benign and malignant. And dark internal septations are most commonly seen in fibro adenomas. So always look at the enhancement patterns also. Non-mass enhancement on the other hand is divided according to the distribution as focal. By focal, we mean it's occupying less than a segment. Linear is self-explanatory, it's a line. You can have a branching pattern. That means it's enhancement and adopt. Segmental is a triangular shape of enhancement with the apex pointing towards the nipple. And this represents a Tdlu. Regional will occupy a larger area than a segment. Multiple regions is more than a larger area with normal breast tissue in between. And diffuse is involving a large part of the breast. So linear and segmental are pointers towards malignancy. Focal, regional, multi-regional or diffuse, you can see in benign or malignant cases. So like masses, even in non-mass enhancement, we look at the internal enhancement pattern, which can be homogeneous, heterogeneous, clumped or clustered ring-like. Homogeneous we can see in benign conditions. The remaining three we normally see in malignancies. But a country like ours clustered ring-like is also seen in cases of tuberculosis. And then what do we have? Other kinetic curves. So this is the software after we've acquired the dynamic contrast images. We divide the contrast into two phases. The initial phase, which is the first two minutes, and the delayed phase is two to six minutes. In the initial phase again, you have a slow, medium or fast version of contrast. So what do we mean by this? Slow is when the lesion enhances less than 50% of what it was before contrast. Medium is between 50% and 100%, and fast is more than 100%. So the fast ones are associated with malignancies. The medium and slower are normally seen in benign conditions. Having said this, you will see cases which are malignant and they show slower enhancement. I'll show that in my talk as we go along. The delayed phase is divided into persistent, plateau and washout. Persistent we see normally in cases of benign conditions, but you have malignant conditions like invasive lobular carcinoma, DCIS. They can also show you a persistent curve. Then we have the plateau and washout, which you can see in malignant conditions. Plateau can also be seen in benign. So this is a general overall I'm telling you, but just remember, always morphology trumps over kinetics. So always look at the morphology of a lesion, which is very, very important. And then we look for associated findings like neo-angiogenesis. You can see this in malignancies or any vascular malformation. Look for architectural distortion, which can be the only pointer towards invasive lobular carcinoma. Look for nipple involvement. And then look for this hook sign. This is what happens when there is an invasive ductal carcinoma, which is causing a lot of desmoplastic reaction. It is basically engulfing the Cooper's ligament. And so what happens, the pectoralis major gets hooked. It's like a tent. So this doesn't mean that the muscle is involved. This is just that the Cooper's ligaments are getting involved. The only time we call pectoralis involvement is when you have enhancement, and the same goes for skin. Only enhancement of the skin and not only edema is skin involvement. And now with the new barats, which is going to be coming up, they're including this very good thing that is a T2 signal. So remember, as a general rule, T2 dark lesions are malignant. There are lots of exceptions. I'll show you that. And T2 bright lesions are generally benign. But again, there are lots of exceptions, like a case of mucinus carcinoma that will also be bright. But for you, the take home right now is T2 dark is malignant. T2 bright is benign. So now let's move on to the cases. This was a 24-year-old high-risk female who presented with a palpable lump. So what do we see? This is T2 bright. Again, so if it's T2 bright, we think of benign. Now look at the contrast. There is just thin, smooth peripheral enhancement. And there is no diffusion restriction. A word about diffusion here, like in any part of the body, if there is high-density fluid, like pus, that restricts. If it's a solid tumor, that restricts. So what happens in case of malignancies? The ADC is very low. That means they are restricting because they are solid. So that's how we differentiate benign from malignant masses based on diffusion. So coming back to this, so we have a lesion which is circumscribed T2 bright, very thin, smooth, peripheral enhancement, and no restricted diffusion. So my question to the audience is, what is your borax in a case like this? You can just even just type your answer into the chat box that we won't have enough time otherwise. So the answer to this is, this is a borax too. It's an inflamed cyst. Why are we calling it inflamed? Because it is thin peripheral enhancement. If it was no enhancement, we would just call it a cyst. So remember, benign lesions, T2 bright, circumscribed, no restricted diffusion. A 35-year-old female came with a discharging sinus in the right axilla and redness to the skin with pain. So the clinical history itself is pointing towards benignity. And what do we again have a T2 bright lesion, which is showing this peripheral enhancement. It seems fairly circumscribed, but what you need to see is the diffusion. So what are we seeing in diffusion? The part which is T2 bright is showing very dark signal on ADC. So we know we're dealing with high density contents or an abscess. And it's not solid because we only have peripheral enhancement. And we have ancillary findings like a sinus tract and matted nodes. So we are pretty sure this is a benign case and we put it at birette 2 and this first just tuberculosis. Now this is a 42-year-old female came with a palpable lump in the left breast. Again, T2 bright. So when you say T2 bright, you think of benign. But what you really need to see here is the morphology. What you see, the margins are really irregular. And now look at the enhancement pattern. This is what we call is the rim enhancement and we also have enhancement of the septail. And look at the diffusion. The part which was T2 bright is not restricting. That is showing a T2 shine through, but the solid component which was T2 dark is showing you restricted diffusion. So we can safely put this into a barat 5 category and this was an invasive ductal carcinoma with central necrosis. Sorry, I didn't ask you to answer this, but this is now going to be in barats 5 category. So how did we differentiate between an abscess or a malignancy with central necrosis? In an abscess, the central component, the T2 bright component will be restricting, whereas in a tumor with necrosis, the solid peripheral component will restrict. So that's how you differentiate the two conditions. This was a young liver donor who first found to have a mass on screening mammography. So what do we have? We have this mass. We don't use the term lobulated, but you can see there are less than three lobulations. So I can put it into a circumscribed category. It's not showing any restricted diffusion. And on contrast, what are you seeing? These are these non-enhancing septail and it's showing you a type 2 curve. So this is very much like a fibrodeanoma because you have these non-enhancing septail. So my question to the audience is, what is your barat? Maybe one, two, three or four. We know it's a benign lesion. Will you put it at two or a three? So remember this, if it is a first-time diagnosed fibrodeanoma, you always either biopsy it, especially in these young patients, or you put them in barat three category. And why do we do this? Because they mimic malignancies a lot. We can miss malignancies which are circumscribed, thinking it's a fibrodeanoma. So either you go ahead and biopsy, or you do a short interval follow-up. Now, how did we differentiate between a fibrodeanoma and a malignant mass? Both had septae. In a fibrodeanoma, the septae do not enhance, whereas in malignancy, you have the enhancement of the septae. So you can use this point to differentiate one from the other. This was a 42-year-old female, came with a lump in the right breast. She had a strong family history of breast carcinoma. So what do we find on T2? Again, it's T2 bright. But what do you want to need to see? It's not uniformly bright, like we were seeing in the other cases. And on T1, it is low. It is not showing any restricted diffusion. It's bright on diffusion because of the T2 shine-through. Inherently, it was bright on T2. That's why it's bright on diffusion. And that we can say because it's still bright on ADC. If it was restricting, it would have been low on ADC. And on the dynamic contrast, what do we see? There is progressive enhancement of the lesion. So now, should we just put this into a fibroidinoma? Most people would do this, but what you really need to see are the details. Look at the margins of this lesion. These are basically small micro-lobulations. So this will not come into the circumscribed category. And on T2, if you look closely, there are these T2 hyper-intense areas within it, which are not showing enhancement. So we know there are areas of fluid clefts within the lesion. And we all know fluid clefts in the lesion are quite classical for phyloids tumor. And this turned out to be a borderline phyloids tumor. And why is this important? Because if it's a fibroidinoma and they want to remove it, they just remove the lesion per se. Whereas if it's a phyloids tumor, they will do a very wide local excision so that there is no recurrence. So it's very important for you to tell the surgeon that you have a doubt and this can be a phyloids tumor. This was a 38-year-old female with family history of breast arsonoma. And she was on short duration oral contraceptive pills for basically infertility. Again, T2 bright, you might think it's benign, but like I told you, look at the morphology. It's so oval mass, the margins are very irregular. And what happens on the contrast? You have a peripheral enhancement to start with and I don't have the delayed images for you, but it was slowly filling in. The contrast was seeping from the outside inside. And on diffusion, there is no restricted diffusion. So when you have an enhancement pattern like this, always think of mucinous tumors. If you have a pure mucinous tumor, what happens in those? The mucin will start absorbing the contrast from periphery and it'll keep seeping in. So the delayed images will get it uniformly enhancing and not in the initial. Whereas if it is a mixed mucinous tumor, you will get a heterogeneous enhancement. And these are very commonly mistaken for fibrohalenoma. So you have to be very, very careful when you're looking at T2 bright lesions. Another T2 bright lesion, this was a 40 year old, this was a young lady. So what I want you to see, this is again a T2 bright lesion, but it has a nice hypo intense rim. So what does this hypo intense rim? This is actually a fibrous capsule. So what happens when you give contrast on the early contrast, the rim is not so nicely seen, but on the delayed contrast, this rim is beautifully seen. So this is a fibrous capsule around the lesion. The other thing what you need to see are these nodular densities around the lesion. So this is because of the lymphoplasmastic response. And this is very classical for medullary tumors. So if you have a circumscribed mass, showing a T2 hypo intense rim, which is showing nice enhancement on the delayed contrast images, and a few cystic areas in between with washout of contrast or plateau delayed enhancement characteristics, think of medullary carcinomas. So like I told you, these also occur in younger female. You can easily mistake them for fibrodenomas. So be careful. This particular case, the lesion was irregular, but you may have really circumscribed lesions. So look for the point of what I've told you, the enhancing capsule, these nodular densities around the lesion, as well as you see the enhancement pattern with cystic areas in between. This was a 58-year-old female who came with the right breast lump, six months duration. So what you see here, again T2 bright, it looks very similar to the case, the IDC with central necrosis, what I showed you. They are enhancing septae, there's no angiogenesis, and the wall and the septae are restricting. So one of you can ask me, why can this not be an IDC with central necrosis? So what you need to see, there is a aggressive tumor, this cause skin thickening, nipple thickening, and we are calling this a sarcoma. This turned out to be a primary neuroectrodermal tumor. And what is the pointer that this is a sarcoma? Sarcomas normally have hematogenous spread. You can see here, the node which is not involved, it's a node with no cortical thickening, this is only a reactive node. So such a large mass without any nodal involvement and T2 bright, please think of sarcomas because the way they spread is hematogenous and not lymphatic. If this was an IDC by now, you would have had huge axillary lymph nodes. Another case, this was a very high, in strong history of breast carcinoma. In fact, she even had a biopsy one year back which said benign ductal papilloma. And she was lost to follow-up. I don't know what happened, but probably it was COVID and she didn't come back. And when she came back, she came back with this huge mass after a year and a half. And this was showing basically cystic condense, but what we also see there is no restricted diffusion. And these are these nodular papilla projections inside the lesion. And there is this non-mass segmental enhancement just posterior to this lesion. And you can see how there's an engorged, dilated internal mammary vein arteries, sorry. And this was basically intracystic papillary carcinoma with extensive papillomatosis. The pointer here is solid cystic mass with nodular papillary projections along the wall, along with extensive DCIS. I mean, we called it DCIS, but this was only papillomatosis. Think of papillary neoplasms. This was a very interesting case. A young girl came with low backache. She had fever, she was being investigated for that. An MR of the spine was asked for. The spine was totally normal, but we found retroperitoneal lymphadenopathy. And then she had a CT because of the fever and there they diagnosed a lump in the breast. And a mammography was asked for. So retrospectively, she said, yes, I can feel the lump. And she was also lactating till three months back. On mammography, these were the findings and they thought of Dallomatosis, mastitis, because I think the history also was a pointer towards this. So we went ahead and did an MR. Of course, MR was just done for academic reasons. We had already biopsied by then. But my question to you is, when you look at an MR like this, do you think this is asymmetric breast tissue on the right or this is some pathology? So you can type your answers in the chat box. So let me show you the rest of the images. Definitely, this is pathological. And what do you find? This is a lesion which is showing significant restricted diffusion and the ADC is markedly low. Remember, glandular tissue at high B values will not restrict. So this is definitely pathological. And what is the clue to the diagnosis? This is such a huge mass here, but there's hardly any desmoplastic reaction. You can see the pectoralis is sitting very beautifully. There is no hooking of the pectoralis. So we know there is no desmoplasia. These are infiltrative tumors which are showing intense restriction, a little heterogeneous enhancement. And this is what they call as the penetrating vessels, which I am not very happy with. I've seen it in most of my cases. But basically they say the vessels are leading into the mass. And this is classical for lymphoma. This turned out to be a B cell lymphoma. Lymphoma can present as circumscribed masses, infiltrative masses. They can have a valuable picture. But if you have a mass that is so huge without any desmoplasia and so much restriction, you can think of lymphomas as your first diagnosis. Now coming to this case, this is a 43-year-old unmarried female. She was also already biopsy proven on the right for malignancy. And she just came to us for the extent of disease because they wanted a breast-conservative surgery. So what do we find classical features of malignancy on the right side? But what I am showing you this case is I want to show you what we call as ultra-fast imaging. So what is ultra-fast imaging? Instead of normally when we do dynamic contrast, we acquire images every minute and we acquire six sets of images. That's how we draw the kinetic curve. Whereas in this case, what you're seeing is within five seconds of the contrast reaching the aorta, this is enhancing. So if you have a lesion which starts enhancing, within 10 seconds of contrast reaching the aorta, you can be pretty sure this is malignant. And see in these ultra-fast images, you don't see any background enhancement. And what we are studying is the wash-on characteristics of lesions. So we were very pretty sure this was already proven, so we already knew this was malignant. But what I want to show you is this lesion on the left. You're getting this non-mass enhancement at five seconds. So again, we are pretty sure this is malignant. And you can see this beautiful non-mass area of enhancement in the left. And this was proven to be DCIS. So you can see how ultra-fast imaging is helping in this. This is another lady who was already diagnosed with invasive lobular carcinoma. And that's why MRI was asked for because invasive lobular carcinoma can be bilateral and multifocal. So MR has to be done in all cases of suspected invasive lobular carcinoma. So here you can see how difficult it is to see these lesions here. So why does invasive lobular carcinoma behave like this? Because the way it spreads, it doesn't have any neo-androgenesis. It spreads along a single. That is how it duplicates or replicates. So that's why there is no neo-androgenesis. So there's hardly any vascularity. In fact, it's so faintly seen on our MIP images. So look at the ultra-fast now. It's broken the rule. It's enhancing at 25 seconds. So remember, invasive lobular carcinoma will not follow the rule of ultra-fast imaging that malignancies will appear within 10 seconds of contrast reaching the aorta. So this is why I wanted to show you this case that invasive lobular carcinoma is different. It will show you just clumping of the parankaima and it will not trap much neo-androgenesis. This is just to show you another T2 dark case which can mimic malignancy. You can see on the T2 weighted images, it's really, really dark. The area is a very low signal. And if this is a malignancy because morphology, it looks very irregular. But look at the enhancement pattern. It is very, very homogenous. And once you have homogenous enhancement, but it is restricting. We thought of malignancy, but it was not fitting in right. And on biopsy, this was IDG4-related mastropathy. IDG4 is basically a big time disease coming all over the body. I think you can read about this. But remember, they can be T2-low on MR. Another region which can be T2-low is an example here. Again, low on T2, ISO on T1, but this is not showing you any restriction unlike the previous case. But look at it enhancing. It's enhanced within five seconds of contrast reaching the aorta. So this was something of, and we thought of malignancy and we put it at a barad's fold. And on biopsy, this turned out to be just a pastries-terrose papilloma with fibroadenomatoid hyperplasia. So remember, ultra-fast images hold goods for classical malignancies. If you have papillomas, they can mimic malignancies and start enhancing early. Or if you have invasive lobular carcinomas, they may not present like classical malignancies and they enhance later. But just to recapitulate what we have learned today, cis, remember, no restricted diffusion, abscess, the T2-bright area will restrict. IDC with necrosis, the bright area will not restrict. Only the dark area will restrict. Fibroadenomas have the non-enhancing septae. In phyloordia tumor, you have the fluid clefts, which do not enhance and the margins can be irregular. Muciness carcinomas will have slow filling in of contrast. Medullary again T2-bright, but remember the fibrous capsule, the enhancement pattern and these nodular, enhancing adjoining lesion because of lympho, plasmacitic infiltration. Papillary carcinomas have these papillary projections along the periphery of the lesion. Sacomas will not have any significant local lymph adenopocytes. This is how we differentiate all the T2-bright lesions. T2-dark lesions for you as a general rule are malignancies, but lymphomas can be T2-dark or intermediate like we had in our case. A partially sclerosis papilloma will be T2-dark and even IgG4 will be dark. And another thing which is very commonly mistaken on mammography is malignancy because they show irregular margins. Sclerosis fibroidinomas, these will not enhance and you can safely downgrade these two, a barrage two on MR. With that, I would like to conclude and a big thank you to the organizers once again.