 the imaging reporting further and to improve lesion diagnosis and management and bottom line to facilitate patient care. Thank you and with this I want to thank Shilpa and our entire team for having me here and they're doing such a fantastic job bringing us together in such brilliant academic feasts and I'm really really grateful and thankful to her. Thank you Shikha you were super as always you make MRI look so easy like nobody ever should struggle with MRI but that is in your talks yeah very very clear teaching points beautiful images and very music thank you so much thank you my pleasure really thank you ma'am it's really going to motivate more of us to get into MRI reporting because it seems so complicated that people kind of stay away of it but thank you thank you once again my pleasure ma'am few questions might be coming in the chat box if you could please answer them sure I'll write them there ma'am sure I'll look at it so we had kept the most interesting part of the session at the end but still we have over 300 people online and this is the time to introduce someone who does not require any introduction Dr Shilpa Laad ma'am she is the subspeciality head for breast imaging IRI and ICRI the entire last year all of us had a tough time with the ongoing pandemic but ma'am played a very key role in continuing the education specifically to this field of breast imaging and also for this particular CME she is the key coordinator and key organizer so thank you ma'am for all your efforts ma'am is consultant breast imaging and interventions at NM medical Mumbai and she is former consultant radiologist and assistant professor at the Otawa Hospital University Canada and president appreciation award ma'am received in the year 2021 and invited speakers for over 400 lectures in breast imaging and intervention related topics at various national international forums she has been invited speaker at RSNA 2019 India navigating cultural and socioeconomic challenges in pursuit of global breast health so it's an honor to be with you ma'am on this platform and over to you for the interesting quizzes and you have 15 prizes to be won so ma'am the quiz will have price on all the levels so be really fast and be correct with your answers all the best over to you ma'am thank you Mithusha thank you for your kind words I could not have done any of this without a super partner like Mithusha and Gauri and most of all without all the backing and support from Dr. Deepak Patkar, Dr. Sanjeev Mani, Dr. Jignesh Thakkar and Dr. Shailendra Singh who are always there in the background to support and like I said earlier Mamta ma'am Amit Poonkar and Priyanka oh my god the WhatsApp chats have been going non-stop so none of this could have happened without the support of every single one of you present here and most of all our participants it's almost midnight and you guys are still here it's past my bed time so it must be past your bedtime too so without any further ado let's have a look at some cases let's see if we have really picked on what our excellent speakers have spoken to us this evening so let me see okay Mithusha you can see my screen right yes ma'am okay so my only question is how do I go to okay this is good now so are you guys ready fastest finger first you're going to show you 15 cases and unlike with our previous session where we went through all the 15 cases one after the other after each case I'll give the answer but before I give the answer we will wait for your answer okay so once we know who were the first few people who answered correctly after that my answer will be given out okay so here we go okay one important thing this is one of my favorite authors Mark Twain who says I have never let my schooling interfere with my education which means don't blame your teachers don't blame your institute don't blame the region don't blame the country whatever it takes you get an education learn keep learning all the time and there will be resources okay and the 326 participants who are here are doing exactly that so here's your first case what is the most likely diagnosis this is a 23 year old with new onset palpable lumb in the inferior left breast on ultrasound we see a relatively oval marginally lobulated mass which is T2 hyper intense on MRI hyper intense on T2 weighted images we also did a limited mammogram for her and on the mammogram it looks like a relatively circumscribed mass there also seems to be a fat margin surrounding it what is the most likely diagnosis okay you can type your answers in the chat box okay do we have the answers mithusha i'm going to show you one more slide here we also have early subtracted image which is a dynamic contrast enhanced image which shows a heterogeneously enhancing mass with some non-uniform cystic spaces that is the margin is also not very clearly defined what is the most likely diagnosis that i'm about to give the answer is that okay yes you can go at triple triple negative breast cancer which is PR PR her to new negative okay this is what these type of cancers do they happen in younger women they grow very fast and they are relatively circumscribed they almost look like fibroadenomas because oftentimes they are well circumscribed on ultrasound when you see you may even see posterior through transmission therefore they confuse us even more one often wonders am i dealing with some kind of atypical fibroadenoma how can a 23 year old get a malignancy but it happens okay and as most of our speakers have repeatedly said try to look for the worst by rats features like you know what are the margins like are you seeing angulations microlibrations non-uniform cystic spaces on ultrasound or on MRI like Dr. Shikhar just mentioned to you like you know mass enhancement what is the margin like what is the enhancement like when those features do not fit into classic benign category if you have even one atypical characteristic remember to go ahead and biopsy it now the problem with these triple negative cancers is on ultrasound they can look like avoid masses and on MRI they can be T2 hyper intense the reason being they're very very cellular okay therefore one has to be very careful next case this is a 44 year old who presents with an increasing palpable lump in the right breast since six to eight months what is the most likely diagnosis on the mammogram we see a relatively circumscribed mass with smooth margins okay there almost seems like a halo of fat surrounding it however the patient says that it has been increasing in size of late what is the most likely diagnosis this is what we see on ultrasound on ultrasound it corresponds to what looks like a relatively circumscribed avoid mass okay it is hypoechoic but a little heterogeneously hypoechoic however I see an ecogenic capsule surrounding it and I also see an ecogenic septum like you know a septation within the within the mass what is the most likely diagnosis okay ready for the answer it is a fibroadenoma although she's 44 year old this is a fibroadenoma which is growing sometimes they can grow in the perimenopausal age group also and that happens under the influence of hormones these are typically described as giant fibroadenomas the higher likelihood of this there is a higher likelihood of this being a phalloides tumor because those are the tumors that can grow suddenly but those also are tumors which are new in this case the patient says she has always had this lump ever since she was a young girl okay it is only of late that it has started increasing in size having said that the differential for a tumor such as this is fibroadenoma versus phalloides tumor and this deserves to be biopsy okay next case okay this is a 27 year old she is six months postpartum and she notices an increasing palpable lump at the right breast what is the most likely diagnosis on the mammogram what do we see we see a large relatively circumscribed mass there are also some coarse heterogeneous calcifications within the mass on ultrasound it is a heterogeneously hypoechoic mass the margin appears relatively smooth but look how heterogeneous this mass is on ultrasound she is also lactating so what is the most likely diagnosis okay do we have some answers here okay I think devyani ghai has answered okay this was actually in keeping with a malignant phalloides tumor we were thinking could it be a galactosil when we saw the ultrasound but when we did the mammogram because there were some atypical features on ultrasound what did we notice we notice this heterogeneous we notice this large mass okay we don't see any layering in there like we would see with a galactosil plus we saw these coarse but heterogeneous calcifications so we were concerned and therefore a biopsy was performed and this turned out to be a malignant phalloides tumor like I said earlier malignant phalloides tumor typically happened in the 40s but it is not uncommon to see them in the earlier age group also next case what is the most likely diagnosis now this time the patient is three months postpartum and there is an increasing palpable lump in the right breast okay on ultrasound we see a heterogeneously hypoechoic mass which is oval and it has some clear cystic spaces within it when we do a limited mammogram we see layering inside it what is the most likely diagnosis when you have got this right I think the first is russica again excellent so this is a galactosil the reason I have put the cases one after the other is to make you understand what is the difference what do we typically see in a galactosil versus a solid tumor on a mammogram okay and how do we come to a decision sometimes like Derek said in his talk between benign and malignant features there is a huge category of indeterminate lesions where there are overlapping features and then we are obliged to do a biopsy but some of these features like the layering that we see on the mammogram can be pretty classic for a galactosil next case this is a 70 year old she has had a left mastectomy for breast cancer in 2014 okay at the scar site she now feels a new onset palpable lump at the mastectomy site since two weeks on the right we have the mammogram okay of the uninvolved breast on the left the ultrasound image is of the scar site where she is feeling that new onset palpable lump okay that corresponds to a heterogeneous like you know it almost looks like a complex solid cystic mass okay and the solid component looks irregular okay besides this is a new onset lump however one point is within the cystic component although there seems like a cystic component there is no posterior through transmission what is the most likely diagnosis excuse me okay i'm going to show you one more image here okay because of this appearance on ultrasound although the patient had had mastectomy from the little bit of breast tissue residual breast tissue or or tissue at the scar site we decided to do a limited mammogram of the mastectomy site and what did we see on the limited mammogram this is what we saw first okay we saw what look like speculations how do we differentiate whether this is speculations from local tumor recurrence we looked at the 3d tomosynthesis 3d tomosynthesis what do we do on a 2d mammogram we have a two-dimensional image of a three-dimensional structure on 3d tomosynthesis we get slices it is something like you know the difference between a chest x-ray versus CT scan of the chest it's the same thing for mammography that is 3d tomosynthesis on 3d tomosynthesis what did we see at the site of palpable concern we see this fat in the center of the lesion okay so what does this fat indicate that this is fat necrosis okay so this was indeed in keeping with fat necrosis this patient eventually underwent a surgical excision biopsy because she was just too worried okay at the surgical excision biopsy also the the diagnosis was fat necrosis Manisa did anybody get this one yes I think Pushpa's got this right right at the beginning actually right at the beginning excellent that's great okay another similar case okay this is a 77 year old with right mastectomy for breast cancer in 2005 she now complains of new onset palpable lump at the mastectomy site since two weeks what is the most likely diagnosis on the right corresponding to the area of new onset palpable lump on the right mastectomy site we have this heterogenously hypoechoic mass and see these micro lobulations along the margin remember how Derek showed one image of a biscuit that almost looked like Monaco when you see a margin that looks like a Monaco biscuit okay then you be worried that's how you analyze margins how do you analyze them whether I'm seeing the margin of a Mari biscuit whether I'm seeing a margin of a Monaco biscuit or whether I'm seeing a margin of a animal cracker okay that's how you ask yourself what the margin looks like it is a heterogenously hypoechoic mass okay so are you worried about this what about the left mammogram does everything look normal on the left mammogram to you what is the most likely diagnosis okay let's look at a couple more images we also did ultrasound of the left periareolar region because there was some increased density in the left periareolar region besides there was also left nipple inversion I'm going to go back to that image to show you notice this nipple is inverted it has started going in something behind the nipple is pulling it in okay that's the reason we were concerned plus there is this increased density in the left retroareolar region okay and we are also seeing these prominent lymph nodes in the left axilla as well okay that's why we did ultrasound of that side and even on the left periareolar region we see a similar heterogenously hypoechoic solid mass with angulations and microlab relations along the margin in bilateral exilate what do we see enlarged hypoechoic lymph nodes with either complete loss of fatty hyalum or near complete loss of fatty hyalum which means the particle thickening is more than at least four to five millimeters so what is the most likely diagnosis what are we dealing with when he said we do we have we've got multiple answers but your correct answer that you wanted has not yet come okay people have written from multifocal breast malignancy to metastasis bilateral malignancy also yeah but you wanted it specifically as what you wanted it then i don't think that's come yeah but i think we can take it as bilateral malignancy we can there are many who've given that answer then right so on the right there has been recurrence of breast cancer and on the left there has been new contralateral invasive ductal cancer besides there is bilateral metastatic lymphadenopathy okay so we are dealing with recurrence why am i showing this case because i wanted it to register you do like you know what is the difference between fat necrosis which happens at the scar side versus how does a recurrence look at the scar side so you have a clear image of how different the two are next case this patient complains of right nipple swelling since a few weeks she says it is only of late that she noticed that the right nipple is slightly more prominent as compared to the left it feels firm as compared to the left nipple what is the most likely diagnosis i'll show you some more images here this is the spot magnification view of the right nipple that we did and we also did a focused ultrasound of the right nipple okay you can try the answer we have a correct answer i think you do that's awesome from guy three i was sorry one more let me recheck this is from amrita das amrita das okay excellent okay so the correct answer is a nipple adenoma okay what is a nipple adenoma nipple adenoma is basically a variant of intraductal papilloma what happens is there are there are central uh central papillomas which happen in the retroereolar ducts some of these papillomas may increase in size or may occur within the uh within the ducts in the nipple per se okay and that's how only the nipple on that particular side will increase in size when you try to look it or look at it on ultrasound it looks like a relatively well subscribed void mass now in this case we also had calcification so we were wondering are we dealing with something more sinister could there be a associated dcis with this but you have to be cognizant of the fact that just benign calcifications can also happen in benign intraductal papillomas so similarly in this case where there was this benign nipple adenoma there were associated calcifications which were benign okay this was surgically excised and this was indeed in keeping with the nipple adenoma next case now she has shown us some beautiful images of MRI okay so this is a 32 year old who complains of right nipple crusting and bleeding since six to eight months when we did the MRI what did we see on the dynamic contrast enhanced sequences like like um um she covers explaining to us there is asymmetric non-mass enhancement it is in a segmental distribution it is like you know clustered and clumped that kind of a pattern of enhancement besides there is also enhancement seen in the overlying skin and nipple areola complex what is the most likely diagnosis you got many with the right answer okay akanksha jane is is first i think amrita jane okay good once i show you the next image it will be obvious okay so this is the clinical picture so this is what the right nipple areola complex looks like there is right nipple crusting and there is bleeding it is not really six to eight months this has been going on for some time but she did not decide to go to the doctor simply because she didn't think it was more concerning okay this was in keeping with pageant's disease of the nipple with multifocal dci she eventually underwent a mastectomy next case okay this is a 44 year old who comes for a routine screening mammogram and on the mammogram the breast density is category b which is scattered fibro glandular densities however we see an area of global asymmetry in the lower inner quadrant of the right of the left breast what is the most likely diagnosis okay any answers sir yeah you've got the right answer from shanas many have answered this excellent but the problem was ultrasound when we did the breast ultrasound it almost looked like a sinister hypoechoic mass with posterior shadowing we didn't know what we were dealing with when we did the tomosynthesis what do we see we saw what looked like um encapsulated breast tissue okay but the two the two pictures were not matching like here on the left 3d tomosynthesis it looks like encapsulated breast tissue but on ultrasound this looks like a shadowing mass what should we do what is the most likely diagnosis this is indiren keeping with the hamar tomah what is the hamar tomah fibro adeno lipoma is the other name for a hamar tomah it is basically breast within breast which means embryologically a small amount of breast tissue gets separately and encapsulated and that's why we see it as an encapsulated separate mass okay now whatever happens in the rest of the breast can also happen within the encapsulated breast tissue which means fibro adenomas phyloid estumus cis cancers anything cancers also can happen within hamar tomahs but they are not very very common okay they occasionally happen and we have a poster also which was submitted to that effect okay and this was indeed in keeping with a hamar tomah a focal asymmetry or a global asymmetry does not always mean that we are dealing with a malignancy okay next case this is a 63 year old postmenopausal who comes with new onset spontaneous bloody left nipple discharge okay on the mammogram what do we see once again this is a fatty breast fatty breast means the sensitivity is very good again what are we seeing we are seeing an area of global asymmetry one more time okay it is predominantly in the lower outer quadrant of the left breast but some of it also is extending into the upper outer quadrant okay what is the most likely diagnosis what could we be dealing with here so you got answers from papillomar to dcis excellent so here is what it is on ultrasound we saw dilated ducts with some inter ductal lesions in there when we go a little bit more central proper inter ductal masses are seen within these dilated ducts on 3d tomosynthesis you can see this ductal pattern you can see this you know like how we see on MRI a segmental distribution that triangle shape you know with the tip going to the base of the nipple areola complex and the base posteriorly so this is that triangle right and this was in keeping with inter ductal papillomatosis with dcis okay we are almost there 10 cases down five more to go okay are you guys still with me okay excellent next case we saw a beautiful lecture on implants by Derek what is the most likely diagnosis this is a 32 year old she comes for a routine screening she has had a breast augmentation surgery almost 10 years ago and this is what we see on the mammogram we see bilateral retro pectoral silicone implants so this is the pectoral muscle and behind the pectoral muscle we have seen this implant on the mammogram is there any feature which concerns you either in the right or on the left do we have a diagnosis what are we seeing what could we be dealing with what could we be dealing with okay i'm going to show you one more image on MRI this is what we see okay we see this retro pectoral this is the pectoral muscle anteriorly and behind the pectoral muscle we are seeing this silicone implant okay within the implant what are we seeing are we seeing these layers what is the most likely diagnosis do we have a diagnosis sir yes we've got many diagnoses actually coming implant rupture yes yeah and yokesh yokesh was siddhartha has given intra capsular rupture excellent so that is the answer we are looking for so remember how derrick had described there is the linguine sign and then there is one more sign which is called the salad dressing sign you know you see a little bit of hyper intensity there that's what we see but linguine you know i have said this in one of my previous lectures on one of the forums too but before i left the shores of india and that was many many moons ago like in 2005 many years ago i had not i had not seen what a linguine is and today like you know all you kids have eaten pastas and linguines but when we were growing up there was no such thing so like it could be anybody's imagination what linguine is like but after going overseas eating all that coming back to india i realized if anybody had told me something like you know this is like alwadi sign or patra sign you know how that patra we make there are multiple layers in that i would never forgotten what a lingual water intra capsular rupture is like there is a nice little ball there okay and then there are layers in it just like patra okay so remember that when you see something like alwadi sign or patra sign remember it is intra capsular rupture so this is what it was right breast implant has an intra capsular rupture on the other side the left breast implant looks intact okay you have the uh you have the little uh uh layer from the uh muscle surrounding it the fibrous capsule is intact as well as the true capsule is intact here the true capsule is not intact and therefore we have the intra capsule rupture okay moving on to our next case okay this is a 46 year old who comes for a routine screening mammogram but what is the most likely diagnosis okay the breast is heterogeneously dense it is very hard to make out what is going on on your little laptops here so i'm going to show you some spot magnification views okay so this is what we see on spot magnification views one point that everybody should remember is spot magnification view is does not mean we just blow up the digital image okay these are taken separately these are taken in the cc craniocaudal and ml ml is mediolateral 90 degree view and the we use a smaller focal spot with a stand there why to magnify why do i need to magnify so that i can do a morphologic assessment of these microcalcifications okay so spot magnification views is not synonymous with zooming in on your monitor okay these views are taken separately with a smaller focal spot and like a distance from the detector the distance from the detector is increased to magnify it okay plus it is not the second view is not in the ml projection it is in the ml projection straight lateral view so that if there are layering microcalcifications you see them layering on that straight lateral view okay so these are some important teaching points having said that what we are seeing here is pleomorphic microcalcifications which are grouped grouped pleomorphic microcalcifications okay pleo pleo means different different sizes and shapes if you see closely there are some dots and then there are some dashes here but all the dots are also not the same shape okay some are bigger some are smaller some are fainter some are darker okay so pleomorphic okay as against this when we say monomorphic mono means the same they will all be like rounded dots of the same density these are not pleomorphic grouped microcalcifications what is the most likely diagnosis many sir yeah you got the correct answer from guide 3 dcis she's given okay guide three is a breast imaging contender she's going for a fellowship so dcis dakthal karsanoma in situ that was the diagnosis how do we come to a diagnosis here there are two ways either we do a stereotactic vacuum assisted biopsy you know dr benu vergis is going to be speaking about that in one of the lectures tomorrow or we do a hook wire localization dick also showed one of the cases where we put in a needle along with the wire we remove the needle leave the needle in there and that much part is surgically excised from the breast okay those are the two ways of coming to a diagnosis there is always value in coming to a diagnosis beforehand like before the patient goes for surgery so that one surgical procedure can be planned okay and the outcome for the patient is also good from that next case case number 13 this is a 45 year old who came for a routine screening mammogram okay again the breast is by a category b which means there are scattered fibro glandular densities there is a lot of fatty tissue here okay again because you can't see the abnormality on your monitors i'm going to show you some spot magnification views what do you see on these spot magnification views this is in the cc projection and ml projection okay and remember these are spot magnification views with a smaller focal spot and increased distance from the detector what is the most likely diagnosis you got it again from akanksha okay akanksha gene excellent so here is what we have on ultrasound it corresponded to this void hypoechoic mass with smooth margin also if you notice here although these micro calcifications are pleomorphic and they are coarse some of them are coarse and some of them are fine they are all within a relatively circumscribed mass okay and on ultrasound it corresponds to an void hypoechoic mass with smooth ecogenic margin okay what happens is with age fibro adenomas are typically lesions of younger women they typically happen in the late 20s or early 30s okay but eventually with age as women reach their perimenopausal or post phenopausal age group these fibro adenomas start calcifying but all the calcification does not happen at the same time small dots and ditches start coming up and then eventually the calcifications become more and more coarse and the soft tissue starts shrinking around it okay so therefore when it is in this phase of transition it can look quite sinister okay so oftentimes we will land up questioning these micro calcifications and oftentimes we will call them 4a or 4b and biopsy them okay there is no harm in that these come in the indeterminate category which means the possibility that these micro calcifications could be malignant ranges anywhere between 10 to 15 percent when we call anything 4a a level of suspicion for malignancy is less than 10 percent when we call something 4b a level of suspicion for malignancy is about 50 percent which means there is still a 50 percent chance that it could be benign okay so remember all these little little facts about making decisions next case 59 year old this time this patient complains of new onset palpable lump in the left breast what is the most likely diagnosis sir do we have any answers we're getting a mix from fibro adenoma to hamartoma okay involuting fibro adenoma okay so for this one we still don't have the answer right no okay okay good so this is one of those oddballs those cases and this case we did a spot compression view okay not a spot magnification view what is the difference between a spot magnification view and a spot compression view when we do a spot magnification view we use one of those parallels you know to increase the distance from from the detector and we use a smaller focal spot okay but with spot compression view we do not do that it can be done on the same detector only the compression paddle is changed why do we do that in the good old days now with tomosynthesis we require it far less but in the good old days just to separate out superimposed normal breast tissue such that we can do the margin assessment of a mass we have to we used to do the spot compression view now notice there is definitely a benign popcorn calcification there okay benign popcorn calcification indicates that there has been a fibro adenoma here which is eventually involuted and calcified but right around the fibro adenoma there is another soft tissue mass which is definitely there and which does not have a particularly good margin the margin here looks quite irregular there are even speculations surrounding it okay on ultrasound what does it corresponds to it corresponds to an irregular hypoechoic mass look at the margins there are angulations along the margins there are lobulations along the margin there is also that dense shadowing that we see from the coarse calcification so this is one of that unusual cases like what is the possibility that a fibro adenoma may turn malignant less than 0.1% literally one in a million cases and this was one of those like in my entire career as a breast imager of more than 15 16 years this is my first case of a calcified fibro adenoma with an associated invasive duct carcinoma but it just makes you cognizant of the fact it reminds you that you know there are always exceptions to the rule now the exception does not make the rule but it teaches you how to be like you know how to look for what is beyond what is obvious the obvious thing here is the benign popcorn calcification but that does not mean what the abnormality that we saw we should ignore okay this was biopsied and this was in keeping with invasive ductal carcinoma with an associated calcifying fibro adenoma okay that is awesome okay now this is our last case and some cases are really humbling and this is one of those cases okay now this was a 55-year-old she complained of a new onset left breast swelling and pain since three to four days okay now this patient was you know for lack of better word like she was a little bit slower like you know she she was she knew what she was doing but mentally she was a little bit slower okay so she gave us all the history and she said she's noticed this swelling and she's in pain so she can't get a mammogram done no matter what when we did the ultrasound what did we see we saw a little bit of skin thickening here and we saw what looked like a hypoechoic mass and there was ecogenic breast perenchyma around it there was also a prominent lymph node it almost seemed like you know there was irregular cortical thickening here okay our thinking was maybe we are dealing with um like a inflammatory breast cancer or a locally advanced breast cancer she's 55 she's postmenopausal um and sometimes when there is swelling there can be associated pain okay so we decided to call her back for a biopsy okay she said that she can't get a mammogram done and she was going to come back for a biopsy in a couple of days okay in the meantime nonetheless some painkillers and broad spectrum antibiotics were uh were prescribed to her she did not return back in say two or three days she came back only 15 days later okay but at this stage what is the most likely diagnosis that you would think of i'll show you what happened 15 days later but before that what is the most likely diagnosis that comes to your mind when you see this 55 year old so do we have any answers yeah we got a mixture of answers but you got breast abscess also as an answer we got that yeah so this was what we saw when she came 15 days later there was a huge abscess and there was this blackening of the skin why did that happen because the abscess was so huge that it led to overlying skin necrosis okay but the patient like i explained to you earlier she was a little bit slower she tried to figure out things on her own she tried to take the antibiotics which were not really helping her but in the in this case initially while the abscess was not formed there were only changes of mastitis and i'm going to go back to that image here okay one is like all this ecogenic breast tissue it's a sign of mastitis but the more important thing is when we use linear transducers our depth is not that much okay here we are not even seeing three centimeter thickness of breast tissue okay now when we use the the convex like you know or the larger transducer what what did we have we had a breast tissue of almost four centimeters was getting included here okay and and that time we started seeing all this abscess formation so be know your equipment understand that in bigger breast thicker breast sometimes a beam does not go that deep okay and therefore one has to be very careful and yeah this was one of those cases eventually a deep ride meant was done and patient was absolutely fine but this is it and this is one of those cases which actually teach us what the great Mahatma Gandhi said all the time live as if you were to die tomorrow and learn as if you were to live forever and thank you for your kind attention you are an excellent audience considering that you are here at midnight to learn so thank you to every single one of you congratulations to all those who got the fastest finger first but congratulations to all those of you who participated and Manisa thank you so much for doing everything not just this quiz but everything related to this course it is it is a task by itself thank you thank you Shilpa you you've been wonderful the way you conducted this quiz has been great we we are running it live on youtube also and more than almost 100 150 people were watching without even an announcement so thank you very much for conducting this and everyone who's out here almost 250 people thank you for being with us and we would like to see you tomorrow we'll start again sharp on time there is a slight change right Shilpa in the in tomorrow's session our first session at 9 15 will be by Dr. Raman Verma on how to evaluate nipple discharge Dr. Raman Verma is the assistant professor at the Ottawa Hospital University of Ottawa and he is also the residency program director at the Ottawa Hospital and he's involved with undergraduate medical education excellent teacher please don't miss this lecture and at 10 45 the lecture will be by Dr. Mandar Natkarni who's a breast oncosurgeon he he's a surgeon with more than 16,000 cases he's operated so far in the last 20 years he's been at Tata Memorial Hospital and Ammani Hospital and he is going to tell us exactly what the surgeons expect from radiologists we could find all the things and write fancy fancy reports two three pages but if they don't make any sense to the surgeon it is not going to reflect in our patient's treatment and our goal at the end of the day is that our patients should get the diagnosis in time and treatment in time so he's going to explain to us what we should be spending in those reports what he should be writing in those reports so please don't miss those lectures and then there is a whole bunch of other expert speakers all of them excellent speakers and very good teachers so please be there in time Mitusha any final words before we switch off nothing sir just that ma'am has already told them about tomorrow's the session and we'll start on time so I think all of you can join us tomorrow on time with these excellent panel of speakers tomorrow okay thank you everyone good