 Amit for so much patience with an old woman. So the breast imaging reporting and data system provides us with standardized breast imaging terminology. It gives us a standardized reporting format and it gives us assessment categories which are fairly consistent amongst the modalities which we use in breast imaging and hence we can convey pretty effectively and clearly our findings our impression of the findings to the clinician as well as to the most important person the pathologist in the patient management system. So before I start off with the descriptors there is a section on general considerations in the ultrasound by rats fifth edition which we are following right now it's on breast anatomy techniques and factors that optimize image quality which are very important but that's something that I'm not going to dwell upon in this lecture because of the time constraint but I would like to mention that every report that we start in ultrasound we must make a comment on the tissue composition. So what do we see? If we see a breast which has a lot of fat predominantly fat breast fat we call it homogenously fatty if we see a lot of glandular parenchyma like we see here we call it homogenously fibro glandular and if we see a variable proportion of fat and fibro glandular parenchyma we call it heterogeneous. What are the descriptors for feature analysis of lesions that's the crux of this talk but before I go on to tell you about all the descriptors I have some quiz questions for you. So we are going to do this quiz right now all of you will poll and the results can be either shared or they can be kept with the admin and we will again discuss the same cases at the end of the talk. So this is case one you need to apply the by rats descriptors the lexicon onto this and say which one is the most appropriate description. Please use polling for all those who are in here another maybe five seconds and we'll move on to case two please. Okay we'll hold that see for this one we are not commenting on it right now and we'll see this again at the end of the talk. Okay case two now that's case three now can you see the case or is it is the poll question on it right now I hope you can see the image admin are we doing fine with the cases? Okay great so now we'll go on to the descriptors and the crux of this talk. So the mass descriptors are five basic descriptors shape orientation margins echogenicity and posterior features let's go through each one of them. For the shape it can either be oval or egg shape like we see here two to three gentle lobulations that we see here we don't need to comment upon and we can just call it oval round when we see a round ball spherical and anything which is not oval or round is given as irregular please remember that irregular is a shape it is not a description for the margins. Orientation look at the long axis of the lesion and see whether it parallels the skin line anteriorly if it does it is said to be in parallel orientation and if it doesn't like we see here it's perpendicular long axis perpendicular to the skin it is said to be not parallel or anti-parallel margins what are circumscribed margins when there is an abrupt transition between the margin of the lesion and the surrounding tissue it is said to be circumscribed like we see here if not they are called non circumscribed now if you're describing margins as non circumscribed you have to further say what kind of non circumscribed margins are these are they indistinct where you just can't make out the margins of this lesion are they micro lobulated now these are not gentle lobulations these are tiny bumps on the surface of the mass which are actually like this that's why I put this figure here are they angular do they make acute angles with the surrounding tissue like we see here or are they speculated look at the lateral margins of the mass and you will be able to see these alternating radiating hypo and hypoechoic lines and these are speculations mass echogenicity anechoic we know what that means clear contents isoechoic so what do we compare it with we compare the echogenicity of the mass with the surrounding fat if it is the same it is said to be isoechoic if it is darker it's hypoechoic if it's whiter or brighter it's hypoechoic and if it has a wearable echogenicity some areas are hypo some are hypo it's called heterogeneous another important echogenicity that we should know about is complex cystic and solid if you have a cystic lesion with a solid vascular component like we see here we would describe it as a complex cystic and solid lesion posterior features what effect does the mass have behind it posterior to it if there's no change in the echogenicity of the posterior parenchyma you would say that it has no posterior features if there is darkening or blackening like we see here it is shadowing if there is bright there is increased transmission of the sound beam behind the mass it is known as enhancement and if there is a combined pattern parts of the mass are shadowing and parts of the mass are causing posterior enhancement it's known as a combined pattern of shadowing calcifications so this is the next category or the subpart in the ultrasound byrads we no longer use terms like micro calcifications or macro calcifications but we look and describe whether we see calcifications within the mass like we see here coarse calcifications in these fibroidenomas or this highly suspicious looking mass with tiny echogenic foci these are also calcifications within the mass look carefully around the mass you may pick up tiny echogenic areas around the mass like this these are calcifications outside the mass and sometimes with our very high resolution machines we can even pick up nicely secretory calcifications like we see here very rounded benign appearing calcification within the duct or intraductal calcifications now the next subheading in the ultrasound byrads are the associated features and we'll quickly go through each one of these so the first one is architectural distortion for the longest time I didn't know what architectural distortion meant I would read about it but I didn't know how to describe it or how to explain to somebody what it meant very simply put it's the effect that the lesion is having on the surrounding tissue so you just have to look at the surrounding tissue or the area of abnormality what is happening around it and we saw that Rupa very nicely showed us about a mass on mammogram with surrounding architectural distortion or secondary architectural distortion here is one such case on ultrasound you see a mass you see duct extension but see what's happening to the planes the mammary interfaces are completely blurred you see that the tissues are kind of curving in concaving into the mass this is surrounding architectural distortion one must also look carefully for duct changes which could be just an increase in the caliber of the ducts or it could be abnormal arborization or branching pattern of the ducts like we see here skin changes normal breast thickness skin thickness is two millimeter except in the nipple area now in this you can clearly see that the thickness is increased what does breast edema look like you see echogenic fat like you see here and you see these little clefts anechoic clefts which is nothing but fluid within the parankalma and this is representative of breast edema sometimes you have a mass which has completely infiltrated the overlying skin this was one such an ulcerated mass which was completely visible on the exterior the other associated features which are important are vascularity if a mass has no vascularity within and your settings are all good you say that there is no vascularity or vascularity is absent if you have vascularity within the mass it also helps to see what is the branching pattern of those vessels we know new vascularization in cancers will cause an abnormal branching pattern of the vessels like we see here and one must always pay attention to the vascularity of the surrounding tissues this is the same case where we saw dilated abnormal appearing ducts next to the mass and look at the periductal abnormal vascular signals rim vascularity is usually seen with inflammatory conditions particularly the bacterial breast abscesses and you see a complete rim of vascularity but no vascularity within elasticity assessment if you have the software please go ahead and you can comment on whether the mass is soft or it has an intermediate hardness or it is a hard mass now the next section in the ultrasound byrides pertains to the special cases and there's a whole list of special cases which actually has expanded in the fifth edition let's look at examples rather than go through this long list simple cyst we know what that looks like anechoic thin imperceptible walls no vascularity clustered microsys when you see tiny cysts which are 1 to 3 to 4 millimeter in size bunched up together it is known as clustered microsys usually these are benign if you see it in the background of an altered cystic you know change in the breast you can conveniently say that these are likely benign complicated cysts you see a cyst but the contents are not clear you see homogeneous internal echoes that's a complicated cyst axillary nodes you can get normal reactive appearing nodes but you can also get these ugly suspicious nodes with a loss of hilum you can look for intramamory lymph nodes and you have to comment on them these are all special cases listed look carefully at the skin this was a skin cysty circuses a sebaceous cyst which had breached the anterior mammary fascia and had the infection had spread into the breast implants are also listed under special cases as is fat necrosis just a word about this if you were ever to see a lesion like this on ultrasound what would you do next you should do a mammogram if you see that this lesion contains fat you can be rest reassured that this is fat necrosis and the biopsy may not be needed so the next step whenever you suspect fat necrosis should be a mammogram vascular abnormalities this was one such case venous malformation in a young 13-year-old who had copious bloody nipple discharge so having looked at the birats the descriptors the associated features calcifications and special and special cases let's come to the assessment categories birat zero it needs additional imaging you see something and you feel that it needs a mammogram for further evaluation you will give it a birat zero category birats one means that on ultrasound you're not seeing any abnormality if there is an abnormality and the higher assessment category has been assigned basis mammogram or MRI that will be the final assessment category so you look at all the modalities and then decide what the final assessment category will be and give a combined report birats two means that it's benign and what is included under this this list which is right here on your screen what is birats three that means that we are suspecting that it is most likely a benign lesion but there is a small two percent risk of malignancy what would you do then if you have a circumscribed lesion like this both on mammogram and on ultrasound but it is a new lesion or it is not a part of other similar lesion seen in either breast you would want to follow it up for an interval of at four to six months interval for a period of two years so how we do it is we do a follow-up at six months at 12 months and then at 24 months before we finally say that we can downgrade this to a birats two birats four now we've reached the suspicious lesions for what for which we recommend a biopsy now if you see on your screen there is a sub categorization into four a four b and four c and it is said that we should it is encouraged that we should use these categories what is the importance of these categories like you've heard in the previous talks we are talking radiology pathology concordance or discordance when you have a low suspicion you have certain suspicious features but you feel that it will come back as a benign result you can give it a four a and if the pathology comes back as a benign it is considered a more result on biopsy would be taken as concordant what is important is that if you have a four c you've given it a four c very speculated mass high suspicion and you get back a report which says benign pathology then there is something definitely wrong and this is considered as discordant you will further manage this patient you will not send her back home you have to look at the reports yourself and see whether you have got an appropriate radiology pathology concordance a solid cystic mass that we see here complex solid cystic mass biopsy of these ecogenic areas revealed a papilloma it was benign there was no atp associated and this was a four a four b this was a fairly large four centimeter mass which was palpable the woman had recently palpated it so we went in for the biopsy it came back as a benign phyllogeist and we knew that this was a concordant result and this a very very suspicious mass with angular margins ductile extension of the lesion and if this had come back as benign we would have further managed this with either a wab or an excision biopsy by rats by this is going to be malignant lesion characteristics pigmented hypotension all the way up to the nipple by rat six when you have a known malignancy before you start new adjuvant chemotherapy you'd like to do an ultrasound take the size of a mass maybe place a clip inside so that you can assess the mass after a few sessions of chemotherapy now this is the new part which I have added for all those who've heard that talk before the next by rats is expected in 2023 and very recently a few days ago these expected changes have been sent out by acr the first one is what we call an echogenic ring if you looked at the fourth edition of the byrads we had a section called lesion boundary in which we spoke about an ecogenic halo well this is more like it it's a thick band of echogenic tissue that surrounds the lesion and it represents likely desmoplastic reaction or peritumoral edema now when we see something like this you would ask what about a fibro adenoma which has a thin white echogenic capsule this is a pseudo capsule it's uniform it's associated with a benign mass but if you see a suspicious mass like this and you see variable thickness of this echogenic ring then it is highly suspicious for malignancy when you take the measurement of such a mass you should include this echogenic ring in the measurement of the mass and not stop shot at the hypoechoic area the next change which is expected in the update overview that has been sent out is non-mass so a lot of times when we do ultrasound we don't see something which can which we can call as a mass it lacks a definable shape and a margin for assessment so we can't really say what the margin is we can't say what the shape is but we see an abnormality we see that there are there's an hypo or an isoechoic or a mixed echogenicity area it could be in a regional focal linear or segmental distribution we may also be able to say whether it's parallel or anti-parallel but we can't comment on the shape or the margin so we must look if we have such a finding we must look at associated imaging variables what does that mean look at this you have an irregular altered echogenic texture there you know there's something there but you can't put call it a mass okay look around it do you see an echogenic rind around it there's hyper echogenic area around it the ducts are converging into this area the mammary interfaces are blurred like you see here so this is suspicious and this is what is going to be introduced as the non-mass also put on par Doppler and see what is happening in this area increased abnormal vascular signals this is non-mass and this is a suspicious finding and should be or will be included in the next edition likely to be released in 2023 the third thing is that so far we used to always just comment on lymph nodes and say we see axillary nodes and we used to call them reactive or we used to look at the cortical thickness and we used to say this appears suspicious and we used to write our reports likewise now they say that we must give a absolutely you know proper location of the nodes we must look for intramammary nodes if we are commenting on axillary nodes we must say whether it's level one two or three if we can recall our surgical levels we look at the levels in relation to the pectoralis minor muscle that you see here if you see nodes just posterior or behind this that's level two if you see it in ferrolateral to the pectoralis minor then it is level one and superior medial to the pectoralis minor is level three one must also look for internal mammary nodes supraclavicular nodes and a lot of emphasis is now coming upon the morphology of the nodes what is the cortical hyalur relationship you see an echogenic hyalur but you see a very smooth cortex this is maintained echogenic hyalur you see a normal hyalur vascular pattern contrast that with this image you see increased cortical thickness and it's as if it's just compressing the echogenic hyalur another case where you see that there's a complete loss of hyalur and there is increased abnormal vascularity coming in from the periphery into the center of this node so the next byrads is likely going to have all these changes i've finished my talk let's get back to the cases so we saw these cases initially we'd like you to poll again on these please and if admin could tell me because i don't know about the second and the third case i don't know what the poll results were i don't know whether you can show both together the poll results if you can't just let me know whether there's an improvement or whether we knew it all and you know um well we just revised byrads okay all right so that's case one please poll so most of you got it correct 74% said that it's an oval circumscribed hypoechoic mass in parallel orientation without posterior features or calcification okay this little bump here gentle lobulation does not make it irregular and that is why that was the catch in this statement and it is not heterogeneous and that was the catch in this statement okay so we move on to the next case polling please okay can we have the results again about half of you got that correct and i'd like to say what went wrong with c option okay just let me close this all right so now what is happening in this what is wrong in the c option it's the parallel orientation look at the axis of the mass the long axis this is anti-parallel it's perpendicular to the skin surface and therefore option c or option three is not correct and option two is the correct answer let's go on to the last case to end this talk okay can we have the results please i'm so glad that at least more than half of us got this correct i don't know what happened before the talk if the results are the same then i have actually failed in this talk but had said ma'am before the talk 65 percent had said b second one said b oh so that's great good okay i'm happy yeah okay so yes the answer is a and the reason why it is not b is because you cannot describe this mass as oval it's irregular it's not smooth it's not oval okay and it's definitely not circumscribed can you see that even if you call it oval it's not circumscribed it has these bumps so it's micro lobulated the tiny bumps they're different from the gentle lobulations and that is why b is not correct thank you very much for the talk for giving me this opportunity and to the audience for being here thank you parkas sir and thank you dr sanjeev mani sir of course gauri amit mitusha shilpa i owe you a big huge thanks it was fun being here it was worth the wait it was so good like you know like a teacher speaking one by one by one i'm happy our polls went up so i'm happy