 Can you hear me should I try sharing the article on the screen. We can just start the intro slides. We pardon me. So I can just start with the intro slides in two minutes and then we can start with the article. Okay. Sounds good. I'll just keep everything ready. Hello everyone. And we welcome you to the next session of Journal Club initiative by Indian radiologist. As already discussed, this is one initiative where we take one relevant updated article from a recent and authentic journal. And one of our experts discuss that article and inputs from the experts enhance the utility of the article itself. So it's like a two-part thing you can put on your questions and doubts across and then we can have a good discussion. Today, we are taking the specialty of breast imaging and for breast imaging in our country, we know the best people possible we have with us today so please take this opportunity and get your doubts clear today in this particular topic. This is the cancers in non-bracka positive patients in young adults with breast cancers and lumps. So we have our speaker today Dr. Shilpa Ladman and I'll be moderating the session myself Dr. Mithusha Verma. So this initiative is started last year we had every month the German clubs and we took relevant topics and some specialties. And this year also we'll have similar discussions every Sunday, one of the Sundays of the month. This session will also get shared on our YouTube channel of Indian radiologist so that you can revise this topic. Also, I will take this opportunity to bring to your notice that the much awaited annual MRA teaching course is now here and that is scheduled on 26, 27, 28th of May. So we are creating comprehensive onsite course which is the venue is the hotel sequences to move by. We have the new sessions they will be online on Sundays before the main event and we will be discussing physics and an actually online but rest of the conference which will be covering comprehensively MRI based imaging of CNS neuroimaging topics then in the chat box shortly and we have great panel of speakers so please do join us for this MRA teaching course. We have workshops as well. There will be five workshops on advanced neuroimaging topics including breast imaging, including lyrats, pirats inside including various compo imaging aspects as well as cardiac imaging will be on site. So the links to register for the course will be shared in the chat box shortly and we have great panel of speakers. So on advanced neuroimaging, cardiac imaging, then we'll discuss breast imaging case based and also prostate imaging multi parametric with pirats and lyrats topics in the workshops. They'll be dedicated one to two hours of workshop for these particular topics we will have a live MDT multidisciplinary meeting for MSD cases with ortho radio and patho team together on table for discussing the sarcoma board. So all these things are coming up for the MRA teaching course which is made last week that is 26, 27, 28 of me so please do join us for the same. And not only this we will on 7th of May we will have a complete online session on breast imaging masterclass again I'll be sharing the link to join and register for that so that we will be a single day online event for all of you who are interested in the sustainability of breast imaging, we will be comprehensively covering these relevant topics from mammogram to ultrasound interventions and MR relevant to breast imaging on 7th of May. So with this I take opportunity to introduce our speaker for today Dr. Shilpa Lalma. She is the subspeciality head for breast imaging of ICRI that is Indian College of video medical imaging, and she is consultant breast imaging and interventions at NM medical Mumbai. She was the former consultant and assistant professor at the hospital University of Ottawa Canada, and she has special interest in specific interest to breast imaging and intervention. Thank you ma'am for joining us and we welcome you for today. Thank you for the kind introduction and for all the teaching activities that Indian radiologist is doing on the online platforms as well as in person platforms. So without any further let's start with our discussion for the day, how we thought of discussing this article and what was the what was the inspiration or motivation. Yes ma'am, yes ma'am. Okay okay, perfect, sorry about that some internet glitch there. So what was the motivation for selecting the article that we selected today, and I'm just going to share a slide here. So give me just a second here. Can you see my screen now Mithusha? No sir, it's not visible. Now it's visible? Okay. So I dedicate my talk to my beloved Sir Guru Sri Vaman Rao Pai. And so here was the thing, we saw this 23 year old she had a new onset palpable lump in the inferior left breast ultrasound had been done. Initially it had been reported as questionable fibroadenoma. And then they had said nonetheless biopsy recommended biopsy was subsequently done. But before the biopsy was done we also did an MRI. On MRI it looked like a heterogeneously enhancing mass nonetheless what confused us or what was confusing in this case was it was also T2 hyper intense. Well it was oval it was T2 hyper intense the temptation was, could it still be a fibroadenoma. Okay, however the early post contrast images showed a heterogeneous enhancement and irregular margins, although some of the margins were partially subscribed. Okay, biopsy was performed and in this 23 year old this turned out to be a cancer. A triple negative breast cancer ERPR her to new positive cancer. Okay, which which brought us to the point that and you know it wasn't that small it was sizable it was almost three centimeters. So when we asked the patient how long have you felt this long. She said that she felt it for a few months initially she spoke to her mother about it. Her mother said maybe it is just hormone related lumpiness in the breast. Nonetheless because she persisted she spoke to her mother about it again. And then her mother took her to her gynaet doctor and the gynaet doctor prescribed some vitamin ecapsules and Primosa, hoping that it was just hormone related changes. So another one month went by in that nonetheless instead of the lump getting any better after the period the lump becoming smaller. It kept increasing in size so she went back to her gynaet doctor again. And this time the gynaet doctor recommended that investigations be done first starting with an ultrasound. Okay, and all this these investigations ultrasound followed by MRI followed by a biopsy that led to a diagnosis of a triple negative breast cancer. Okay, so during the process we realized a few things it is not just the patients, but also for a lot of referring doctors or for that matter. A lot of radiologists also this is something new. We were used to predominantly seeing cysts and fibroadenomas in this younger age group. And suddenly that graph is tilting in the other direction. Okay, we are seeing more and more breast cancers. But there are a few challenges here and what are those challenges? Okay, and this is what inspired us to do a literature search and that literature search led us to this beautiful article. Very, very comprehensive article which has been published in Radiographics which we have shared on the link. Non-brake breast cancers in non-brake young women. Non-brake is non-genetic mutation. They have no family history of breast cancer therefore no genetic testing has been done and they are the first cancers in their family whatsoever. So this is a very interesting topic. Why? Because nobody expects to get a cancer, especially so in their 20s and early 30s. And even when that happens because the awareness about this new entity is less even referring physicians don't know how to deal with it. Okay, and oftentimes where we radiologists get confused is they look very similar to fibroadenomas. They are oval, they are well circumscribed, they have what looks like almost you know most of the margins are smooth. So then how do we raise our level of suspicion? That becomes an area of concern in question. Okay, so these are some of the points we want to highlight here that 90% of breast cancers in women less than 40 years of age have no family history of breast cancer. So there are new cancers in the family which means all of a sudden when a woman gets a new onset palpable lump gone are the days where you can sit over it. Okay, secondly, majority of early breast cancers are occurring in non-carriers. They do not have BRCA mutations and there are many challenges associated with it and one of it we already showed that these cancers look exactly like benign lesions. Some of the subtypes rather look exactly like benign lesions. And therefore detection and treatment in younger women becomes a challenge. Okay, although it also is true that only 20% of palpable lumps are cancerous or pre-cancerous and the rest are benign. Have I got disconnected? No, right? No ma'am, no ma'am. And you're continuing to see my screen, right? Yes, yes. And I'm on the correct screen? Yes. Also the first slide we can see of your presentation. Okay, sure. And then I'm on that slide right in here. If you can make it to your first screen, yes ma'am. Yeah, so 20% of palpable lumps are cancerous or pre-cancerous and the rest are benign. That is true. But those 20% give us enough grief and they're so challenging that making their diagnosis in time becomes absolutely relevant. And to add to all this, nuanced palpable lump is the most common presenting sign or symptom, which means we cannot ignore any of these lumps. Of these nuanced breast cancers, about 10 to 11% are in less than 45 years. Okay, younger age, advanced age, aggressive disease. This is the trinity of these kinds of cancers. It's the lethal trinity. Okay, and because they are so aggressive and advanced age, a lot of these young women actually die of cancer. Okay, die of breast cancer. Acute loss of socioeconomic productivity and worst of all, critical disruption of family life. These are young women, they have young families, little kids. So one can only imagine what happens, what the family goes through and eventually when the child's mother dies, when a young family gets disrupted. It is really heartbreaking and first for much grief. So what can we do to change that? First, start by educating ourselves. As a radiologist also, we need to educate ourselves because 10 years ago, 20 years ago, this was not the case. It is in the last few years that the epidemiological trend has started shifting and younger and younger women are getting breast cancer. So therefore, we selected this article for discussion. Non-braca early onset breast cancer in young women. Okay, it is a very comprehensive article published in 2022 in Radiographics. We had shared it on the link also. If you have not been able to open the link for whatever reason, so have not downloaded, go back to Google, download this in the PDF format and give that half an hour to read and study this article. You will land up saving a few lives by just thoroughly studying this article. Okay, and this article is what has highlighted all the points. You know, the points like, you know, we have to know about tumor biology because only when we understand tumor biology, we will understand why some of these cancers are looking so much like fibroidinomas. What are the little subtle differences that will help us make the diagnosis? Why is it so important to make that diagnosis in time? Because some of these aggressive subtypes like triple negative breast cancer or first two positive breast cancers, they increase also rapidly, they metastasize also rapidly and they recur also very rapidly. Okay, however, the challenging part is, we have been seeing an increasing trend of ERPR positive cancers. These were traditionally thought to be good cancers. But somehow, when they are happening in the younger age group, patients are presenting not just with that ERPR positive cancer, but also bone beds. Now, these ERPR positive cancers are the ones which do not metastasize as much to the liver, lungs, etc. They metastasize directly to the bones. They're slow growing, but nonetheless, that is the nature of these. Okay, therefore understanding that part is also important. Okay, so much education is required for us as radiologists to understand and diagnose this in time. Okay, with that intent, we are going to touch upon few of the relevant points that have been discussed in this article. And then after that, we'll open the forum for discussion. Okay, so what does ACR appropriateness criteria say about palpable breast lumps in general? Any woman presenting with a palpable lesion should have a thorough clinical breast examination, no doubt about that. But because many breast masses may not exhibit distinctive physical findings, imaging evaluation is necessary in almost all cases to characterize the palpable lesion. That is the first starting point. Okay, one of the days where, you know, we could just say that, okay, you're young, it may just be more induced palpable lumpiness in the breast. No, we are not going to take that chance with even a single woman. Okay, what are the other factors that we need to understand? Age, how does that affect? Younger age at diagnosis is an independent risk factor for pulprognosis. This is what the article is highlighting on. And therefore, the timely diagnosis in this age group becomes even more important. They are also saying in this article that 90% of early onset breast cancers, what do we mean by early onset? In this particular article, they're calling early onset as less than 45 years of age. So any woman less than 45 years of age is considered early onset. Okay, but predominantly we see women less than 40, which means anywhere between 20 to 39 years of age where there is no screening recommendation. Women, even if they show up, we only do ultrasound because their average is there, no family history. Okay, and these early onset breast cancers are happening 90% in non-carriers. That's the age group where it is happening. And only 10% in carriers, those are the high risk women with two or three first degree relatives with BRCA1 or BRCA2 mutation. So what is happening in this age group is because they have no risk factors, they have no family history. There is no escalated screening. At least BRCA1, BRCA2 mutation carriers, they have some form of escalated screening. In the West, they actually do a mammogram each year, mammogram and MRI each year. Like, you know, if a mammogram is done in January, then they'll have an MRI screening in June. In India, it depends on what the patient asks for, where the patient wants it. But a lot of patients are having an MRI once a year, even in that early age group. But for average risk women, there are no recommendations. Okay, less than 40, there is no screening that is done for women less than 40 years of age. Okay, therefore most women are unaware. Non-carriers like women with average risk, they're detected clinically and therefore typically they are at one stage. Cancer is more than three or four centimeters in size, which have already metastasized to the axillary lymph nodes. In some cases, there are distant metastases even at presentation. So that becomes a challenge for us. Okay, next is the molecular subtype. You know, why do we as radiologists need to know anything about pathology? Because our ability to diagnose this cancer depends on our understanding the molecular subtype. Therefore, we will have to educate ourselves, educate ourselves through reading, through articles, through listening to lectures. That's the way we are going to educate ourselves. Okay, so what happens in age group less than 40? Okay, most of these cancers are more likely to be HER2 positive and triple negative breast cancers. This is the most aggressive tumor biology with overlapping morphologic features with benign etiology, which means they are oval, well circumscribed. They may have gentle lobulations. So immediate thinking because of our education, our explicit learning that has happened over the years is, she's a 23-year-old, I'm seeing an oval mass, there are one or two gentle lobulations. You know, that's fine. This is most likely a fibroid enoma. But at best, I'm going to give this a byrath 3 and call her photofollow. No, we can't do that anymore. Okay, because now we have been educated that triple negative breast cancers can have an appearance similar to a fibroid enoma. So make sure you scan through the lesion properly. Okay, you look for all those subtle signs. You know, are there micro lobulations? Are there any speculations? Do I need to do a biopsy in this case? For a biopsy, would it be worth it to do a mammogram to see if there are any associated features that I can look for? Okay, and even if you have 10% doubt, which is a 4A, 10% doubt that this could be cancerous, don't hesitate to do that biopsy. That is one important learning point we have to understand. Okay, you may feel that biopsy, another expense for the patient in a city like Mumbai, a biopsy can cost anywhere between 10,000 to 12,000 rupees in private. Another 6 to 10,000 for histopathology. Another 6,000, 3 to 6,000 for histopathology. Why put the patient through that expense? That expense of less than 20,000 may actually save your patient's life. Okay, so don't let economics interfere with your medical decisions. That is what this article is saying. Okay, don't let a good clinical judgment and a good radiological decision interfere with additional expense in a biopsy. Okay, and regardless of the tumor subtype, cancers happening in less than 40 years are surgically, even surgically treatable cancers. Initially, they were only localized to the breast, but they have a high recurrence rate and worse prognosis. Okay, therefore we want to be very, very cautious in this age group. What this article says is in less than 40 years of age, triple negative cancers account for about almost 25% of cancers happening in this age group of less than 40. And her to positive cancers account for another 25%. I'm rounding it up. Okay, I'm rounding it up. So 50% of the cancers in less than 40 years of age are TNBC and her to positive cancers. Okay, and in about 40 years of age, they are less than that they are less than like, you know, about 30% of the cancers less than 30% of the cancers will be in this TNBC and her to positive but in less than 40 years of age 50% or more than 50% will be TNBC and her to positive. Okay, so what is it that we need to understand about these about these cancers. Okay, just bear with me through this and this is directly quoted from the article I just tabulated it and put it in a tabular form for everyone to understand but this is what the article says. Like what understanding of the molecular subtypes we need when they say when they are throwing words at us like you mean a little bit her to end rage triple negative. What do they mean, let's understand that. Okay, when a cancer is luminal a. Okay, it is typically estrogen receptor, progesterone receptor positive which is ERPR positive and her to negative. Okay, usually the key 67 C when you ask for a histopathology report, along with tumor markers. These are the things that will be there on in your report histopathology will say invasive ductal carcinoma grade three. Then it will say estrogen receptor positive and then there is some score besides it as radiologist, you know, we got to understand these reports also progesterone receptor positive or negative her to receptor positive or negative key 67. It's given in percentage 12 to 14%, 50%, 60%. It indicates how aggressively aggressively the tumor is growing. Okay, so these are the factors. So luminal a is considered the cancer with better prognosis ERPR positive her to negative key 67 is low level is usually have good prognosis and low recurrence rate. But typically when they metastasize, they metastasize straight to bones. They will even skip the lymph nodes. Okay, that is the nature of the, of this luminal a. Luminal B is typically ER positive PR negative. It may be her to make it will be her to negative also, but these have a higher key 67. Therefore, these cancers, although they are positive, they are intermediate to high grade, and they have a high prognosis, they have a worse prognosis with a higher recurrence rate. Okay, so don't get just happy looking at her to ER positive. But if it is PR negative her to negative high key 67 remember it is luminal beta. What is luminal be like it is ER positive PR may be positive or negative her to will be positive and key 67 can be any level. Okay, what is the prognosis of luminal be like cancers. They grow faster than luminal a and have a slightly worse prognosis. Okay, fourth type. This is that her to enriched cancer. Okay, what does that mean they are typically her to positive PR PR will be negative her to positive and key 67 will be high. So they grow faster than the luminal sub types. They have a higher grade was prognosis. And these are the cancers that will very quickly metastasize to the brain and the viscera lung meds liver meds brain meds. They can be however successfully treated with targeted therapy. Okay, these are the cancers which are very, very effectively treated with targeted therapy. Then there are the triple negative. They are the radiologists worst nightmare. They are ER PR her to negative the key 67 will be higher. They grow very fast. Therefore, they don't give any despo plastic reaction in the surrounding breast issue leading to those world well relatively well circumscribed oval masses. They are more aggressive than luminal a or B. They have the higher grade and the worst prognosis higher rate of meds to brain and lungs. And these are the types which are also very common in Bracka one women younger women of you know all sub types like you know whether your Bracka one Bracka two or no genetic mutation all younger women. This is the highest sub type and in black women these are single. Okay. So let's let's just talk a little bit about the end these triple negative cancers and I'm not going to take you through the images because we are just focusing on what the article is saying to us. Okay. So TNBC like we have been constantly saying on mammography in younger women the breast has a higher density which in decreases the sensitivity. Okay. They even when they see them they're typically round the oval masses with a pseudo circumscribed margin. They typically have no micro calcifications ultrasound is one modality which has the highest sensitivity for detection of masses in this younger age group. Okay. Not as high as MRI do but it is higher than mammography. Okay. Smart TNBCs they may look exactly like benign lungs because so far when they are less than one centimeter analyzing the margin etc becomes a challenge. Therefore, careful assessment of margin for subtle features is important. Rounder shape in when they are early enough is more indicative of sinister lesion like TNBC than oval shape. Okay. MRI typically has the highest sensitivity but remember on MRI the big confusing factor is that they are T2 hyper intense which means on T2 weighted images just like a fibro adenoma or just like a cis they will be hyper intense on T2 weighted images. Okay. But on post contrast images they may have you know some heterogeneous enhancement or remenhancement so occasionally they may have remenhancement therefore that overlapping feature you may get confused whether this is a complicated cyst. Okay. But even one small atypical feature don't hesitate to biopsy. Okay. The prognosis and treatment in these cases high risk of early local recurrence and the peak is at one to three years. What does that mean when a patient a younger woman who has been treated for breast cancer typically a TNBC comes for her first year follow up scans. Well in the first two three years you be extra cautious you look at that mammogram more carefully you look at that ultrasound more carefully because in the first first three years there is the highest incidence of recurrence. Okay. Therefore be extra cautious higher near term mortality rates than other cancers and close clinical imaging surveillance in the first few years is highly recommended. Okay. Despite overall poor prognosis remember these are the cancers that respond best to new adjuvant chemotherapy with complete pathologic clinical response. Okay. Complete response to treatment. They have a distinct metastatic pattern to the lungs and brain but often poor prognosis in late stage of the disease. So how is her to positive cancer different. Okay. In her to positive cancers. They have micro calcifications in them invariably you'll see micro calcification and these are the women who will often argue with you or the guy next will often argue with you. She's a young woman. Why do you want to do a mammogram. Sometimes it is just that one mammogram which will help us look for those micro calcifications and we have discussed this a team number of times. Don't be afraid of doing that one single diagnostic mammogram. We are not saying do a mammogram for every woman who comes in her twenties that is wrong. Any woman just coming for screening who's a 20 year old or a 30 year old average risk woman do a screening mammogram. That is not what we are recommending. Please note this. Okay. But if there is a new onset palpable lump and you have done a ultrasound and you have some concerns about what you're seeing on ultrasound then don't hesitate to do that mammogram one single diagnostic mammogram because that may help you find those micro calcifications which will lead you to the diagnosis of cancer by doing a biopsy in the right time. So how, what do her to positive cancers look her to positive cancers more likely than luminal or PNBC to have extensive and high grade DC is and hence the calcifications so mammogram is strongly recommended in these younger women with suspicious findings and oftentimes these her to positive cancers are highly focal, multi-centric or contralateral. Of course we will see a lot on ultrasound also because in this younger group breast is dense MRI however has the highest sensitivity again in this age group. Again, they are highly aggressive with better static spread. Therefore close clinical and imaging surveillance in the first few years is paramount. Despite overall poor prognosis again this a this particular subtype of cancer is sensitive to a combination of chemotherapy and her to targeted monoclonal therapy. Okay, 75% success rate with complete pathological response. Okay. So this kind of reduces the mortality rate as well as recurrence rate. However, when they metastasize they also metastasize to the brain and visitor. Okay, so what about the luminal cancers. This is the cancer which has the classic speculated masses. Okay, and therefore in younger age group when there are suspicious features or vocal features mammogram will give you those classic speculated masses. Again, we'll find these cancers very well on ultrasound also and MRI has the highest sensitivity. So, the one point to understand is this is the fastest increasing subtype in this age group. Earlier we were not seeing as many luminal cancers, but now we are seeing more and more of these classic speculated cancers in younger women. So why are we so scared of these ERPR positive cancers in younger women who are getting these ERPR positive cancers. We are often getting bone mets. That's why we are so worried about these ERPR positive cancers. Okay, they cause distant disease in about 31% cases and local regional disease in 86% cases. Okay, median survival rate for stage four means when they get bone mets is about 45 months if they are her to positive and 25 months if they are her to negative. So in this subgroup also both subgroups overall 10 year disease free survival is less than 20%. So as you can see, repeatedly our discussion is coming up around this point that overall disease free survival in this age group no matter what the subtype becomes a little challenging, a little bleak. Why is that happening and how are these cancers different from BRCA carriers. So in the same article discusses that in BRCA carriers what happens is typically we see triple negative breast cancers in BRCA one and in BRCA two we see ER positive and her to negative cancers, but non BRCA carriers are predominantly prone to TNBCs and her to positive cancer with an increasing incidence of ERPR positive subtype. Okay, imaging features we have we have extensively discussed. What about screening guidelines for BRCA positive patients that are well established screening guidelines, whereas in non BRCA carriers there are no screening guidelines to add to all this the treatment in is about the role of risk reduction surgeries. Some of these BRCA one or BRCA two carriers, they may have prophylactic mastectomies or prophylactic pooferectomies to reduce their risk of getting cancer. There is no such guideline for non BRCA carriers for the right reasons. They have had no risk factors. So why will this discussion also happen. Okay, so there is no question about that. Okay, having said that, therefore when cancers happen in this age group, they're very aggressive. Okay, then prognosis, because all these risk factors have been identified risk reduction surgeries are put in place. So the prognosis is better in BRCA carriers. Now, despite the fact that they are BRCA carriers, but in non BRCA carriers, because there is no awareness, we don't know which woman is going to get cancer, invariably they are advanced stage cancers with higher recurrence rates. Therefore, the prognosis in this subtype is much worse. Okay, so what are the other challenges and barriers that this article has discussed. This article has discussed that there are these inherent, inherent disparities beyond screening, not just screening, screening, screening, BRCA one carriers have screening. Oh, average risk women do not have screening, but beyond that, there are other challenges, like lack of awareness and we see that all the time, not just amongst patients, but amongst physicians also that cancers can happen in young women as young as 20s is something new. So this awareness has to increase lack of resources, and that is something we face across the board from not to South East to West when we go to different parts of our own country. There are certain cities, certain towns which are far better equipped to handle treatment of cancers to, but not every, every part of the city and the every part of the country is equipped to do that. And these healthcare disparities also lead to poorer prognosis. What about race and ethnicity? It is found that like within the Indian population, we don't know how it works in different parts of the country. But as per this article that is that we are discussing, they find that the race and ethnicity also plays a big part in the incidence of cancer amongst black and Hispanic group is more than that in non-Hispanic white women. Okay, so three times higher incidence of cancer in less than 40 years of age in black and Hispanic women. 61% more likely to have triple negative breast cancer. Higher proportion of stage three and stage four cancer. These are the factors to consider for prevention strategy. So, you know, there are certain subgroups of populations that we can target more aggressively such that we can find those cancers early enough. So, what is the impact of this cancer? Why do we need to even bother so much about it? Okay, a few young women get cancer, but it leads to a lot of problems for these young women. Remember that they are less than 40 years of age, so they have greater psychosocial morbidity for a quality of life, decisions regarding reproductive health. Now they have been suddenly diagnosed with breast cancer. This woman is in her 20s or early 30s. She's just got married, just started with her career in life and she's not had kids yet. Then the question comes, what about my ovaries? After chemotherapy, you know, am I going to get a chemical menopause? Can I do anything about cryoprevention of my oocytes? And of course, there are body image issues, issues related to sexuality and relationship. And these are real life issues, okay? So, how do we deal with all that? Do we have any peripheral care in the form of a psychologist, in the form of a gynecologist who specialized in care related to cryopreservation or making patients understand how to deal with the other factors that come along with the treatment of breast cancer in younger women. So that is an area which is an area of work, okay? And also, you know, because there is a higher recurrence rate, how does this impact the life of a young family? It's not just that one patient, but it impacts the life of that entire family. Are we able to come up with strategies? The strategy is recommended as for these articles and they seem practical at this point. Population-wide early breast cancer awareness. They are not talking about screening, but let's at least start with awareness, like having advertising or, you know, on social media, on bigger platforms, you know, increase the awareness. Because there is no pain in breast cancer, women don't realize that there is anything wrong. So all those delays can be avoided. Increase not the awareness amongst patients, but also in the medical community, like the OBGYN and also radiologist. Because we are the primary people where the patients get there first for imaging. But because of the overlapping imaging features, sometimes we may also get confused. So we also have to get ourselves educated about these subtypes and this paradigm shift of breast cancer in younger women. What is the NCCN recommendation, annual breast clinical examination after the age of 25 years? It may not be a bad idea. I know clinical breast examination does not have, it is impossible to make a randomized control trial to figure out what happens, how many cancers are detected after clinical breast examination. But, you know, having some safety net in there, maybe better than not having any safety net in there is what this article recommends. So as for this article, less than 40 year old early onset breast cancer, early education and awareness to mitigate these challenges and do a proper diagnosis. And to be aware of the overlapping features as radiologists between benign and malignant breast patients, and therefore understanding the molecular subtypes becomes important. That is the importance of understanding the molecular subtypes, not just, you know, of course, to understand the prognosis, etc. But if we know more about molecular subtypes, we will understand how to differentiate between the benign appearing features of a fibroid enoma versus TNBC. How does her to positive, those microcalcifications who went to ask for that mammogram, all these factors will help us make proper diagnosis in time. And timely diagnosis and treatment are the cornerstone for improved survival. So with that, I will, I will just stop right here. This is a very, you know, heart wrenching little video. I wonder whether I should show it. But maybe not in the interest of time, you only have 15 minutes for question answers. Maybe we will reserve it for some other time. But I will stop sharing the screen here. And this is exactly what we have taken from this article. I would recommend I would strongly recommend every single one of you to read this article. And if there are any questions or if you have any, any pertinent points to make, may I kindly request you to take over here, please. Thank you for taking us through the article, but not only the article but such an important topic of discussion. And making us aware that even the young breast masses may turn malignant. It's not that they are always benign and we can just leave them like that. So that is very important. Till now, there are no questions in the chat box, but I would like all of us to share if you have any doubts or anything we asked regarding this particular topic or anything relevant to breast imaging in young breasts. So basically just a quick revision like if somebody has a young girl around 30 years of age has some breast lump feeling. Then first, like how to go about imaging, starting with ultrasound and then it's required next step to be done. Yeah, that's correct. So any young woman who presents with a new onset palpable lump, we always start with a breast ultrasound women less than, you know, typically less than 40 years of age 30 to 40 is considered, considered the age group where you can start this way or that, but as a rule for women less than 40 years of age, we always start with a breast ultrasound. On breast ultrasound, if there are any suspicious features, you know, if it is a plastic fist or a plastic fibroadenoma, we stop right there. You know, we do not want to, we do not want to start over calling also, but at the same time if there are concerning or suspicious or for that matter indeterminate features, I'm not very sure. Let me just get a quick mammogram done. Then we definitely do a mammogram in those cases. Okay, after the mammogram and tomosynthesis, sometimes we will see signs like pleomorphic microcalcifications or peripheral speculations, which really help us make the decision whether to biopsy or not biopsy. Okay, based on that, we make a decision to biopsy. Okay, we go ahead with a biopsy. People often ask me, should we go ahead with an MRI first before doing any invasive procedure. But a biopsy is the one test which will give us tissue diagnosis and therefore if you have indeterminate or suspicious features based on your initial ultrasound and mammogram, then go ahead with a biopsy. Okay, and after the biopsy is done, if need be, depending on the density of the breast to look for any additional lesions, extent of disease, one can also do an MRI. So that's how, that's the protocol typically followed. So we have questions, like one of the question is, which are the ultrasound features, one should look out to upgrade these lesions to byreds three or two byreds four in. So this is a decision to be made. Yeah, so we follow the stavros criteria. So we look at the shape of the mass. We look at the margin of the mass. We look at the heterogeneity of the mass. We look at the posterior acoustic features of the mass. So when we say, what is the shape of the mass, an irregular mass, classic sign of breast cancer. If it's a smooth oval mass, then classic sign of, you know, a benign lesion such as fibroadenoma. Well, circumscribed anechoic mass with posterior thru transmission and smooth margin, classic sign of assist. Okay. But if there are micro lobulations along the margins, okay, angulations along the margins, then we that raises our level of suspicion. If it is a heterogeneously hypoechoic mass, you know, there are non-uniform cystic spaces within the mass, then it increases our suspicion for cancer. And because we were discussing the article today, I did not include the images, but on 4th May, we are having a full day course on breast imaging for the Indian radiologist. And in that course, again, we will be taking this topic on young female breast at that time, I'll actually walk you through the images and show you one by one all the features on imaging, how to differentiate between the benign classic, benign classic malignant in this age group and how to look for those subtle features. But overall, these are the things we go by the shape, the margins, the overall ecogenicity, the posterior artifact. We base everything on those ultrasound features to make a decision without biopsies or do not want biopsies. Thank you for that, ma'am. And one more question is there, what is the role of PET CT management of breast cancer? PET CT is for staging. So, PET CT is not done when a patient presents to you with a nuanced palpable lump. So, nuanced palpable lump, you always start in a younger woman with the ultrasound, mammogram, biopsy. And then once we have a diagnosis of say a triple negative breast cancer with the axillary lymph node, which looks positive for metastasis, then the treating oncologist will ask for a PET CT to see if the breast cancer has spread to any other parts of the body, liver, lung, bones, brain, whatever it is. So, it is for staging. PET CT is not for initial diagnosis, PET CT is for staging. So, just one more, they're asking that should we do more biopsies even for fibroidinomas? Not for classic fibroidinomas. That is not the message we want to give the audience. However, given the increasing incidence of breast cancer amongst younger women, and given the increasing incidence of those overlapping features, what ACR appropriateness criteria is recommending is for nuanced palpable lumps which are fibroidinomas, do a 6, 12 and 24 month ultrasound follow up. So that if any of these lesions start increasing at the end of 6 months or 12 months, you know you have to biopsy. Just to keep the patient in the safety net. But in our practice in India, we find that patients invariably don't land up coming for follow ups. Therefore, that first time when the patient comes to you that initial assessment becomes important and having that protocol in your own mind of looking through all the features of that lesion before you come to a decision whether to biopsy or not biopsy becomes important. But every single fibroidinoma where we are absolutely certain this is a fibroidinoma, you need not biopsy just because you want to biopsy. No, that is not recommended. And also, what advantages of tomosynthesis? Yeah, tomosynthesis does have its own rule. And we find that in dense and heterogenously dense breast also. Sometimes because it is, you know, slice by slice imaging. Sometimes this well circumscribed mass, we will just see some peripheral speculations along one margin. And that may help us come to a decision that, okay, this definitely needs a biopsy. Although it is oval on ultrasound, although I'm seeing through transmission because it is such a cellular mass. Despite of that, you know, on tomosynthesis when you see peripheral speculations along one margin, you know, you want to. There is a high level of suspicion for cancer and you have to go ahead with the biopsy. So, tomosynthesis has a has a definitely a role in in making the decision of biopsy on the maps. Thank you ma'am once again for taking these questions. And I think they can all be questions in the Q&A section. Again, I would like to remind you that the entire video will also be shared on the YouTube channel of Indian radiologist and we should revise this once because it's difficult for us to actually go through the articles and to take out time but when we have these kinds of discussions, we actually update our knowledge quickly and very conveniently. So thank you ma'am once again for your time. And as ma'am told we are coming up with a complete full day online masterclass on breast imaging which will be headed by Dr. Ma'am and we have a comprehensive coverage of all the modalities pertinent to breast imaging. And I have already shared the links in chat box to register for the same. So kindly to join us for the online event as well as the upcoming onsite, complete MRI imaging course by Dr. Deepa Patrasar and team. Again, I have shared the link for the same as well on the chat box. So I think ma'am with this we can come to the conclusion of today's session of Jarnal Club. Yes. Thank you so much Mithusha and thank you for to everyone who has joined on this Sunday morning given time from your family commitments to upgrade your knowledge. So we truly appreciate that and I highly recommend every one of you please go through this article. It is truly a game changer. It will upgrade your knowledge and help make that right diagnosis and save a patient's life. So without any further ado, I thank you all. Thank you especially to Mithusha, Dr. Deepak Patkar, Dr. Sanjeev Mani and everyone at Indian Radiologist for giving us this opportunity to upgrade.