 Thank you, Mithusha, for the kind introduction and a very good morning to all the breast-emitting enthusiasts out there. I really like the way Shilpa has titled the talk, Thank You Shilpa for inviting me, the language of breast-emitting. And I'm really happy to say that we as breast radiologists, you know, to kind of quote the idiom that is very famous, speak and talk the same language. And all this is made possible by the presence of a very robust reporting and imaging system in place, which is called as the Bayerad's reporting system. Now I want to just kind of reiterate that reporting is nothing but communicating what you are thinking in your mind to the clinician, and that is the medium is your report. So this is an example of how you will not communicate in your report because it really doesn't give you any extra or additional details. So the same thing, if I, you know, a 50-year-old patient who was reported as just as a lump measuring so much and so much, if we do the correct technique and reported it correctly, then how do we actually go ahead and report this patient? Now this, when she was imaged on ultrasound, you see that this lump was a large cyst in the retro area in the region, and you have certain more findings on the mammogram. So I would like to start off with a quiz asking, or any of you who wants to take it, is that which biurides would you assign to this breast or to the palpable lump? So the thing is that if you have multiple lesions in the breast, you remember that those, the more sinister biurides will trump your lower biurides, and the final assessment category is going to be the worst biuride, which is in this case, a biurides fight. So this biurides reporting system was initially developed in 1993. So it's gone undergone multiple, multiple revisions, and you know, so it is something that really standardizes the reports across the board. It acts as a very good communication tool with the clinicians, and it also serves as a quality assurance tool for us. So it gives you a real, you know, standard reporting format, which we can all follow in our day to day practice. And we are going to look at each and every point of this, starting with the first point, which is the indication. Now you are supposed to mention in the report whether this, you know, the patient who has come to you is just for a routine screening evaluation, or is come to you for a diagnostic evaluation means that the patient has some breast related problem. It could be a breast lump, it could be a discharge, something of that sort. All right. Now, the first important thing that you will mention in your report is what is the breast density in that patient. Now this is nothing but a subjective assessment of the percentage of fibro-glandular tissue that is seen in the breast. So it ranges from a purely fatty-appearing breast to scattered fibro-glandular, which is type B, to heterogeneously dense to extremely dense. So type A, B, C, D, the importance here is because in type C and D, because of the breast density, you might miss out on small cancers. Third most important finding point that you will include in your report is the descriptors. Now you can either have a mass, asymmetry, architectural distortion, calcifications, and certain associated features. So let's just revise quickly before we come to the final conclusion or the assessment categories. So a mass is something but nothing but a three-dimensional structure, which is seen in two different projections. We have to remember that it has a convex outer border. It is denser in the center than in the periphery, and you describe it with its location. Location we all know, which breast, then which quadrant and clock face location that it exists in, you have to give the distance from the nipple and also mention whether it is in the anterior middle of the posterior depth of the breast. Now, the shape of the mass, I remember the pneumonic ROI, so that which is round is round, then oval, and that which is not round or oval falls into the irregular category. Then you describe the density. Density of the mass is described as comparison with equal amount of surrounding fibroglendular tissue. So you have a mass here, which is containing fat density. It is lesser or lower in density to the surrounding fibroglendular tissue. Here you have a mass which is equal in density, and here you have a mass which is higher in density as compared to the surrounding glendular tissue. Now, the most important descriptor of a mass is going to be its margin. So let us spend a couple of minutes and understand the margin descriptors that are described in the pirates. Now, when more than three-fourth of the margin is well seen and well circumscribed, you are going to call this mass as a circumscribed mass. Now, conversely, if you have a margin which shows these irregular, you know, I call them sunburst kind of appearance, then these are nothing but speculation and this becomes a speculated issue. Now, if you have these little lumpy, you know, bumps along the margins which are more than five in number, this margin is going to be a micro-logulated margin. And let us understand these two margins. You have a margin, you have a mass where the margin is seen. But in spite of being seen, you do not see the distinctiveness or the edge of the margin or the edge of the mass very properly. So this becomes an indistinct margin. This is an obscure margin where you have a mass where the part of the margin is not seen because it is obscured by surrounding fibro-landed tissue. Now, the importance is that the indistinct margin is a bad margin. So you have to remember that this is not a good margin to have. So except circumscribed, all these margins are suspicious margins. Now, let us talk about the other descriptors. Asymmetric is nothing but the unilateral deposits of fibro-landed tissue that do not conform to a mass. Now, it is usually a one-view finding and occurs as a superimposition shadow or as a result of summation artifacts. The other types of asymmetric are global, focal, and developing, which are seen in more than one projection. Then, as opposite to a mass, they will have concave outer borders and they are also interspersed with fat areas. Now, coming to the third descriptor, which is also the third most common appearance of non-parallel breast cancers, and that is architectural distortion. It means simply that the architecture of the breast is distorted, but you do not see an associated mass in its center. Now, this can be a primary finding or an associated finding. So how does it look like? It looks like radiating thin lines or speculations, which are seen. You can see a focal retraction of the pancamel edge or blurring of the fat fibro-landed juction. You can also see straightening or thickening of the coopers ligaments or compression of tissue around the mass. Now, calcifications are something that we saw in great detail in the beautiful talk in by Dr. Rupa. So I will just quickly run through them. We know that there are morphologically benign and morphologically suspicious appearing calcifications. What are the benign appearing calcifications? We saw them, skin, dystrophic popcorn, the calcifications of plasma cell, mastitis, milk of calcium, and punctate calcifications. And you have these suspicious appearing calcifications just to revise cos-heterogeneous, fine pleomorphic, and fine linear branching with fine linear branching having a positive predictive value of almost 70%. Again, just to quickly revise, you have distribution, which is either diffuse. It is grouped linear or regional and segmental in distribution, okay? So what are the associated features which you may describe in addition to these four findings that we saw? That is mass, then you saw asymmetry, architectural distortion, and micro calcifications. You may have associated skin thickening or nipple detraction. You may have, this is the skin thickening. Then you have, you may have, you know, trabacterial thickening in the breast. You may have presence of axillary adenopathy, and all this has to be put down in your report. Now, there are certain special things that you can just describe, and you do not have to give a descriptive description as such. One of them is an intramamary node. So intramamary nodes, you can just put down an intramamary node was seen as such and such a position in the breast, then presence of skin lesions, and solitary dilated tongue. Now, after you put down all this, you have to make a note as whether this was, you know, compared with any previous imaging which was available or not. Now to quickly run through ultrasound biorects, because, you know, they come concomitantly a lot of times when we do a mammogram, we have to take the patient to the ultrasound room and screen the patient on ultrasound. We have to remember that the composition is differently labeled. You have either a homogeneous or a heterogeneous appearance on ultrasound with fat or fibroclantular elements being predominantly seen. Now, in the cases of masses, besides the, you know, description of shape and margin, we also give the orientation of the mass. So whether it is oriented parallely to the breast tissue or anti-parallel, then we have what we can describe as eco-appearances ranging from anechoic to hyper-echoic to whether they're hypo-echoic, iso-echoic or to the heterogeneous lesions. And very importantly, we can also describe the posterior features of the mass, you know, whether there is, you know, posterior acoustic enhancement, whether there is just shadowing posterior to the mass or there is no really remarkable feature or there's a combined pattern. So all these can be added in the description of the masses and you come to extra findings, that is presence or absence of vascularity, that is the Doppler findings. Then we can also add on the elastography findings, but you have to remember that it really doesn't change the bioregist assessment category, it just adds to the radiologist's confidence, right? Now, the most important part is we put all this information together and give a logical conclusion to the patient, right? So these are the seven assessment categories of which I personally feel zero, which needs additional imaging, is something that we should not put down on our reports. We should try and do everything possible to call the patient back, complete the imaging and give one of the rest six possibilities. Now, by that's one, you've done the mammogram and you found that it's a nice fatty breast, there's nothing in this mammogram that really stares out at you. So you give this as a category one or negative, essentially 0% likelihood of cancer and the patient goes back to routine mammographic screening. So it is obviously given in the screening setting. So let's think about what happens if a patient has come to you with a complaint. Like she said, I have a palpable mass, but you do a mammogram and you actually don't see anything on a mammogram and you really want to give it a barrage one. Can you do that? Yes, you may, but at that time, you may have to give an additional recommendation that you need a surgical consign or a surgical reference or you may need to do a tissue diagnosis of the palpable lump, in spite of this being a negative mammogram or a barrage one category mammogram. Now, what is a barrage two category? A barrage two category is nothing but a normal assessment with added description of a benign finding. So it is very commonly given in a follow-up case of a breast conservative surgery in cases of calcified fibroidinomas when you've seen vascular calcifications or intramarimany lymph nodes in presence of breast implants or fat-containing lesions like lipomas or hamatomes. Now, this is an example of a patient who has multiple bilateral breast masses, which appear partly circumscribed really. And when you put the ultrasound on her, you've confirmed that all of them are nothing but cis. So multiple bilateral breasts, if you visualize the breasts and see that there is no inter-cystic solid components, becomes a barrage category two or benign, there is essentially 0% chance of cancer and the patient goes back to routine mammogram screening. Now, this is another example of a focal asymmetry which you see in the upper outer quadrant of the left breast. Now, this focal asymmetry, you take the patient of the ultrasound and confirm that it is nothing, you can use either TOMO or you can use an ultrasound and confirm that this is just nothing but a summation shadow and this is nothing but asymmetric prominence of glandular tissue, again, a benign finding and this becomes a barrage too. Now, you've come to this case of a post-operative patient who's been operated, then irradiated and has come to you for a follow-up. You see this again, a area of focal asymmetry in the breast which is nothing but an organizing serum. You see the surgical staples, you do not see any added mass. This is actually just an expected post-operative sequelae and this becomes a barrage too. Now, this is a well-circumstried mass with coarse calcifications within it and it follows all other features of a fibro adenoma. It is oval, it is wider than tolu, it is well circumscribed with coarse calcification and this becomes a barrage too. Now, sometimes while giving a barrage too, very often I have students who ask me, ma'am, should we describe the intramambulance movement? Should we describe the skin-based finding? I would say yes, more often than not. Put down the finding that you see, whether to describe it or not, if that is the question in your mind, you're better off describing because eventually if this patient goes off to another radiologist or not, you don't want somebody else confusing skin-based lesion for something within the breast or something like that. So, it's better to put it down. You can give this in the screening and diagnostic setting. It is also to be given when you have bilateral and large reactive appearing axillary lymph nodes, right? And very often than not, you really don't need to do anything for these barrage to lesion, except a follower, but you can very rarely recommend management in cases of infected cyst or abscesses. Now, coming to the barrage five category, now these are highly suspicious lesions and these three lesions straight away go into this category. Which are they? You have speculated high density masses, then you have irregular or speculated masses with pleomorphic calcifications and you have fine pleomorphic calcifications which are on a linear or segmental distribution straight away by that five category, right? So, let's look at the examples. You have a speculated increased density mass lesion which appears highly suspicious and greater than 95% chance of cancer. Now, this is nothing but a large irregular mass lesion with pleomorphic calcifications within it. Again, this becomes a barrage five lesion. And here you have these fine linear branching and pleomorphic calcifications in a, actually this is more than, it's almost like a regional distribution and this is also a barrage five category, right? You also have to describe the associated features with the mass lesions and you have to put down presence of overline skin thickening. You may have enlarged abnormal appearing axillary nodes. All these features have to be described in your findings, right? So, we finished with barrage category one, which was negative. Barrage category two, you saw finding just definitely benign. Then we looked at the obviously malignant category that was suspicious and barrage five. Now, let's come to barrage four. Now, something that appears suspicious to you where you really want to consider a biopsy, but it is not falling into those prototype three that we described as barrage five become barrage four, okay? Now, barrage four actually has a wide range of probability of breast cancer and it ranges from two to 95%. So, it is further subdivided as three, okay? You have three categories in that. You have four A, four B and four C. Now, four A we use when there is a low suspicion or almost up to 10%. And this is typically seen with atypical solid lesions which are actually fibroidinomas, but they are not calcified or you have complicated cis, these become four A category lesions. Now, you have indistinct masses and amorphous calcifications falling into the four B category, 10 to 50% of a positive predictive value. And you have four C, that is anything that looks suspicious, but does not fit into the barrage five category becomes four C and it definitely needs to be biopsy to rule out breast cancer. Now, let's look at this case. You have a focal asymmetry which is there in the upper of the quadrant of the left breast. The magnification views shows you that this asymmetry hides a small mass lesion. Now, you've done the ultrasound. You see that this is an irregular mass lesion with indistinct margins and it is what we call as taller than wider. It shows a speck of vascularity. It does not fall into the typical three that we describe, but yes, this is very, very suspicious. So this becomes a biorad's four C category. Now, again, you have an increased density lesion with indistinct margins and when you put this patient under ultrasound, you see that this is nothing but an irregular lesion with densely packed equals within. And this was nothing but a patient of an abscess with IGM and you had an enlarged lymph node as well. Now, this becomes a biorad's four A category, right? Then you have, this is a biorad six. It was an already proven case of breast cancer on the opposite side, which came for a follow-up. There was a grouped amorphous calcifications in the opposite breast and therefore this was given a category as four B and these were biopsied and it was luckily for this patient, it was not malignant, right? Now, you come to the category three. I left it especially for the last because I want to go through it, just to reiterate a few points. Remember that when you're putting something as category three in your mind as a radiologist or as an imaging person, this lesion has to be benign. All right? It has to be benign, but it is not falling into the prototype benign. Therefore you are doing something additional and that is you are following it up, right? So it is greater than zero, but less than 2% chance of malignancy. So in your mind, remember, it has to be a benign lesion, right? So what's the protocol that you follow with category three lesions? You do a six-monthly evaluation and you do this for a two-year leave period and the end of two years, you either downgrade this lesion to BioRATS 2 or if there is a change in between, then you upgrade it to BioRATS 4 and biopsy the lesion. So we had Dr. Rupa tell you, you have this solitary group around calcifications is one thing that falls in a category three lesion. Then you have a non-calcified solid mass with circumscribed margins, that is what we call as a prototype fibroadenoma without the coarse calcification and you have a focal asymmetry without associated calcifications or distortion, again, falling into the BioRATS 3 category. Now, just quickly to run through the ultrasound BioRATS 3 as well, again, you have the circumscribed oval solid mass lesion, again, your prototype fibroadenoma without the coarse calcifications, you can have an isolated complicated cyst or clustered microsys. These may fall into category three. Then you have areas of fat necrosis. These, if you are quite certain that it's closed or it's post-surgery or something and you're pretty much certain that this is an area of fat necrosis, you can follow it up as BioRATS 3 and post-operative breast. Now, these are the categories that you may, the distortion which you see in cases of post-surgical scar this may be put into this category and followed up. So let's look at a few examples. Now, this is nothing but a fibroadenoma which looks like a fibroadenoma. You have an oval-shaped lesion which is hypoechoic which is wider than TOLO and it does not show calcifications but margins appear pretty circumscribed. So you are going to call this a BioRATS 3 lesion and follow it up. Especially if this is the first time that you've seen this lesion in this patient. Next, you have an area of focal asymmetry. Now, this focal asymmetry you've taken the patient to ultrasound and you've seen that this is asymmetric prominent glandular tissue and there is no associated mass and this patient, there was an area of few small cysts in this region. This goes into category three. Now, this is a fairly circumscribed increased density lesion in the left retro area of the region which you put the ultrasound and see that this is nothing but a complicated cyst. So this becomes a BioRATS 3, okay? Now, the category six is nothing but you've imaged the patient, you've done a biopsy, you know that it's proven cancer but you've imaged the patient again before the final definitive surgery has occurred. So this can be because you've done a second opinion on this patient or you've done a monitoring post-NACT or you've re-looked at the patient after the surgery with positive margins. So any of these cases, you will give category six. Now, this is an example of a patient who was clipped prior to NACT and now she's followed up, the mass is completely gone. So we've acquired this lesion for the surgeon to excise and this becomes a BioRATS category six lesion, right? So I just want to reiterate that you have to make sure that your report and your findings gives a clear and concise message to your clinician. We saw BioRATS five lesions, the three prototype lesions. You have to remember that tissue diagnosis is mandatory. Those lesions which are circulated mass lesions which are not the irregular mass lesions with pre-omorphic calcifications or fine linear microcalcifications but are suspicious become BioRATS four and these also need to be biopsied. BioRATS one we saw negative, if we usually give it in the screening setting very rarely you can give it in the diagnostic setting but you need to add this at random, right? BioRATS two, bilateral multiple well-circumstried lesions are given these categories, especially you have bilateral multiple fibrodeanomas, bilateral multiple cis, you may describe the largest or the clinically palpable lesions in this breast. And BioRATS three again, let me reiterate that this has to be given when you have a benign diagnosis in your mind and not when you don't know the diagnosis. Just to end, this is an example of a patient who has a solitary dilated duct in the breast patient she also has a skin-based lesion. So let's see what BioRATS would you assign to this imaging. I would be happy giving it a BioRATS four because I was not able to demonstrate vascularity anywhere but you have to remember that the solitary dilated ductal system with or without vascularity goes into the BioRATS four category, right? When you have a lesion in the breast with multiple findings like you've had, you have a lesion with a margin which is partly circumscribed or speculated. You remember that the speculation will trump the circumscribed margin. So worst imaging feature of the lesion will decide your final conclusion in your mind. In multiple masses, which we saw like if you have a large palpable cyst and three, four speculated margins, it is the worst lesion category that is going to trump the other lesions, right? So it is going to be the worst category that is going to be assigned. Follow the correct sequence, right? Follow the mammogram first and then the ultrasound. So there's no chance of missing things like architecture distortion. Remember in certain cases we can directly say that this is an intramammary node, this is a lipoma, this is a hamartoma. We really don't need to do anything further. Axilla always assessed with the breast. We mentioned that when you have bilateral axillary nodes which appear reactive, it becomes a barrage two. At the same time, enlarged nodes in one axilla becomes a barrage four, right? And we really don't end here. We have to do a radiopathocardons and that is really absolutely mandatory. So I think I will end here and thank you all for a very patient hearing.