 have learned breast imaging under her ABLE guidance. She is consultant breast imaging and interventions at NM Medical Mumbai and former consultant radiologist and assistant professor at the Ottawa Hospital University of Ottawa, Canada. She has received the prestigious President Appreciation Award IRI ICRI 2021 and she has been invited for more than 400 lectures at various national and international platforms. We welcome you ma'am and over to you. Thank you. Thank you. I'm just going to share my screen here. You know this morning I forgot to do something that I normally do and please forgive me. I think it's very important for me so I'm just going to go ahead and do it. A little prayer here. Okay. Without further ado, let's talk about evaluation of palpable breast lumps. Okay. Now, this is an important statement that I came across very early on and this is by Benjamin Franklin. An investment in knowledge pays the best interest means you not just get back for what you have learned but you get back multiplied and magnified. So every minute, every second, every moment that you invest in learning and acquiring knowledge is time well spent. Okay. So what are we going to talk about today? You know, when women get a breast problem, all they are concerned about is do I have cancer or no cancer? Okay. So our job as a radiologist is to give that answer, cancer or no cancer. They don't care about this could be this that could be that it is indeterminate six month follow up biopsy. They want us to tell in simple words. So how can we facilitate that? How can we do that? Okay. Having said that, sometimes it is not that easy. Okay. So we want to know other than the conventional methods, how do we problem solve when ultrasound features or mammographic features are equivocal on our equivocal and we need to we need to do something else. How do we identify which masses we can biopsy? How do we correlate ultrasound findings with mammogram? How do we problem solve when both mammogram and ultrasound do not give us the answer? Okay. And what is the role of contrast enhanced MRI or contrast enhanced mammography in evaluation of palpable breast lump? So these are some of the things that we are going to see in the next 30 minutes. Okay. New onset palpable lump is a common presenting symptom of breast cancer. Okay. Having said that only 20% less than 20% of palpable lungs are cancerous or precancerous. The rest are benign. It is not possible, however, to distinguish benign from malignant just based on clinical palpation. Okay. And therefore we need investigations investigations in the form of a mammogram breast ultrasound. And when do we decide that we need to do more? Okay. Remember, mammogram and ultrasound is basically anatomical or structural imaging for evaluation of palpable lumps. Okay. But sometimes they have limitations. And in those cases, we rely on functional imaging, okay, which is based on the principle of neo angiogenesis. And that's where we require contrast enhanced MRI or contrast enhanced mammography for verbal evaluation. So knowing these basics, we know that these are the few tools that we have in our armamentorium to come to a diagnosis. So let's look at a few cases here. Here are two cases. One is a 63 year old with a palpable mass in the medial left breast. And the other is a 68 year old with a palpable mass in the upper outer quadrant of the left breast. The age group is similar. Patients when they got the ultrasound done, the appearances of irregular hypoechoic solid masses with focal or dense posterior shadowing. Okay. What is the most probable diagnosis? Amitusha, can we have the polling, please? A, Bota cancer. B, Bota benign. C, case one is cancer and case two benign. D, case one is benign and case two is cancer. Or E, we need a mammogram for correlation. I'm glad people are participating. Okay, good. So 150 have voted. And most of you think that we need a mammogram for correlation. About 25% think like almost 50% think that we need a mammogram for correlation. However, 25% are thinking that both are cancer. Okay. Now this is something I want to caution you against. Do not be in the mindset of coming to a diagnosis just based on your ultrasound findings. And I'll explain to you what the reason for that. Okay. So when we did the mammogram, what did we find? Okay. On the mammogram, this is what we see. In case one, in the medial aspect of the left breast, we see a dense mass with peripheral speculations and pleomorphic microcalcifications. While in the left breast, we see what looks like benign popcorn calcification. Oh, I just gave you the answer. So in this case, the right, the case one is a cancer and case two is actually benign. It is an involuting calcified fibroadenoma. However, because of the dense calcification, the appearance on ultrasound can be very similar to that of a cancer. And therefore, this misunderstanding or mistake can happen. Okay. The take home message there therefore is you need an ultrasound and you need a mammogram for correlation. And this is a case from last evening. Like, you know, many of you were there for the quiz, but just to reemphasize the point. Okay. Like in this case, 59 year old nuanced palpable lump in the left breast, we see a benign popcorn calcification. But along with that benign popcorn calcification, there is a soft tissue mass with irregular margin surrounding it. Two pathologies are coexisting here. There is an involuting calcified fibroadenoma and an invasive cancer right beside it. Okay. This happens in less than 0.1% cases, which means one in a million cases. This is not the rule, but the exception to the rule. Having said that, having that mammogram for correlation along with your breast ultrasound is mandatory. Okay. So the teaching points are in women about 40 years of age, presenting with a palpable breast lump always start with a mammogram. If there are pleomorphic microcalcifications associated with the mass, it is more likely to be malignant. And course popcorn calcifications leading to dense shadowing and ultrasound mimics malignancy. Hence correlation with that mammogram becomes very, very important. Okay. Here's the third case. This is a 25 year old with a new onset palpable lump in the upper outer quadrant of the right breast. Okay. What is the most probable diagnosis? A, fibroadenoma, B, poloids tumor, C, cancer or D, cyst. Mitusha, can we have the polling please? Okay. That's interesting. Okay. So we have about 56% of the audience who thinks it's a fibroadenoma and 40% of the audience who thinks this is a poloids tumor. Okay. Now I'll explain why this is what it is and why it is what it is. Okay. So the answer here for us is this is indeed a fibroadenoma. The garden variety benign fibroadenoma. The lesion which is most common in young women only after benign cysts. Okay. Typically these masses, like, you know, we have had the series of lectures yesterday by Summa, Madhvi and everyone was talking and Shikha and they were talking about Byrads lexicon. Like how do we describe such a mass? It is a oval mass, a wide mass with smooth ecogenic margin. Okay. It is uniformly hypoechoic, parallel to the pectoral muscle. It is a solid mass and it has uniform cystic spaces in it. Okay. This is very classic of a fibroadenoma and typically this is the type of lesion that happens in women under 35 years of age with the incidence of about 50 to 75%. Then what does a poloids tumor look like? So let's have a look at this. Here's a 40 year old with nuanced palpable lump in the right breast. Now let's have the polling please. Now what is the most probable diagnosis? Okay. Excellent. So see, look at the power, power of education. 88% of you got the answer right. Okay. Now this one is a poloids tumor. Why? Okay. Now this also has an oval shape, an oval shape, smooth but lobulated margin. It is not exactly homogenously hypoechoic. It is heterogenously hypoechoic. It is parallel to the pectoral muscle, but notice these non-uniform cystic spaces. Okay. This is quite typical. Okay. And these are the lumps that typically happen in the fourth decade of life. We give them B3 or we deem them as high risk and they go for surgical excision, because the borderline cases, like, you know, the ones which are like low grade poloids and like malignant poloids, there can be a little bit of overlap between them and on core biopsy based on limited samples, it may not be, we may not be able to tell. Okay. Therefore, these are considered high risk lesions and they are surgically excised. Okay. Here's another case. 27-year-old lactating female presents with a new onset palpable lump in the upper inner quadrant of the right breast. What is the most probable diagnosis? There is a full lecture coming up on legions during pregnancy and lactation, but this is just one of the cases to give you an idea about, you know, the whole range of fibroadenomas and poloids. Okay. So what is the most likely diagnosis? Mithusha, may we have the polling please? Okay. So almost 50% think that this is a fibroadenoma. Okay. And the other 40% think that this may be a galactosil. Now, here is something that I want to caution you about. I want to caution you that as soon as a lactating woman walks in through the door, even before we scan her or even before we ask her for the history, we are thinking of one of two things. We are either thinking galactosil or we are thinking abscess. Okay. We do not want to broaden our imagination, but that is right also because common things being common will happen first. However, in this case, what was the diagnosis? This was actually a cancer. Okay. How did this happen? This is only a 27-year-old besides she's lactating. Okay. Look at the mass. Although it is an oval mass, it is an ovoid mass, there are micro lobulations along the margin. So see this margin? These are called micro lobulations. This is a sinister sign. The mass is heterogeneously hypoechoic, although it is parallel to the pectoral muscle. There is also one, another sinister finding, which is an enlarged lymph node with complete to near complete loss of fatty hyalum. Okay. So in this case, if you see something like that, a solid mass with some indistinct features or indeterminate features, like in this case, heterogeneously hypoechoic with micro lobulations and an enlarged lymph node, you should don't get biased by the age of the patient or the fact that she's lactating. Pregnancy associated breast cancers is a known thing and Dr. Poonam Bajaj will be talking about it in detail in the subsequent lecture. Okay. But this is just to bring to your attention that don't assume any, any solid lesion happening in a young woman could be a fibroadenoma or at best a phylloids tumor. Cancers do happen in younger women too. Okay. So what are the things that we look for? If you try to imagine the margins, this becomes easier. If it is a fibroadenoma, a classic fibroadenoma will have a smooth margin like a Mari biscuit. If it's a phylloids tumor and there are gentle lobulations, it starts looking like animal crackers. And if it is a cancer in a younger woman, they typically are oval or avoidant shape. It's very hard to come to that diagnosis of cancer immediately. So look for other subtle signs, like not just the shape, but the margins, the through transmission, the ecogenicity, all of that has to be put together. Remember Derek's talk yesterday and look for those micro lobulations. So ask yourself, am I seeing a Mari biscuit margin? Am I seeing a Monaco biscuit margin? Or am I seeing animal cracker margin? Okay. One by one, you start evaluating these features. What are the other things? Like Derek explained in his talk yesterday, other than the, you look for angulations along the margins, you look for micro calcifications associated with the mass, you look for these speculations, lines going out from the mass. And when you put everything together from your ultrasound and your mammographic features, you will be able to reach to a conclusion, whether we are dealing with a malignant or a non malignant lesion. But is that the final answer? Somebody got a muted. Please mute yourselves. Thank you. Okay. Next is a 30 year old who presents with a painless palpable lump in the left breast. And this happened happened so often, right? Lots of young women come with either pain in the breast or they come with focal area of palpable nodularity. Okay. So what is the most probable diagnosis? 30 year old painless palpable lump in the left breast? A, is it normal breast issue? B, is it a fibroadenoma? C, is it a cancer? Or B, do we need a mammogram for correlation? Participate in the voting because that makes you think and anytime you think about a problem, it registers. Okay. So I would encourage all participants to participate in this polling. This is an important exercise. Now, everyone has said need a mammogram for correlation. I would like to caution you first. Okay. First thing is not every young woman requires a mammogram. Okay. Mammogram is reserved for typically performed for women about 40 years of age. But if the woman is less than 40 and there is some finding on the ultrasound, which is inconclusive or indeterminate, then we can perform a diagnostic, that single mammogram is called a diagnostic mammogram for correlation. In this case, I could clearly feel the palpable lump. It was what looked like diffusely ecogenic breast perenchyma. There were hypoechoic spaces, but we were wondering are they calcifications? We could not understand. The fact is we really could not understand what was going on. So the decision to perform a mammogram. Okay. When we perform the mammogram, what did we come across? On the mammogram, although the mammogram is dense, do you notice something? Do you notice something here corresponding to the area of palpable concern? What we saw was pleomorphic micro calcifications in a regional distribution. Okay. Oftentimes, the clinicians will ask us, what are you going to achieve from a mammogram? In any case, this is a young woman, the mammogram will be dense. But things such as pleomorphic micro calcifications and architectural distortions can still be seen on a mammogram. Therefore, performing that mammogram for problem solving can be pertinent. Okay. So given this finding, now what is the most probable diagnosis? A, is it normal breast tissue like we thought initially on ultrasound? B, is it a fibroadenoma? Or C, are we dealing with a malignancy? Once you see pleomorphic micro calcifications on the mammogram and that too in a regional or segmental distribution, what should you be worried about? Okay. Almost 86% of you have got it correct. 85%. Yeah. And everyone, like 85% of you agree that this is a cancerous lesion. Okay. This is indeed in keeping with high grade DCIS. This is very classic, pleomorphic micro calcifications in a regional distribution. So what's about this radiation? What's up with the radiation? Not just the clinicians, but also the patients will question you because they have done enough reading on Google that radiation is harmful and therefore they don't want a mammogram. They will take half an hour of your time in your clinic and complain and argue with you. So what is the remedy for that? What is the solution for that? Knowledge is power. If you know your stuff, you can explain not just to the clinician, but also to your patient. You must know that a single mammogram will give a radiation dose of 0.0004 grade. Okay. One grade is equal to 1000mg. Okay. So, and the fatal dose is usually about 5 grade. To reach that fatal dose, you know, how many mammograms a woman would need? 12,000 mammograms, 12,500 mammograms. Do you think in one lifetime any woman will have 12,500 mammograms for some context? In Hiroshima, the dose that was released in that bombing was 9.4 grades. Okay. Sometimes I simply tell my patients, I assure you that I'm not going to bomb your breast in the mammography room. Okay. Be rest assured. It's minimal mammogram and the real risk in our country is locally advanced breast cancer. Mist cancer is leading to locally advanced breast cancer. That is a real risk, if we are looking at risk-benefit ratio. And the risk of developing a breast cancer from that one single diagnostic mammogram is close to nil. Therefore, don't be afraid of doing that mammogram if you need to do it. Okay. Remember, I said, if you need to do it, don't unscrupulously start doing mammograms for women under 40 who do not need it. But if you need it, there is no harm doing it. Okay. Oftentimes, when you take one flight from Mumbai to London, you will get more radiation than you would get from one mammogram. Okay. So, if you explain this to the patient and if you explain this to the clinician and most of all, if you know that you're doing the right thing for the patient and this radiation is not harmful, then please go ahead with it. Okay. Now, the teaching points here are in women below 40 years of age, thorough assessment of morphological features on ultrasound is paramount. If the features are suspicious on ultrasound, then proceed to a mammogram. If they're indeterminate on or suspicious on ultrasound, then there is no harm in proceeding to perform a biopsy. Next case, this is a 40-year-old who presents with a new onset palpable lump in the right breast. And this is what we see. An oval anechoic mass with posterior shadowing. What is the most probable diagnosis? A, cyst, B, fibroadenoma, C, cancer, or D need aspiration for correlation. Now, we have the mammogram also and we have the ultrasound also. What is your diagnosis? Okay. That's good. Okay. So, most, almost 76% of the audience has voted for cyst, which is the correct answer. However, 22% think that we should do an aspiration. So, that is a point that needs to be explained. Okay. This is how a simple cyst, a classic typical simple cyst looks. Avoid a round mass, smooth margin, predominantly anechoic. It may be parallel to the pectoral muscle or may not be. It's typically a cystic mass with posterior through transmission. And the most common cause of breast mass is in premenopausal women. Okay. We typically do not recommend aspirating benign cysts. The reason being you remove one cyst, you aspirate one cyst, she's going to develop some other. So, when do we actually aspirate cysts? If they are very large, sometimes the patients will say that I can, you know, I can feel the, I can see the lump through my clothes, through my bra. Okay. It's gotten that big, like five centimeter or over, or sometimes they get very painful, which means they have bled into themselves. Okay. In those cases, we do cyst aspiration. Those are the two indications where cyst aspiration is indicated. Otherwise, we do not recommend aspirating simple cysts or benign cysts for that matter. This is the next case. Again, same age group, 40 year old with painless palpable lump in the right breast. What is the most probable diagnosis? A, cyst, B fibroadenoma, C cancer, or D, need aspiration for correlation. Again, we have a well-suscribed mass on mammogram and on ultrasound, we see this, what looks like an ovoid mass with smooth margin and posterior through transmission. So, what is the most probable diagnosis? Mithusha, can we have the voting please? Looks like the voting option is not working here. So, in any case, I'll give you the answer here. The answer here and brace yourselves, people. It is a cancer. Okay. So, how did that happen? Okay. Look at the mass now. Okay. It is heterogenously hypoechoic. Okay. And, sorry, Mithusha, we don't need the poll here because I've moved on. Okay. Although it looks like it is, it is avoidant shape, look at the margins. There are angulations along the margin. There are angulations along the margin. Okay. There are non-uniform cystic spaces, which is a sign of necrosis within the lung. And this is, like I explained earlier, typically seen in very high grade cancers, typically seen in triple negative cancers. They grow very, very fast. They are very, very cellular. So, because they grow fast, that classic speculated mass is not seen. Speculated masses happen in low or intermediate grade cancers. When they grow slowly, they cause a desmoplastic reaction in the surrounding breast tissue. And therefore, we get speculated masses. In high grade cancers, triple negative cancers, they grow very fast, so they are well circumscribed masses. And the posterior through transmission is not a sign of benignity. Posterior through transmission just indicates that it is a very cellular mass. And the satisfaction of search can be a very bad thing in radiology. Okay. As soon as you find the lesion, sometimes you're like, okay, it's a cyst. Finish. Remember to scan through the lesion. Why? Because you notice in the first image, it almost looks like a well circumscribed mass. Only when you scan through the entire lesion, you notice the margins, the ecogenicity, the necrotic spaces, and the rest of the thing. Okay. So, doing a thorough job, even after you find a lesion becomes paramount to coming to a correct diagnosis. Okay. This was in keeping with invasive duct carcinoma grade three. This was one of the triple negative cancers. Okay. So, just to give you an overview about what benign or malignant lesions would look like. A fibroadenoma, a classic garden variety fibroadenoma, this is what it looks like. A phylloidine with the lobulations, non-uniform cystic spaces, a benign synthesis, or an invasive duct carcinoma, which is typically high grade. There can be an overlap of features here. But if you look at the smaller nuances, you will be able to come to a diagnosis and make a decision as to which of these goes to a biopsy. Okay. Important point to remember, posterior through transmission is not a sign of benign lesion and non-uniform cystic spaces can be a rather concerning sign which requires biopsy. Now, here are four cases which have put together. Which is the most probable cancer? Case eight, where we see a well-succumbed mass in the right breast. Case nine, where we see a small little irregular mass in the medial right breast. Do we see anything in case 10? It is a heterogeneously dense mammogram and case 11. It is a complete whiteout. So which of this is most likely a cancer? Yeah. Most of you think that it is case nine and case 10. And I can understand why. Okay. 70% think that case eight and case nine is cancerous. But I have news for you. Okay. And it is not very good news. The news is all of the above have cancer. How did that happen? We are only seeing lumps or masses in case eight and case nine. What happened to case 10 and case 11? We have been advocating mammography all through the talk and now mammography is not helping us. How did that happen? It was not supposed to happen. Okay. Remember, it is the nature of the beast. What does that mean? Breast is a combination of fat and fibro glandular tissue. More the fibro glandular tissue, lesser the sensitivity. More the fat, higher the sensitivity. So when we have what we call a fatty breast type A breast composition, it is very easy to see masses. It is easy in type B also where there is 50% fat and 50% fibro glandular tissue. But as soon as the fibro glandular tissue gets more, like heterogeneously dense or dense, it is impossible to see what is happening behind that fibro glandular tissue. Okay. In this case, there is at least an area of architectural distortion. What we mean by architectural distortion is the normal breast perenchyma is getting pulled in. Remember, we used to have those little pouches. My grandmother used to carry one little pouch to put all those coins. And there used to be a drawstring on top of it. When you pull the drawstring, how things come together. That's what happens when a cancer is developing, rest of the breast tissue pulls in together. And that is what architectural distortion means. Okay. So at least that subtle sign is there. But in case 11, it's a completely white mammogram that subtle sign is also not present. But there are cancers in all four of them. Okay. And like I said, density plays a vital role in detection of lesions on a mammogram. Dense of the breast, lesser the detection rate. So correlation with ultrasound is also mandatory for new onset palpable lumps. Now last couple cases. This is case 12. 46 year old presents with painless palpable lump in the right breast since one month. She also has a strong family history of breast cancer. And this looks like a nice beautiful pristine mammogram. There is enough fat in there, very little fibro glandular tissue. She's complaining that she's feeling the lump. When we do this beautiful high end digital mammogram, do we see anything in the right breast? Not really. Okay. Now we do our ultrasound also, because we are not seeing anything, right? What is the most probable diagnosis? Now this is something, Mithush, let them take the question for a poll for this one. Most probable diagnosis, normal shadowing breast tissue. B, we can ask for a six month follow up because we are not certain what is going on. C, cancer or D, need additional evaluation. Okay. So we have like, you know, the floor is divided literally between C and D. C, like 33% feel that there is a cancer. And 45% think that we need additional evaluation. Okay. We were one of the 45%. I was not sure that if I decided to biopsy also, I would get the right region. Where does the mass start? And where does the shadowing start? Will I know the transition? Even if I do a blind biopsy? Like I wasn't sure. I definitely needed additional evaluation here. Okay. So what did we do? We perform contrast enhanced MRI. And on the contrast enhanced MRI, what did we see? We saw asymmetric non mass enhancement and she explained to us very nicely. Like, you know, how this pattern of enhancement is described. It is in the segmental asymmetric non mass enhancement, which is very, very concerning for two things. What could we be dealing with here? Okay. A, normal enhancing breast tissue. B, fibrocystic change or C, invasive lobular carcinoma. Can you take the polls please? That's correct. Invasive lobular carcinoma. So invasive lobular carcinoma accounts for less than 15% of all the invasive cancers that we see in the breast. Okay. But most of the times they may be occult on conventional imaging, such as mammogram and ultrasound for one reason. These are, these are cancers which grow along the Cooper's ligament. So they do not give rise to that classic desmoplastic reaction or classic masses. But because they are tumorous growths, there is no angiogenesis. And therefore on MRI, we see them as asymmetric non mass enhancement. Okay. And this was indeed in keeping with invasive lobular carcinoma. So other than density, is there any factor at play? Like I explained, new angiogenesis plays a vital role in detection of cancers. Therefore, contrast enhanced MRI has a higher sensitivity as compared to a mammogram. So between mammogram and contrast enhanced MRI, it is like structural imaging or anatomical imaging versus functional imaging. So should we do an MRI for every case? Not really. It is not indicated. We always start with conventional imaging, mammogram, ultrasound, and I'll tell you 80% of the times we can resolve issues with that. It is only those 20% of the times we need high end functional imaging in the form of contrast enhanced MRI. But the problem remains that contrast enhanced MRI is slightly expensive. And sometimes patients can also be claustrophobic. So do we have any other tool that which can be helpful? So let's look at that. Okay, with a contrast enhanced MRI, we at least need 1.5 through 3 Tesla magnet cost of the equipment, image acquisition, longer time of acquisition. Some patients are claustrophobic. And above all, expertise for interpretation, not all the radiologists across the country are trained to read MRI. But women need problem solving in cases like that. So what is the other option? Is there any other cost effective one-stop shop where we will get structural as well as functional imaging? Along with 2D, fulfilled digital mammography, now we can also do contrast enhanced mammography. And there's a full talk coming on that by Rashmi Sudeed later in the afternoon. Okay, so just this one last case to drive home the message, 42 year old with occasional palpable lumpiness in bilateral breast on and off. Do you see any abnormality? The mammogram is beautiful. Pristine, very good technique, very good quality. We see scattered fibro glandular densities, 50% fat, 50% fibro glandular tissue. Are we seeing any abnormality? Perhaps this little focal asymmetry in the lower inner quadrant of the left breast. So when we do an ultrasound, this corresponds to an opioid hypoechoic fibro adenoma in the lower inner quadrant. But in the right retro aerial region, I see all these dilated ducts with inter ductal lesion or inter ductal debris, I don't know. So I compare to the contralateral left retro aerial region. And in the contralateral left area area, sorry, left retro aerial region, I see normal sized ducts. Okay, now what should I do? Is this concerning? What should be the next step? Okay, normally I would have asked for a contrast enhanced MRI. But our newest acquisition was contrast enhanced mammography. And trust me, it only takes 10 minutes to perform a contrast enhanced mammogram. We have to establish a vein, inject contrast, make sure that the patient does not have any contrast media allergies, serum creatinine is done, okay, which in our institute we can get within 45 minutes because it's in the same center and we performed a contrast enhanced mammogram. Okay, what did the contrast enhanced mammogram show us? Tada. There was asymmetric non mass enhancement involving the entire upper outer quadrant of the right breast. Okay, now I know what the abnormalities and where the abnormalities. So we do a core biopsy of the right retro aerial region. And it turns out to be a high grade intraductal carcinoma, okay, high grade DCIS. Okay, so CEDM can be performed on the same unit as your 2D digital mammography, called requires an additional software on the same FFDM unit and time of acquisition is the same as a 2D mammogram. It does not require that much expertise in interpretation because you know the way we look at things is similar to a mammogram. So teaching points, mammogram and ultrasound gives us structural imaging, contrast enhanced breast MRI and contrast enhanced digital mammography give us morphological and more importantly, functional information reliable problem solving tool for excluding malignancy that cannot be confirmed with conventional imaging. Okay, remember it is only a problem solving tool. Most of your questions will be answered on the mammogram and ultrasound and the subsequent biopsy. Okay, and remember be cognizant of this fact most of the cancers will happen in women above 50 years of age. Okay, that age group of 40 to 50 is very risky because 10% of the 10 to 20% of the times it can either be a cancer, cyst or fibroadenoma. So your antennae should be out all the time especially for that age group. But also remember below 40 years of age like 26 to 40 or even below 25 years of age, the incidence of cancer is not zero. Okay, it ranges between 1 to 10%. So don't assume that because it's a young woman, it can't be cancer. Have a thorough assessment of those lesions and your level of suspicion should always be high. In summary, palpable breast masses rank second to breast pain among the common presenting symptoms. Wrist of breast cancer varies with age. For nuanced palpable lumps in young women below 30, always start with ultrasound. For women over 40 or women under 40 with suspicious ultrasound features perform mammogram and ultrasound. And only if your mammogram and ultrasound are equivocal, then go ahead for functional imaging in the form of contrast enhanced MRI or contrast enhanced digital mammography. And remember in breast imaging, it is always, always, always multimodality approach and image guided core bios scenes for definitive diagnosis. Okay, with that I wish to thank you, but I also want to remind you of this Hippocratic oath that we took. I will remember that there is art to medicine as well as science. And that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist drug, which means don't forget your compassion and empathy towards your patient. For you, it may just be one of 100 women that you are seeing. But for that patient, you're the only doctor she's come to. And she's very, very concerned that she may be dealing with breast cancer. Okay, so as long your compassion and empathy is in place, you will be a good doctor. Okay, so thank you for your kind attention. And I'm going to