 that's after the way you conduct all this. So thank you, Barry. And now let's move to the talk, which is just a revision, a quick revision of whatever we have done since morning. And here are 20 interesting cases. We have kept it without polling options. It is fastest finger first, which is just because you can answer quickly in the chat box. And there will be prices for the last three questions. So please stay tuned. And meanwhile, our experts are there in the background to answer your queries in the Q&A, which have been unanswered for a while. And now let's start with the cases. So just you can go through these cases quickly and put on in the chat box the answers, whichever you feel the correct ones for the last three questions are going to be the prize winners. So let's begin with the first case. This is the case on your screen ultrasound image, which is there. Few of these are going to be spotters, few of them are going to be revisions, few of them, which we have not covered. So yes, answers are coming up. And so good beginning. So people are answering intraductive papilloma and that is what it is. So it's a very perfect image of an intraductive papilloma and ultrasound, where a well defined ecosionic lesion they have shown quite well in a dilated duct. We might not get this kind of image but if we truly have a high resolution system and we can get this kind of image and we can always put in Doppler to see the vascularity if it is any. Sometimes they might be just in speciated secretions, which may appear as ecogenic areas within the dilated ducts. Our next is this case on your screen, few MR images, which are all fat suppressed, few of them are post contrast. So they are very typical images so you can just quickly identify and put up the answers in the chat box. So we are receiving answers, abscess, mastitis. So mastitis is one thing, then mastitis with abscess. So let's see what it is. This is mastitis, inflammatory granulomatous mastitis and Dr. Sabita Desai took this in details, told us about differentiating it from tuberculosis variety of mastitis from a typical granulomatous kind of mastitis. A patient will complain of a painful lump or painful swelling in the breast. Sometimes it will be not like a lump but a diffuse swelling or redness in the breast and then we kind of see these features on MR. It starts with ultrasound, usually mammogram is not possible because of the pain in the breast. Our next question, these are a few of them are just like spotters in the exams and we do understand that for various exams including DNB, MDs and FRCRs we do have at least five to six spotters from the breast imaging perspective. So all of you are correct who have identified this as oasis. It's a typical pattern of thin wall calcification, which we do see in our routine practice. It's a benign breast lesion where an area of focal fat necrosis becomes wall with a fibrous tissue. So you see this kind of axial calcification. Our next typical spotter which everyone must have seen in their collections of spots and correctly you have identified it as neurofibromatosis. So this is the typical appearance of multiple exophytic lesions which on mammogram have superimposed and this is breast neurofibromatosis. Now this after the last talk will be very easy, which Dr. Sonal Garb took in depth. So this is a 41 year old and fat macrosis, gynecomastia, nodular gynecomastia. So correct, this is asymmetric glandular tissue and this is gynecomastia. So Dr. Sonal took in details about the type of gynecomastias, the nodular and right equipments and that also in pediatric age group. The mammograms are usually not performed, but this was a 41 year old with asymmetric lumpish feeling in the retro aerial region. So this is gynecomastia. Here you have one single image and two different pathologies, one in the right breast, one in the left breast. So you can just mention the pathology in the right breast first and left breast next. So these are your MR images, axial MRT2 weighted images. So one pathology is in the right breast and one of them is in the left breast. So this is your right breast, this one is your right breast and this is your left breast. So people are answering intra-capsular rupture in the right breast and extra-capsular rupture in the left breast. Okay. So for implants, breast implants is a little bit different topic in itself and we have been keeping 15-20 minutes talk on the implant imaging. And the most common question which arises in implant is whether there is rupture or not, that is the first query. And then rarely we have masses associated with the breast implants, lymphomata, proliferative diseases associated with breast implants, etc. So this is something which we commonly see in evaluation of these breast implants and this is something which is related to the complications of the breast implant. So in the right breast, this is not rupture but this is just a radial fold. And in the left breast, this is intra-capsular leak or rupture. So basically these radial folds are going to be well defined and they are going to be continuing. From the outer margin, you can just trace them and just coming back into the continuity with the rest of the implants. Shape of the implant is well maintained and these are also very small lesions as compared to the different signs which we all of us know for the intra-capsular rupture of breast implants. So after implantation of a silicone or a saline breast implant, a fibrous capsule forms around the implant and when the implant ruptures within that capsule, it is the intra-capsular rupture. Otherwise, if it is a complete leakage of silicone outside that particular capsule, that is an extra-capsular rupture. So most commonly what we see is intra-capsular rupture and all those signs which we have been reading that linguine sign, all those are for the intra-capsular rupture. Whereas in extra-capsular rupture, what is going to happen is the implant contour is going to change and that can even be detected with clinical examinations or mammography. But intra-capsular rupture can be easily missed on clinical examinations and even on mammography. So for the intra-capsular rupture, MRI is the best technique to evaluate the implants. We have specific sequences where we can suppress the silicone, we can suppress the water content and the saline implants can be evaluated as well. So we run those sequences, we might not need contrast for evaluation of the implants and we can always comment upon the status of the implants. Next is this case, again a typical exam kind of spotter. A mammographic image you can start answering in the chat box. So we are receiving the answers, extra-capsular rupture, silicone granuloma, silicone leak. So this is definite extra-capsular rupture and the silicone has leaked out of the breast implant into the adjoining parangaima. Now this is not something which is difficult, but what happens is usually on a routine mammogram if we see this lesion, we may get confused. And the second local ultrasound or the ultrasound with the mammogram can clear all our doubts. But sometimes we have seen patients who have been referred even for MR for this kind of lesion. So these are benign intra-memory lymph nodes. So all of you are correct in identifying these. A very common typical finding and asked as an exam question regarding the type of calcification. So fibroidinoma, popcorn calcification. Somebody has also answered has hama-toma. So these are typical macro calcifications which have happened in cases of involuting fibroidinoma. So benign lesions with benign pattern of calcifications. Next 10th question on your screen. So hama-toma calcified fibroidinoma calcified implant. So quite variety of answers, but most of you are correct in saying that it is implant which has calcified. Not, it's going to be a very well-defined structure with calcification and patient is going to tell you that they underwent implants. And then this kind of pattern of calcification has occurred. So calcification of the fibrous capsule around the breast implant can present like this. And that is not a hydratid or a fibroidinoma, but with the clinical correlation, it's very easy to identify this. Now coming next, these are commonly seen maybe at least once a year or so. If you are practicing dedicated breast imaging, you may get these kind of large typical lesions. So as correctly said, breast within breast appearance, you have this lucency around this lesion, a well-defined large lesion dense, but has a lucent margin breast within breast. So hama-toma. But one of them, one of the answers is also phyloids. So sometime it can really be confusing. So I have kept a few slides regarding the same. So these are fibroidinolipomas. So they have all the components which a normal breast has. Normal breast also has fibrous adenomatous, that is glandular and lipomatous components. So that is why it is nothing but like a normal breast parent faima. So breast within breast and this is truly a hama-toma. Mean age is usually 45 years. And you can identify them very clearly on mammograms, ultrasound. And sometimes even if they are large, very large or confusing with phyloids, MR may be done for these. Lesions. If they are very lucent and fibro fatty breast is already there in the background, you might miss these lesions if you don't see carefully. And these are the large bulky tumors, the phyloids which are fibro epithelial tumors. So most of the time they will be solid lesions, large solid dense lesion in the breast, parent faima, not that typical appearance of fat content and lucencies as we see with hama-tomas. So there have been one reported case. This is a borrowed example where the breast has both the lesions. So you can see here that on the mammogram there are two separate lesions present inside the breast parent faima. One with fat content with a lucent margin. Another which is more dense and more bulky. Here both of them are superimposed with each other. And here we can see them separately. So this is the MR picture making everything very clear. So you can see this lesion is soft as if it is insinuating along the larger solid lesion. And it has clear fat components. So this is the hama-tomatous component or a separate hama-toma. And this well-defined lobulated solid lesion is the phyloids which is a fibro epithelioma. So that was about the two which might confuse with each other sometimes. Now the next question. So what is the procedure and what is the pathology? So ductography, galactography, ductal ectasia. So this is ductography also called as galactography. And you can evaluate specific ductal pathologies using this particular technique. And what we are seeing here is ductal ectasias. We can also perform these for introductory lesion specifically papillomas and papillomatosis as well. Another case on your screen, case number 13. Now here I have just given the mammogram. But usually for these patients ultrasound will be done. And sometimes even MR might be done for further evaluation. As ma'am talked about contrast enhanced mammography that also can play good role in these kinds of cases. So breast carcinoma, inflammatory breast cancer. So you can see that large area which is of increased density with overlang dermal thickening, some nipple retraction, ill-defined margins. So this is inflammatory carcinoma of the breast. Next case, case number 14. So one single MR, axial, T1 weighted image and then mammograms. So you see quite a loosened lesion which is of fat intensity, well-defined fat intensity. So here this is lipoma as against hamatoma which had everything and fat as one of the part of the lesion. So all of you are correct in identifying this as a lipoma. Next is this one. So one typical ultrasound image. Definitely multiple, when actually the patient was screened multiple images were taken and a lot of other sections were also taken. But this is like an echoic cystic lesion with a small eccentric ecogenic component. And Doppler is showing the color flow as well. So intraductive papilloma and intracistic CA. So just to make you aware that these lesions which are present within the dilated ducts or even within the cyst, they are not always benign, but they also can be malignant. And specific those characteristics or criteria for malignancies, they also fit to these lesions whenever we are evaluating. On ultrasound, they will be seen clearly on Doppler evaluation. They might have color flow that is one of the characteristics, irregular margins. So this is intracistic papillary breast carcinoma. Another typical exam kind of spotter on a ductogram. So all of you are correct in identifying this as a filling defect on a ductogram. A well-defined filling defect which is within the lumen of the duct and it is intraductive papilloma. We cannot comment whether it is carcinoma or not just based on this ductogram. But the other modalities will also be required for a complete evaluation. So this is spotter number 16. From spotter number 18 onwards, we have prizes. So please stay tuned 18, 19 and 20. Whoever gets the correct answer first, we will be giving sharing prizes with you. Easy question, just as a revision. Identify the types of kinetic curve on this image. So yes, it is type 2 curve. Just a quick revision of these kinetics curve. So when we perform dynamic MRs and now with contrast. Captain is the winner of this one. Captain is the winner. Captain is the winner. So the prizes are from the next question onwards. 18 number. I am watching out for the first prize. Yes ma'am. So these are the three types of curves which we get in all the kind of dynamic evaluation. One we have to see how early is this rise getting in as compared to the normal breast parent kinema. That angle is important. How quickly is the contrast getting inside this lesion. That is one feature. Next we have to see how the contrast is behaving afterwards in the same lesion. So a rapid enhancement followed by either wash out or a plateau phase or a persistent kind of enhancement. So persistent enhancement is type 1. Getting into a plateau phase is type 2 and wash out is type 3. So type 3 are the types of lesion which are more prone to be malignant and type 1 are benign. Type 2 are also mostly 60 to 65% they are benign. But it is also said that we cannot simply rely on these curves. Most of the time we may get combinations of type 2, type 3. But whenever we are getting features corresponding to type 3, we should be taking in efforts and characterize and see whether it is coming into Bayerat's 4 or 5 category. Now is the question which will have a prize. So this is the question on your screen. So you can identify the type of calcification. This is a very basic question. So easy ones. Just the last session for the day. So relax. So Surbhi got it first. She gave plasma cell mastitis. Right. So Dr. Surbhi congratulations. And please share your meal ID and phone number so that we can share your prize. Plasma cell mastitis is that is the answer to this. And this is the kind of typical rod like calcifications. So that is what is shown in this image. So congratulations Dr. Surbhi. Next on your screen. Easy one again. So we just kept easy questions for the prizes. Utkarsh Yadav got the first answer for this one. Correct. So congratulations. Utkarsh and congratulations to everyone. Actually you have been really fast in answering all the questions. And Dr. Utkarsh please share your mail ID and phone number in the chat box. So this is page it. This is and it may sometime just be limited to the nipples. And clinically also there will be features which will help identify the condition. But still imaging will be playing important role because we have to understand that it is a pre-malignant condition where DCIS may be associated. So it has to be imaged ideally using MR will be a good modalities to understand the depth of involvement. Stage zero is when the lesion is confined only to the epidermis. And stage one where DCIS is there associated just beneath the nipples. Stage two extensive DCIS and stage three is invasive ductal carcinoma in association with this disease. We have got our first two winners Dr. Surbhi and Dr. Utkarsh. Dr. Utkarsh please share your mail ID. And now the last last question. And this is also a price related question. So this is the case on your screen. People are thinking confused. Yeah, this is a little rare case. So philories we have already discussed. So this is not philories. You can just re-attempt. That's not a quest problem. Till we get the winner you can keep on attempting no problem. I'll just keep this slide for 15 seconds more maybe. Yeah, we are still waiting for the correct answer. So if you are very close but... Okay, I think we are getting there. Yes. Okay, now you give the answer. So I think ma'am we can give it to Dr. Mona. Yes, absolutely. Mona has got it. Congratulations Dr. Mona Mehta. And requesting you to share your mail ID and phone number. So this is the last case. And this is really a diagnosis of exclusion. So it's difficult to identify on just limited images on the screen. But this is something which we should be aware of. Pseudo angiometer stromal hyperplasia. It's a benign condition relatively uncommon form of stromal overgrowth within the breast tissue. And that is mainly because of the hormonal reasons. That is the imbalance between progesterone and estrogen. And most of the time the tissues which will respond to these kind of conditions are those with receptors for progesterone and estrogen, both of the hormones. So it is usually... It's often grown over time and may recur even after biopsy. They are neither associated with malignancies and nor they are considered to be pre-malignant lesions. In histopathology, we see a bit... lacunes of blood or spaces within the mesenchymal stroma. Mammography-wise, there will be well circumscribed masks which will be present asymmetrically in one of the breast and they will lack calcification. Ultrasound-wise, this will resemble fibroidinoma. And MRI-wise, again, non-specific features but persistent. Contrast enhancement is one of the features which can be seen. This is a patch which is the lesion which I showed on the last screen. So thank you all of you for participating, staying tuned. And congratulations to Dr. Surbhi, Dr. Uthkarsh and Dr. Mona. So your prizes are on the way. And thank you, Dr. Gauri, for helping us with this session. So with this, I would like to thank you all and for being a part of this entire masterclass event. And not only this, but since morning, we have all our experts who took out time on a Sunday and they brought all the concepts which we wanted to learn about regarding the breast imaging. So thank you, everyone, once again. And over to Shilpa, ma'am, to conclude the session. Yes. Thank you, Mitusha, for a nicely conducted session. Thank you to all the participants who actively participated in the quiz at the end of a long day. And for joining in on a Sunday for being a great interactive audience. So without you, we can't have the program. I have said this before also once. You know, at reclamation, there is one beautiful sculpture. And below the sculpture is a writing by Vithal Kamath. There's a child and a mother. And the writing says, a child gives birth to a mother. You know, till then, I only thought a mother gives birth to a child. But it is the other way around also. We will conduct all the sessions and good lectures. But if we don't have good participation, who will we speak for? So we are truly grateful to all our participants. We are truly grateful to all our faculty. We know some of them are so busy. Some of them are actually doing two lectures today. So that's why they have sent recordings for us. So their commitment to teaching, their commitment to sharing their knowledge, their commitment to making it easy for all of us to understand is what we truly appreciate. So we thank every single faculty member, Amir Kulkarni, Jwala Shrikala, Rupa Ranganathan, Poonam Bajaj, Sabi Desai, who's Sabi Desai, Shikha Panwar, then Binu Vargas, Sonal Garg, Mitusha Gauri, did I forget anyone, Mitusha? Yes, I'm fine. Well, I can't thank myself. But no, thank you every single one of you. Amandhaftari. So thank you everyone. And Dr. Deepak Patkar, Mamta Ma'am, Mani Sir, Dr. Jignesh Thakkar, Dr. Shailendra Singh, Amit Poonkar, who's always in the background, making sure everything works fine. And my dear friends, Mitusha and Gauri, always being there. So thank you every single one of you, heartfelt gratitude, enjoy the rest of your Sunday. And we will see you again next year, same month. The dates may be a little variable,