 Dr. Kothari. A leader is one who knows the way, goes the way and shows the way. He knew even in times before technology and radiology became center stage of imaging that this was the way to go. And he was the one who established MRI center at Nanavati Hospital along with Dr. Deepak Patkar. He also mentored many, many radiologists who now serve the society, community and the nation at large. So he continues to be an inspiration for us. And till the day that we recognize our leaders, we acknowledge them and we walk on their path, our country and our society is in safe hands. So without any further ado, I thank you all for this honor today. And we hope to walk on the path that has been set for us by Dr. leaders such as Dr. Sureen Kothari and now Dr. Deepak Patkar. So thank you all and without any further ado, I shall start my talk on breast MRI pathologies. Mithusha, can you see my slides? Yes ma'am. I can see them. Yeah. Yeah. So this is to Dr. Sureen Kothari, our heartfelt gratitude for being a wonderful teacher, professor, leader, visionary and mentor to many. And today I'll be speaking about MRI in breast pathologies. We will use a case-based approach. Now for the last few weeks, all of you in the audience, 1100 of you in the audience have been learning many, many, many things about the utility of MRI in various systems of the body. Breast is a small part, but before I end this talk today, I would like to discuss just two things with you. The two main enhancing patterns and what is it that we are supposed to think about when we see those enhancing patterns on breast MRI. The first pattern is asymmetric non-mass enhancement and the second pattern is an enhancing mass. What does it mean to us? How do we correlate these findings with the clinical signs and symptoms? A radiologist is considered a good radiologist only if we can put two and two together, which is the clinical findings or clinical signs and symptoms with what we see on imaging. Otherwise, we are lost. A clinician is lost and then technology doesn't make any use to our patients. We do not want to be those radiologists. We do not want to be the ones who say clinical correlation recommended. We want to be the radiologists who clinically correlate and put our thoughts in there. Having said that, we also have to recognize the strengths of the modalities that we use and the weaknesses and how we can overcome those weaknesses. So, what are we going to do in this talk? We are going to look at three things. What is the clinical presentation? Based on those clinical presentations, what is the MRI finding that we saw and what is the pathology that we suspected? Before going further, let's understand one basic thing about breast MRI. When we do breast MRI for finding pathologies in the breast, it is always contrast enhanced breast MRI and the way we acquire it is dynamic contrast enhanced, means the gadolinium is injected and dynamically images are obtained. I won't go into the technicalities of how we obtain a breast MRI today because that is not the purpose of the talk but knowing this basic is very important before we go further. What happens is if there is any kind of tumor growth benign or malignant, there is new angiogenesis. To support that tumor growth, there are new blood vessels that form in that area but these blood vessels are not perfect. They are leaky vessels. Therefore, the contrast agent which is the gadolinium gets pulled in that area of new tumor growth and it can be sometimes leaky. It disappears also fast enough. This is the principle on which we try to find abnormalities on breast MRI and come to a conclusion. Tumor develops randomly distributed small new vessels. They are more permeable and that results in tumor enhancement. When there is tumor enhancement, also remember breast like the uterus is under direct influence of hormones and this hormonal influence will cause background perenchymal enhancement. There will be a certain amount of enhancement in the normal breast tissue also but that is usually symmetric and bilateral whereas in the region of the tumor there will be early enhancement and there will be rapid enhancement. Based on this principle, we use subtraction which means first we obtain non-contrast images and then we subtract the contrast enhanced images. Whatever is typically symmetric and whatever is present bilaterally will get subtracted most of the times and whatever residual abnormal enhancement will be seen on those subtracted images and that is what we try to detect. It has a very high sensitivity close to 100% but lower specificity which means along with cancerous and pre-cancerous lesions some of the non-cancerous or benign lesions are also going to enhance and therefore we want to be careful. We do not want a person or patient or woman to undergo any kind of breast intervention in the forms of surgical intervention without knowing the diagnosis of that enhancing lesion. That is one point which is very important to understand. So without further ado, I'm going to show you a whole bunch of cases here about 7 to 10 cases so that this point is understood properly. Here is a 44-year-old she complains of spontaneous bloody left nipple discharge since one month. The mammogram looks pristine. It is a predominantly fatty mammogram. I don't see any abnormality, no microcalcifications, no masses, no architectural distortions, there is no skin thickening, there is no nipple inversion. It is a high quality pristine mammogram. However, patient has a new symptom so do not ignore that new symptom and the symptom is new onset, bloody left nipple discharge. How do we problem solve in a case such as this? So we go ahead and do a focused ultrasound of the left retroary oleration. We still do not find any abnormality. Now how do we problem solve? What do we tell the patient? What do we tell the surgeon? Go ahead and have a surgery but we don't see any abnormality. Is it right to subject the patient to the surgeon's knife without exactly knowing what is going on in this case? Not really. So do we have any problem solving tool? Yes. Remember, when we do a mammogram and ultrasound, we're doing structural imaging. When we do a contrast enhanced MRI, we're doing functional imaging which means if there is any tumor growth and there is new angiogenesis, contrast is going to pool in that area and we are depending on that principle. On contrast enhanced MRI, what do we see? This is what we see. We see linear non-mass enhancement in the left retroary oleration. It is within the duct. This is the area that we see and therefore the patient is experiencing bloody nipple discharge when we see an area such as this with the clinical symptom of spontaneous bloody nipple discharge. What do we suspect? The two most common things are intraductal papillomatosis or DCIS. Can they coexist? Well, 85% of the times benign intraductal papillomatosis, papillomas will just be benign. But 15% of the times they will be associated with DCIS or a small invasive cancer. Therefore, in this case, we need a diagnosis. Typically, we could have gone ahead with a MR-guided breast biopsy. However, at the time, we did not have the facility, but it gives me great pleasure in sharing with all of you in the audience that very soon at Nanavati Hospital, we will be starting a MR-guided breast biopsy facility. In future, we would be able to do that intervening step. However, in this case, a microdochectomy was done and the offending duct was removed. The duct pathology demonstrated intraductal papillomatosis with ductal carcinoma in situ, DCIS. So, we were able not just to problem solve with contrast enhanced MRI, but also find this lesion early enough. If we would have said everything is okay based on the mammogram and ultrasound findings, one year or two years later, she would have come with an invasive cancer, probably a papillary cancer, invasive papillary cancer with skin involvement and a more extensive surgery would have had to be performed for this patient. So, with the help of contrast enhanced MRI, we were able to do a timely diagnosis. Next case, and like I said, papillary lesions, they're complex group of lesions arising from the mammary duct, 72% percent with suspicious nipple discharge and sometimes they're associated with ADHD, DCIS or invasive cancer. Here's another case. This is a 52 year old. She presents with spontaneous, bloody left nipple discharge on the mammogram. All we see is a global asymmetry. What do we mean by global asymmetry? I'm seeing something in the left breast, but I do not see anything on the right breast coinciding to that area. Normally, breast perenchyma is absolutely symmetric. So, in such a case, what do we do? But I don't see any mass, I don't see any micro calcifications, I don't see any architectural distortion. Is this good enough reason to intervene? Well, we don't know yet, but we know for sure, this is a postmenopausal woman with nuanced nipple discharge and that too, bloody nipple discharge. On focused ultrasound of the left retroaerial lesion, what do we see? We see dilated ducts with echogenic intraductal material. Can we biopsy this? Well, we could do a ultrasound guided vacuum assisted biopsy, but at this point, neither the surgeon nor the patient were very keen on going ahead with the biopsy. They wanted to know whether there is any other investigation we can do to prove or disprove what we were suspecting. So, we went ahead with a contrast enhanced MRI. On contrast enhanced MRI, what do we see? Again, we see asymmetric non-mass enhancement involving more than 50% of the left breast. And this was biopsy, this time under ultrasound guidance with ultrasound vacuum assisted biopsy. And this was in keeping with high grade ductal carcinoma in situ. Things that cannot be very subtle on mammogram or ultrasound can be detected just based on the principle of neo angiogenesis on breast MRI. And we are still talking about asymmetric non-mass enhancement. What are the other clinical things where it will help us? In this case, this was nipple discharge. When the nipple discharge is unilateral, spontaneous, bloody or watery, we worry about it and we call it pathologic nipple discharge. These are typically associated either with intraductal papillomas in up to 48% of cases or ductctasias in up to 36% of cases, but also ductal carcinoma in situ, DCIS in 5 to 21% of cases. And therefore, we are very cautious. And typically, this will be seen only as linear or segmental or regional asymmetric non-mass enhancement as we saw on the MRI. Now here's another case. This is a 54-year-old who presents with scaling and crusting of the nipple. And what do we see? On the mammogram, it's very hard to see. The breast almost looks okay, but there are these subtle, very fine microcalcifications. We are not even sure what we're dealing with. In such a case, how do we problem solve? Because there is new onset scaling and crusting of the nipple, we are suspecting we could be dealing with a pageant's disease of the nipple. Of course, the patient undergoes a skin punch biopsy of the nipple. However, we also know that pageant's disease of the nipple can be associated with cancerous or precancerous lesions in the breast in up to 50% of cases. Therefore, an optimal evaluation and confident diagnosis is pertinent. In this case, this finding was subtle. How can we problem solve? So we went ahead with a contrast-enhanced MRI. Again, asymmetric non-mass enhancement involving one whole quadrant, the upper inner quadrant of the right breast. This was biopsied and was in keeping with ductal carcinoma in situ. Now, presentations can be slightly different. First time, it was nipple discharge. Second time, it was just crusting and scaling of the nipple. The point we are trying to make here is things associated with high suspicion symptoms, where conventional imaging such as mammogram and ultrasound is negative or equivocal, MRI can be a very effective problem solving tool. Typically, when we see asymmetric non-mass enhancement, as was seen in the previous case and these cases, one of the top differentials can be ductal carcinoma in situ. In this case, as we discussed, this turned out to be pageant's disease of the nipple with associated DCIS. Here's a 32-year-old. Now, this is a patient who had mass in the right breast and it was extensive. It involved more than one quadrant. It involved large area of the breast. Although she was 32, the possibility of saving the breast was not possible. Therefore, she underwent right mastectomy and prophylactic left mastectomy also. However, it was a skin-sparing mastectomy that was done. When they do a skin-sparing mastectomy, the small sliver of the subcutaneous tissue and the nipple areolar complex is left behind so that implant can be inserted and the patient feels like, you know, cosmetically fine after the surgery as she's so young. In such a case, how do we follow up these patients? That can be particularly challenging. After the biopsy, after the mastectomy is done, can we do a mammogram? The implant is in place. Will we be able to see enough? Implant per se is not a contraindication for doing a mammogram but with the implant in place and a small sliver of subcutaneous tissue present, are we able to evaluate properly? That is the question. The patient presented with nuanced palpable nodularity. It was not possible to identify what was going on on the mammogram. Therefore, we did a contrast-enhanced breast MRI. And what do we see? Within that tiny sliver of subcutaneous tissue, there was asymmetric non-mass enhancement involving the tiny sliver of subcutaneous tissue between the breast implant and the skin. And this was all in keeping with DCIS. And this was anterior to the implant. She had a revision surgery but before we did the revision surgery, we wanted to know, would we be able to see this on mammogram? We did a compression spot magnification view and you can see in this area subtle, very subtle pleomorphic microcalcifications. Sometimes when we just do a mammogram, these microcalcifications may not even be seen. Here we had done spot magnification views. Remember, with a smaller focal spot and a magnified image, just because we had found something on MRI, we were able to correlate this finding on a mammogram. So MRI, contrast-enhanced MRI and the finding of linear non-mass enhancement in these symptomatic patients has a very high positive predictive value for identifying DCIS. Now, DCIS will typically manifest as microcalcifications on a mammogram. What are these microcalcifications? They are typically necrosis and subsequent calcification. What happens is there is intraductal tumor growth but the tumor growth sometimes can be just too fast and therefore outgrows the blood supply and hence those tumor cells undergo necrosis. After necrosis, next step is calcification and therefore we see those pleomorphic microcalcifications on a mammogram, toxin dashes. But sometimes the high-grade DCIS, it grows so fast that there is not enough time for necrosis and subsequent calcification to happen. And this is the DCIS which will be identified as asymmetric non-mass enhancement on contrast-enhanced MRI. And it is important to understand that half of all DCIS lesions will be occult on mammogram and they're detected only on MRI as non-mass enhancement. So if there is one teaching point you want to take from this lecture, remember how to identify, how to correlate breast symptoms with contrast-enhanced MRI and how to look for this non-mass enhancement, whether it is linear, segmental or regional non-mass enhancement. Where else do we see non-mass enhancement? Where else do we see non-mass enhancement which is really, really concerning? Here's another case. 69 year old presents with just one symptom. I don't feel any lump doctor, I don't have any nipple discharges but I feel that my right breast is getting smaller than the left breast. This is all that the patient says. The patient says that I feel that my bra on the right side is getting looser but on the left side it is just fitting normal and I cannot understand. So we do a mammogram. On the mammogram what do we see? The breast is heterogenously dense but we do not see any masses, we do not see any microcalcifications, we do not see any architectural distortions also but the patient is pretty sure. This was not always like that. Sometimes there can be developmental abnormalities where the patients will tell you that my right breast has always been smaller than the left ever since development. So that is not considered concerning. That is a developmental variant. Our bodies may not be absolutely symmetric, there may be some variations in symmetry and such a thing can happen in the breast but when there is new onset shrinking of the breast we are concerned. Why are we concerned? I'll come to that in a minute. So on the mammogram we saw nothing. So we did a breast ultrasound. On the breast ultrasound what did we see? Nothing in particular. It just looks diffusely heterogenic. We are not seeing any abnormality. Should we tell the patient go back home? Maybe you're imagining things. Maybe you're just getting into the postmenopausal phase and that's when the breast starts changing in contour and size because the fibro glandular tissue is getting replaced with fatty tissue. Should we just send back her home? But no. In her case you saw that there is barely any fatty tissue. It is predominantly fibro glandular tissue and despite of that she's complaining of a shrinking breast. How should we problem solve? We did a breast MRI. On contrast enhanced breast MRI what did we see? We saw asymmetric non-mass enhancement. Now let's put two and two together. She has shrinking breast. Her right breast is getting smaller and she has asymmetric non-mass enhancement. What do you suspect? Any idea? Well this is in keeping with invasive lobular carcinoma. These are the cancers that grow along the Cooper's ligament. The breast is supported. The breast, the stroma and the fibro glandular tissue is supported by Cooper's ligament. On ultrasound you see them as white lines where they meet. So these cancers they don't typically cause masses and that classic speculated masses with desmoplastic reaction. These grow in that single Indian file pattern along the Cooper's ligament and therefore neither on the mammogram nor on ultrasound you will see a mass but when you do a MRI you will see a non-mass enhancement in a regional or a segmental distribution and this is exactly what we saw but these are very very sleazy and very very scary cancers because they can be easily missed on mammogram and ultrasound and oftentimes these patients directly present to us with either leptomeningial meds or peritoneal meds because the cancer just did not get diagnosed. So being aware of this sign of shrinking breast is important in older women and knowing what shrinking breast will look like on your conventional imaging and on MRI is important. Asymmetric non-mass enhancement associated with the shrinking breast is a sign of invasive lobular carcinoma. Here's another case. This time this is a 46-year-old who presents with a new onset palpable lump in the right breast. Have a good look at this mammogram okay. Have a good look like you know see as much as you want to. Do you see any abnormality in the right breast? It's a pristine mammogram. It's a high quality digital mammogram okay. What do we see on it? Redominantly fatty tissue. A very little fibro glandular tissue but I don't see any abnormality. Are you seeing any masses? Are you seeing any micro calcifications? Are you seeing any architectural distortions? None of the above okay but the patient is confident that I definitely feel a lump. She's a doctor herself okay so she tells me that Shilpa you know what I have never felt this before and this is new okay so we do an ultrasound. On ultrasound what do we see? No definite mass just diffuse shadowing okay. One mind says that should I go ahead and biopsy but my second mind says that what if I miss this whatever shadowing is after the biopsy I'll be back to square one if it comes back negative simply because it would simply be doing like a blind biopsy okay. Therefore what do we do? We decide to problem solve. How do we problem solve? We problem solve we're doing a contrast enhanced MRI and what do we see? Again the same old asymmetric non-mass enhancement and remember which are those sleazy cancers that give rise to asymmetric non-mass enhancement invasive lobular carcinoma okay. Again I'll remind you they grow along the Cooper's ligament therefore on conventional imaging sometimes you may not see it. You have to be listening to your patient. You have to be talking to your patient. You have to be a clinical breast radiologist to come to a diagnosis only when you put the two and two together you will be able to come to a diagnosis. The patient has a symptom nobody likes to go to the doctor trust me there are very few people who have the habit of picking themselves up and going to the doctor again and again okay. To make a visit to the doctor you really have to be having something especially in these COVID times people do not want to go to the hospitals or clinics okay. If the patient has come to you with a sign or symptom remember be cognizant of the fact that you have to correlate the clinical signs and symptoms with your investigations. You will be a good radiologist if you know the strengths of your investigation of your modalities but you also know the weakness of your modality and that does not make the modality bad. It just means that we are not all perfect we are not all in in true life also just like our technologies we are not good at everything right. We're good at few things so the same thing for our technologies the mammogram is good at finding a few things the breast ultrasound is good at finding few things but MRI has its own role in finding things where conventional or modality spales us and having that knowledge when to do it don't do it for every case because then nobody is going to trust your word but do it when it is absolutely essential and this is one such case and after you do it you should know how to correlate your findings if you're seeing this do I have to pay attention yes I have to pay attention because I see asymmetric non-mass enhancement this was biopsied and the patient eventually had a mastectomy okay. So talking about invasive lobular carcinomas they account for 10 to 15 percent of all breast malignancies of which 10 percent present as shrinking breast and there is no other word to describe this these are really sleazy cancers they can be occult on mammogram and ultrasound until advanced stage and typically seen as asymmetric non-mass enhancement on MRI if there is one cancer that can fool even an experienced radiologist it is this invasive lobular carcinoma so be very very wary and be aware of what you will see on MRI when you do your MRI as a problem-solving tool. Okay here's another case this time this patient is a 52 year old and she presents with a lump in the upper outer quadrant of the right breast okay this was in Jan 2012 okay at the time when the MRI ultrasound was done the interpreting radiologist thought that probably this corresponded to a benign cyst okay it looked like a well circumscribed mass there was some amount of posterior through transmission the margins were smooth so nothing was done at that point in time okay six months later however patient presented with an increasing palpable lump now there was also nipple inversion and skin changes you see some changes definitely on the mammogram okay however problem solving was done with breast MRI just because nobody wanted to miss this lesion on ultrasound definitely there is a shadowing mass with irregular margins okay on MRI what do we see we see a heterogenously enhancing mass okay which is involving more than one quadrant the margins are irregular and speculated and on delay post contrast images there is also washout okay so this is the classic presentation of invasive cancers this is what invasive cancers will look like we looked at non-mass enhancement and we looked at what we suspect when we see non-mass enhancement when we see enhancing masses we apply the same rules that we would apply when we see a mammogram or a breast ultrasound as far as morphology of the mass is concerned what do we mean by morphology well is it round is it oval or is it irregular okay that is the first thing what does the margin look like is the margin smooth is the margin irregular is it speculated is it micro-librated and what does the enhancement pattern look like is there rapid enhancement on the early post contrast images followed by washout okay then we are very suspicious but with the enhancement pattern there can be a little bit of an overlap between benign and malignant findings okay therefore we put a lot of interpretation ability into the morphologic features even on MRI just as we would on a mammogram or ultrasound okay so this is the classic appearance of invasive ductal carcinoma the reason I'm showing this here is for you to understand what an invasive lobular versus what an invasive ductal carcinoma looks like okay now these account for 80 percent of all breast cancers typically present as palpable lumps and most of the times you will be able to detect and diagnose them on conventional imaging like your mammogram with 3d tomosynthesis with ultrasound okay but sometimes you will have to take help of contrast enhanced MRI just because the nature of the beast is such that breast is a composition of fat and fibro glandular tissue if there is more fibro glandular tissue breast cancers can hide on conventional imaging and that's where your MRI will detect those cancers and this is what they look like on contrast enhanced MRI okay now can it detect both for us together now here is a case 44 year old with new onset palpable lump in the left breast we saw these pleomorphic micro calcifications for which a stereotactic biopsy was done and this was in keeping with DCIs at the time the extent of the micro calcifications was was thought to be about three centimeters okay but when MRI was done what did we see we not just saw the non-mass enhancement corresponding to the pleomorphic micro calcifications but we also saw enhancing masses anteriorly multiple of them the largest being in the left retro aureolar region which was also biopsy and this was in keeping with invasive ductal carcinoma with associated DCIs posteriorly and now the total extent was about eight centimeters so there can be multiple things going on in the breast at the same time in this case we like you know uh unfortunately for the patient it was invasive ductal carcinoma along with DCIs and both was proven and that's how she underwent a mastectomy however life is not this simple all the time when it comes comes to contrast enhanced MRI okay I'll show you another case here here is a case where the patient had a biopsy proven cancer invasive ductal carcinoma as you can see in the bottom line of images you know where we have marked it as IDC it is a heterogeneously enhancing mass with some speculations along the margin but in addition to that there were additional lesions anteriorly in the retro aureolar region patient was keen on having a breast conserving surgery if that was possible in such a case how do we prove or disprove that this is cancerous the additional lesions that we were seeing in the retro aureolar region were cancerous pre-cancerous or non-cancerous there is no choice but to have biopsy where possible we have a targeted second look ultrasound and ultrasound but guided biopsy but where it is not seen on targeted second look ultrasound it becomes mandatory to have a MR guided breast biopsy in this case there were three type of pathologies which were coexisting and all three were benign the three additional lesions in the left retro aureolar region was sclerosing adenosis inter ductal papilloma and fibro adenoma all three of them can look as well circumscribed progressively enhancing masses sometimes they can be hyper intense on t2 and sometimes they may not be okay and in cases where there is a existing cancer they can be an overlap am I dealing with a smaller satellite lesion or is this a benign lesion should we subject the patient to a mastectomy based on this finding well if this patient would have had a mastectomy because we interpreted this as could be satellite lesions along with the biopsy proven IDC she wouldn't have been a happy camper because she was keen on a breast conserving surgery therefore understanding that on MRI the sensitivity is high but the specificity can be lower is absolutely pertinent and because the specificity is lower ability to do a biopsy of MR detected lesions should be is mandatory about 73% of the times we will be able to find these additional lesions on targeted second look ultrasound and have a histopathology diagnosis for them but about you know 27% of the times we may not be and that's where the role of MR guided breast biopsies comes in and we'll show you a case here now this is the last case I'm showing okay so here is a case where the patient presented with a new onset nipple inversion okay on ultrasound the left retro aerial lesion can be particularly hard to see because there is inherent shadowing from the nipple aerial complex so the first time when we did the ultrasound biopsy all we saw was fibrous tissue with ecstatic ducts okay but the patient is saying this is a new onset nipple inversion I have never had an inverted nipple now there can be cases where patients have chronic unilateral nipple inversion but in those cases patients will clearly tell you I have not even been able to breastfeed my child from that side simply because my nipple has always been inside but where there is new onset nipple inversion there also the patient will clearly tell you that my nipple has never been like this it is going in and I have noticed it over the last few weeks or the last couple of months that the nipple is going in it's getting retracted day by day okay and that is the time you do not want to ignore that symptom simply because like I said you're the mammogram may show you something like this nipple inversion but on ultrasound just because the nipple aerial complex is a region as such there is too much shadowing from the nipple aerial complex itself which can obscure or may hide a cancer which is developing there therefore contrast enhanced testimary was done and what do we see we see an irregular heterogenously enhancing mass in the left retro aerial aeration our first ultrasound biopsy was negative so how do we problem itself there is no way but either to subject the patient directly to a surgical excision biopsy which will involve removing a whole chunk of tumor or we do a MR guided breast biopsy in this case the MR guided breast biopsy was done and this was in keeping with an invasive lobular carcinoma okay and with this diagnosis the patient underwent a breast conserving surgery so in summary contrast enhanced MRI is an invaluable problem solving tool in symptomatic as well as high risk patient however optimal imaging technique in protocol experience and expertise in interpretation and biopsy facility is a must simply because there can be an overlap between malignant and benign findings okay with experience and expertise we get better at it at interpreting as well as doing targeted secondary ultrasound and biopsies having said that remember those 27 cases which will require additional biopsy facility and like I said earlier I'm very happy to say that with the support of Dr. Deepak Parker we are able to start this very soon at Nanavati Hospital so thank you very much and I dedicate this talk to Dr. Sureen Kothari, Dr. Deepak Parker and the entire team at Nanavati thank you Mithusha, thank you Dr. Malum thank you Gauri. Thank you Shivna. If there are any questions invasive ductal cancer can also present as non-mass enhancement on breast MRI how to differentiate invasive duct cancer from invasive lobular cancer that happens very rarely there is a question here that invasive ductal cancer can present as a non-mass enhancement if there is associated non-mass enhancement with the enhancing mass it means there is an invasive cancer with associated DCIS invasive ductal cancer alone presenting as a non-mass enhancement happens very very rarely practically doesn't so if there is a non-mass enhancement associated that means there is DCIS associated with that typically so that's the answer to that question yeah okay I don't see any other questions in the Q&A so thank you all.