0:02

Hello and welcome to Case Crunch Rapid Case

0:04

Review for the Core Exam hosted by Medality.

0:07

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0:14

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0:33

Without further ado, please enjoy this case review.

0:37

Great.

0:37

Thank you so much for the introduction, and

0:39

I'm happy to be lecturing today to MRI Online.

0:42

Um, this lecture is called Diagnostic Workup, and

0:46

it's gonna focus on some basic but important,

0:48

um, topics that I really want to emphasize.

0:52

And I think they're board-relevant and

0:54

also practical, clinically relevant.

0:56

So I hope you find it helpful,

0:58

and please feel free to ask me any questions.

1:00

Um, a diagnostic—uh, I focus

1:02

on breast and abdominal imaging.

1:04

I'm at MD Anderson and Cooper, um, in

1:06

South Jersey, right outside the Philadelphia.

1:09

Um, all right.

1:10

So the goals of the lecture are to highlight

1:12

the diagnostic workup for masses, asymmetries,

1:15

calcifications, and palpable lesions.

1:17

We're gonna discuss the different types of diagnostic

1:20

views and emphasize appropriate management.

1:23

So before we get started, I'm gonna ask some

1:25

pre-test questions just to kind of test your own

1:27

knowledge before you even start this lecture.

1:30

And hopefully you'll know the answer by the

1:32

end of the test if you—by the end of

1:34

the lecture, if you don't know it already.

1:36

So what view should you get if you see

1:39

a lesion on MLO, but not the CC view

1:41

if you're trying to triangulate in the breast?

1:44

A-Rolled views. B-True lateral, C-Spot

1:48

compression, or D-Exaggerated

1:51

CC lateral?

1:54

So a poll just came up.

1:56

Host and panelists vote.

1:58

Okay, so now the agreed time to vote.

2:01

I'll give you the answer at the end.

2:06

All right.

2:06

Next case or next question, what view should you get

2:11

if you see a lesion on the CC view but not the MLO?

2:14

So kind of the opposite of what I just asked.

2:16

Do you wanna get rolled views,

2:17

true lateral, spot compression, or exaggerated lateral views?

2:23

Alright, we're gonna keep moving on.

2:25

So next slide.

2:27

This is a pre-test question.

2:28

I'm gonna go over all this during the lecture.

2:30

Um, and lastly.

2:34

If you roll the superior breast medially and the lesion

2:38

in question rolled medially, it is located in, actually,

2:44

I feel like I'm missing a piece of information.

2:46

I have to tell you if it's in the

2:48

superior or—I'm sorry—if it's in the,

2:51

um, medial or lateral breast,

2:53

but we're gonna get to that more.

2:54

So, don't answer this question because I don't

2:57

actually think this is the correct way to

2:58

ask it, but— So the diagnostic examination

3:01

is different from the screening exam.

3:03

So the indications for a diagnostic exam is if

3:06

a patient comes with a focal breast complaint,

3:08

lump, pain, or discharge—most commonly, um,

3:12

it could be a callback from screening.

3:13

So patient came in for a screening,

3:15

mammogram, had an abnormality that got a

3:17

BI-RADS 0, or you need more information,

3:20

um, and they're there to work it up further.

3:22

Um, and the third type of

3:25

uh, indication would be a follow-up

3:26

of a probably benign finding.

3:28

So a patient is on every six-month protocol.

3:31

They're gonna come in every six months for

3:32

two years to kind of document stability.

3:35

Um, and then after that two years,

3:37

and they can go back to the screening exam.

3:39

Um, and most places, the diagnostic exam,

3:42

the patient comes, um, to the clinic.

3:45

The workup is done that day.

3:47

We get additional, uh, mammographic

3:49

views and ultrasound if needed.

3:51

Off a diagnostic exam, you can give

3:53

a BI-RADS one through— actually, six.

3:56

If you know they have cancer and they're getting

3:58

neoadjuvant chemo, um, and you wanna assess response

4:01

to chemotherapy, then they would be a BI-RADS six.

4:03

Um, so before we go any further, I'm just going to, um,

4:07

you know, define BI-RADS categories, uh, BI-RADS,

4:10

of course, stands for Breast Imaging Reporting and Data System.

4:13

These are the categories that you are gonna give at

4:16

the end of your final diagnosis— your final workup.

4:19

A zero needs more imaging.

4:21

Um.

4:23

There's really minimal role for

4:25

a zero off a diagnostic exam.

4:27

You should have a conclusive,

4:29

um, BI-RADS at the end of it.

4:31

Usually, rarely give a zero, and there's a few

4:34

circumstances where it would be appropriate.

4:36

Other than that, you're pretty much

4:38

gonna give them a one through a six.

4:40

Um, one is negative.

4:41

There's essentially—you're saying

4:43

it's a normal test. Two is benign.

4:45

Both of those—the likelihood of that

4:46

being cancer should be about zero.

4:49

Probably benign means that it's—you're gonna

4:52

follow it every six months for two years,

4:54

and there's specific criteria that fall into

4:57

the probably benign or BI-RADS three category.

5:00

Uh, the likelihood of cancer should be less than 2%.

5:04

Um, and just to kind of, this is an important

5:07

point that I always try to tell my residents.

5:08

So there's three real good.

5:10

Um, situations where you can give a BI-RADS 3,

5:14

um, it's usually a focal asymmetry without a

5:16

correlate on ultrasound, off a baseline mammogram.

5:20

Um, a, a fibroadenoma-appearing lesion

5:24

that's non-palpable off of baseline.

5:26

And also, um, a cluster of.

5:30

I'm sorry, a group of calcifications on a baseline.

5:33

If any of those lesions were new,

5:34

then they wouldn't be a BI-RADS

5:36

um, 3.

5:37

But those are the three kind of

5:39

classic, uh, scenarios for BI-RADS 3.

5:42

Um, RADS 4 suspicious, you know, you could

5:45

subcategorize it into 4A, B, and C, um,

5:49

depending on your level of suspicion, but it's

5:51

anywhere from 2 to 95% of risk of it being cancer.

5:56

BI-RADS 5 is a highly suspicious lesion.

5:59

The rate of cancer usually is greater than 95%.

6:02

So even if you get something benign, you're probably

6:04

gonna recommend excision to get that area taken out.

6:07

If it comes back benign, 'cause that

6:08

would be a discordant. And a BI-RADS 6

6:10

is known biopsy-proven malignancy.

6:13

Like I said, if you're, you know, assessing response

6:17

to chemotherapy, that would be a good RADS 6.

6:19

Um.

6:21

So case number one, a 58-year-old female

6:23

presents for baseline screening exam.

6:25

And when you're reading these cases, it's

6:27

really important to note if whether they're

6:29

a screening or they're a diagnostic case.

6:32

Um, it helps you with what RADS you're gonna give.

6:34

So in this case, it's a baseline screening.

6:37

Um, so here's her CC view and here's her MLO view.

6:44

Um, and if it's not projecting well...

6:48

There are some calcifications in the left, lower

6:52

central breast, kind of middle to posterior third.

6:55

Um, so like I said, she's a screening exam, so

7:00

therefore, what is the appropriate RAD category?

7:06

So office screening exam, um, exam.

7:08

The, the appropriate criteria would be, uh,

7:11

BI-RADS would be a zero, actually, because...

7:15

They are suspicious, there's no doubt

7:16

about that, but they're a screening exam.

7:18

So first you need to call them back, and then

7:21

you're gonna give them the RAD 4 or the

7:23

5, depending on what, how you're feeling.

7:27

Um, so that, that, that appropriate RAD would be a zero.

7:29

You need more imaging.

7:31

Um, so even if a cancer is obvious on a screening

7:34

exam, you're gonna wanna give them a zero.

7:36

Nobody wants to get a letter in the mail

7:37

saying you have highly suspicious for cancer.

7:40

So the zero allows us to, um, well, number one,

7:44

you can be fooled, but clearly these are cancer.

8:56

I mean, both are right 'cause they're

8:58

ultimately gonna lead to biopsy, but

8:59

these are more, of course, heterogeneous.

9:01

So what BI-RADS is this going to be?

9:05

Leave it up for a minute.

9:07

Remembering now this is a diagnostic good.

9:10

So everyone's got that.

9:12

You know, these are highly suspicious calcifications.

9:14

Now you can give them the BI-RADS

9:16

five that we wanted to give them before.

9:19

Um, so highly suspicious.

9:21

So I just wanna go over, um, the.

9:26

Lexicon, they were updated in 2014.

9:29

There's a few types of changes, a

9:31

few important changes in that update.

9:33

Um, "clustered" is no longer a category.

9:37

It's now grouped instead, and instead

9:40

of, they used to have benign, intermediate, and suspicious.

9:42

Sorry, intermediate and suspicious.

9:45

Um, now they just have benign and

9:47

suspicious.

9:47

So amorphous and coarse heterogeneous

9:49

got bumped up to now they're suspicious.

9:51

So whenever I tell the PA, my residents, if

9:54

you're using the word "coarse heterogeneous," the

9:56

next word outta your mouth should be biopsy.

9:58

So if you think it's like, um, a fibro

10:00

adenoma, don't use the word "coarse"

10:02

heterogeneous, use the word "popcorn" or um, "coarse,"

10:06

you know, so it gets a little confusing there.

10:08

Um, so, um, "eggshell" and "lucent-centered"

10:14

calcifications are now called rim calcifications.

10:17

Round and punctate are now just round.

10:20

Um, and in terms of, um, distribution, it goes

10:23

from, you know, least suspicious to most suspicious.

10:26

So diffuse and regional when they're kind of all

10:28

throughout the breast, that's not that suspicious.

10:31

It gets more suspicious as they

10:33

become grouped or linear or segmental.

10:36

Like in our case, these would be the suspicious,

10:38

um, the suspicious, um, distribution.

10:43

And I wanna remind you.

10:45

That morphology and distribution trump stability.

10:49

So if there's coarse heterogeneous calcifications

10:52

that have been stable for a few years, it still

10:55

can be DCIS and it still may warrant a biopsy.

10:58

I've seen a, we've had a few cases like that where I.

11:01

You know, we're all, the first person doesn't recommend

11:04

a biopsy and then they're kind of, we're all kind of

11:06

falsely reassured that they're okay and then five years

11:09

later they're still there, but they've never really

11:11

been addressed and they biopsy them and they're DCIS.

11:13

So, you know, it's important.

11:15

We always say stability, uh,

11:17

morphology trump stability.

11:20

Okay, next case.

11:22

So these are segmental, you know, coarse

11:24

heterogeneous or pleomorphic calcifications.

11:27

Um, but they're not linear in this case.

11:30

Um, so you really would wanna do this if you

11:32

had the ability to do a stereotactic biopsy.

11:35

Um.

11:36

You would wanna do that in this case, when

11:38

there's six centimeters of calcifications,

11:41

typically we biopsy the front and the back.

11:43

So we'll biopsy two areas.

11:45

And the reason we do that is because if a patient wants

11:48

to be a candidate for breast conservation therapy,

11:51

you need a cal. You need to document the extent.

11:53

So in this case, six centimeters of disease.

11:56

That's typically not a good candidate

11:57

for breast conservation therapy.

11:59

We usually say under five centimeters.

12:01

Um, you know, or localized to a quadrant of the breast

12:04

that's very surgical dependent and patient dependent.

12:07

Like if the patient has a large breast, you might

12:09

be able to do some segmental lumpectomy, but in most

12:12

cases, that's a criteria to, to do a mastectomy.

12:16

So it's always really important to

12:19

document the extent of calcification.

12:21

So if you see a large area of biopsy two, the one

12:23

in the front, one in the back, um, if it is greater

12:26

than two centimeters and they are gonna go to breast

12:28

conservation therapy, we usually put in two needles

12:32

and wires on the day of their, um, needle localization

12:35

and make sure that all the calcifications are removed.

12:38

Please, and this is, you can interrupt

12:41

and ask a question if there's something

12:42

I say that you don't understand.

12:45

I don't exactly know who my audience is, so I'm not

12:47

sure if these, if you guys are people in practice

12:49

or you're out of practice and it's been a while.

12:51

So if I'm saying a word you're not familiar

12:53

with, please don't hesitate to ask.

12:56

Okay?

12:57

Case number two.

12:58

So 45-year-old female presenting

13:00

for screening mammograms.

13:01

So remember, screening is important as opposed to.

13:05

Um, this is not the best image,

13:07

but I'm circling calcifications.

13:10

Okay, so remember a screening exam.

13:14

What BI-RADS are you going to get?

13:15

I'm sorry.

13:16

It's a BI-RADS zero.

13:17

They're gonna get a further workup.

13:19

My question to you is, what views are you going

13:23

to recommend to assess these calcifications?

13:27

Do you wanna get spot compression in the CC

13:29

and ML spot magnification in the CC and M?

13:33

Or spot magnification in the CC and ML.

13:38

They kind of all sound the same,

13:39

but they're very different.

13:43

Okay, good.

13:44

So, exactly, so it's, it's CC, um, spot

13:47

magnification in the CC and ML and I wanna

13:50

drive this point home because there is really

13:53

no reason to ever get a magnification MLO.

13:57

So, I'm gonna repeat that again slowly.

13:58

There's no indication to ever get

14:01

magnification views in an MLO projection.

13:04

You always wanna get a true lateral projection, and

14:07

the reason is because you want to let them layer.

14:11

The reason you're getting a true lateral

14:13

is you think they might be milk of calcium.

14:16

You wanna see them layer on the true lateral view.

14:18

I'm gonna go over milk of calcium protocol

14:20

in a minute, but there's no indication

14:23

for MLO that will not let them layer.

14:24

So always, always, always get, um, you're

14:27

gonna get magnification views, get a CC and

14:29

ML. You can either get spot magnification

14:31

or you can get full field magnification.

14:33

Doesn't matter.

14:34

But the point is you can get

14:35

CC or ML. So here is the CC.

14:41

Where they look a little bit smudgy, if you'd say, and

14:44

here's the true lateral where you see this type of

14:47

tea cupping, and that's really what we're looking for.

14:50

Um, this would be what BI-RADS would this

14:53

be then, based on what I just showed you?

14:58

Okay, good.

14:59

I'm glad that some people got this wrong.

15:00

So this is a very classic case of milk of calcium.

15:04

It's benign.

15:04

It's a BI-RADS two, and that's the reason

15:07

we are getting these true lateral views.

15:10

So, milk of calcium.

15:11

Well, milk of calcium is.

15:13

I'm gonna go into it in a minute.

15:15

I just wanted to take a moment about magnification views.

15:18

They're always used for milk of calcium, I'm sorry.

15:20

They're always used for calcifications.

15:22

It uses a smaller focal zone rather than the typical

15:25

mammogram 0.1 millimeters versus 0.3 millimeters.

15:29

You don't use a grid like other types of magnification.

15:32

Instead, you're using an air gap,

15:34

which I'm gonna show you in a minute.

15:36

So basically, um, this is the picture that

15:40

of course we're gonna lose this picture

15:41

when we actually show this on, um, online.

15:44

'Cause I don't have, I don't have copyright

15:46

to this image, but basically you're taking the

15:49

object away from the detector, I'm sorry, from

15:52

the receptor, which creates the magnification.

15:54

So this is one type of, um, this is a

15:57

formula you need to know from your board.

16:00

So this, um.

16:01

Uh, the image distance, uh, source to

16:04

image distance over the source to object

16:06

distance is what creates the calcific.

16:08

The magnification.

16:10

So instead of, um, placing it exactly, you're

16:14

gonna, you're gonna place an air, you're

16:16

gonna remove the breast from the detector.

16:19

Um, and that's what causes the magnification.

16:21

By bringing it closer, the receptor,

16:23

it's gonna make a magnification view.

16:26

Um, so magnification views, like I said, there's no

16:29

indication for an MLO, I'm gonna repeat that again.

16:32

No indication for an MLO mag.

16:34

Um, the reason you're doing this is

16:36

you wanna see if it's milk of calcium.

16:38

So if it's milk of calcium, it's gonna

16:41

look like layering in the bottom of

16:42

a teacup on that true lateral view.

16:44

Um, it's this layering appearance, and

16:47

it's gonna be you're, they're gonna

16:48

be s or even hard to see on the CC.

16:51

And then what you do is.

16:52

Um, you get the CC mag first, the tech shakes the breast

16:56

and waits five minutes and places them in compression.

17:00

And then you get the ML mag and you're basically letting

17:03

the calcium kind of fall to the bottom of the cyst.

17:06

This is caused by cyst calcium in cysts and it's benign.

17:10

So if you ever see that layering

17:11

appearance, they're trying to say it's

17:13

milk of calcium, it's a BI-RADS two benign.

17:16

Okay, hope that's helpful.

17:18

So like I said, you can get full

17:19

field or spot magnification views.

17:22

Um, full field you wanna do, if it's a large area

17:25

of calcifications or you're trying to get some

17:27

anatomy, anatomic landmarks to make sure you've

17:30

got the right area, um, spot magnification, you

17:33

wanna use that if you have a mass or asymmetry

17:37

associated with the calcifications and you want

17:39

that to go away or look at a little bit better.

17:42

So basically, um, you're, you're applying

17:45

compression, but you're also getting magnification.

17:47

The, the, the drawback is that

17:49

there, it's a smaller field of view.

17:52

So you're not, you really kind

17:53

of have to be more accurate.

17:54

The tech has to be more accurate with what

17:56

they're magnifying as opposed to a full field

17:58

map, which lets you see more anatomic landmarks.

18:02

Um, so case number three, a 71-year-old

18:06

female presents for screening mammograms.

18:10

So this is in 2016, and this is in 2012.

18:16

Okay.

18:17

Um, it's a subtle difference, but I'm going to point

18:21

out the abnormality to you, which is right here.

18:24

Um, you can see that it's, I would

18:27

call this a developing asymmetry.

18:29

It's a new lesion, um, on the MLO

18:33

view in the right upper breast.

18:36

Really hard to see on the CC.

18:38

It's really kind of, so far

18:39

back, you probably don't see it.

18:41

Well, she had some kind of surgery in 2012.

18:44

She had that scar, but it kind of went away.

18:47

So based on this, what's your appropriate BI-RADS?

18:49

This is a screening test, so the

18:53

appropriate BI-RADS here would be a BI-RADS zero.

18:56

Good.

18:57

Yeah.

18:57

So there's an abnormality, it's a screening exam.

19:00

We need to call her back, um, for further workup.

19:05

Okay.

19:07

So what views will you request?

19:09

And that gets a little bit complicated.

19:12

Um, or there's a few ways you can do it.

19:14

Right now, all we know is we see it on the MLO view.

19:17

We don't know where it is on, you know,

19:19

so we know it's in the upper breast.

19:20

We don't know anything else about where

19:21

it is, if it's in lateral or medial breast.

19:24

And then that's where it gets a little confusing.

19:26

So we're gonna get a thigh

19:27

compression to see if it goes away.

19:29

Um, we're gonna maybe get a tomosynthesis.

19:32

That really helps with

19:33

triangulation, and we've been doing.

19:37

Instead of SP compression, because if

19:40

it's real, it will persist on the tomosynthesis.

19:42

Also, there's some talk of when you press on something,

19:45

even if it's a cancer, it might look like it goes away.

19:47

So you could be falsely reassured

19:48

with the, um, so in this case.

19:53

This is showing, I don't know if you're

19:55

familiar with this image that I'm showing you.

19:57

So this is an MLO tomosynthesis, and this

20:00

is giving us triangulation information.

20:02

So while you're scrolling through the MLO

20:04

image, it tells you where you are in the breast.

20:08

So in this case, we know we're in the upper breast.

20:10

So this line is saying it's in the upper outer quadrant.

20:13

So we never really saw it on the CC, but

20:16

we know it's in the upper outer quadrant.

20:17

So now if we wanna go to ultrasound,

20:20

we know exactly where to look.

20:22

So I'd say it's probably like 10 o'clock, and

20:25

the next step is gonna be, what's the next step?

20:28

We don't need to do spot 'cause it's pretty real.

20:30

We see it there.

20:31

But we do wanna go to ultrasound.

20:33

So on ultrasound, we see it 10 o'clock,

20:36

10 centimeters from the nipple.

20:37

We see an irregular hypoechoic mass

20:40

that's taller than it is wide.

20:42

Um, that corresponds.

20:44

We're gonna look in the axilla 'cause

20:45

right now we're a little suspicious.

20:47

And the BI-RADS would be a BI-RADS 4 or BI-RADS 5.

20:51

I think a BI-RADS 4 would be appropriate

20:52

here because there's not a slam dunk.

20:55

This is considered a developing asymmetry,

20:57

and one point I just wanna make, let's

20:59

say you saw this on the mammogram.

21:01

You did an ultrasound and you didn't see anything.

21:05

The BI-RADS is still the same.

21:06

The BI-RADS is still a BI-RADS four.

21:09

Just because you don't see an

21:10

ultrasound, doesn't mean it's not real.

21:12

But a developing asymmetry needs to be biopsied.

21:15

So you would biopsy this under stereotactic biopsy.

21:18

Um, there's no need for MRI.

21:20

We see a correlate on mammogram.

21:22

So this is very easy to biopsy under stereo.

21:26

Um, so asymmetry, if I'm gonna just go over

21:29

some basic lexicon, but asymmetry is, um,

21:33

an area of tissue that you see on one view.

21:36

A focal asymmetry as opposed to an asymmetry is

21:38

in a, um, a tissue that you see on two views.

21:42

A global asymmetry involves more than one

21:45

quadrant, but you see it on two views, and then

21:48

a mass has convex borders, so it bulges outward,

21:51

so it's a true mass rather than an asymmetry.

21:54

And of course, you're gonna

21:55

see that on two views as well.

21:57

So developing asymmetry is a special type of situation.

22:01

It's a focal asymmetry that

22:02

is new or increasing in size.

22:05

It, it really emphasizes the

22:07

need to compare to remote priors.

22:09

Like this one in 2012, it wasn't there.

22:11

So now I have to take this seriously.

22:13

This is a slow, it can be a slow change.

22:16

Um, like I said, focal imagery,

22:18

you see it on two different views.

22:20

The risk of malignancy is way above

22:22

2%, so it doesn't meet the criteria for

22:24

BI-RADS three, so it needs to be biopsied.

22:26

It's about 2012 to 27% Biopsy is necessary, whether it's

22:30

under ultrasound or to, um, or a stereotactic biopsy.

22:34

If you couldn't find it on ultrasound, um.

22:38

So just wanna emphasize the

22:40

importance of a developing asymmetry.

22:42

Now, if that was a baseline and that was her

22:44

first one, and you don't know if it's newer

22:46

or old, then you can give it a BI-RADS three.

22:48

But it, uh, increasing or developing

22:51

asymmetry is something that needs a biopsy.

22:54

Um, so digital breast tomosynthesis, multiple low

22:58

dose images are obtained in an arc. Um, about 15

23:02

to 60 degrees depending on the manufacturer.

23:05

It makes a quasi 3D image.

23:07

It's not a true 3D image, but it helps

23:09

decrease the effect of superimposed tissue.

23:12

We, we've started doing these in lieu of spot

23:15

compression, so if we see something on a mammogram

23:18

on an MLO, instead of bringing them back for MLO

23:21

compression, we'll just do an ML and image and see if.

23:27

If it's cancer or anything, it will definitely persist.

23:30

This really tells you where it is in

23:31

the breast, especially if you only

23:33

see the mass on the MLO projection.

23:35

We now know it's in the upper outer quadrant.

23:37

We know where to look on ultrasound, um, and

23:40

it's really helpful in that, um, instance.

23:44

Okay.

23:44

Case number four: 76-year-old female presents with

23:47

a palpable area of concern in her right breast.

23:51

So by definition, this should be a diagnostic study

23:54

she's presenting with a, um, with a complaint.

23:58

So, um, you could see she's got, we use

24:01

this triangular marker to indicate that

24:03

this is a palpable area of concern.

24:06

So you can see in her right upper outer

24:07

breast, she has an irregular spiculated.

24:10

This is a true mass.

24:11

It has convex borders.

24:13

Um, so what do you do next?

24:16

Um, here we would get some spot compressions.

24:21

And actually, you see now that the mass persists,

24:25

you can see some calcifications associated with it.

24:28

You also see the more circumscribed appearing masses.

24:33

Just posterior to it.

24:35

So next step, I'm gonna give you a minute

24:37

to think about what we're gonna do.

24:39

Obviously, we're leading down the road of biopsy, but

24:42

before we even do that, we're gonna go to ultrasound.

24:46

So you can see in the right breast at 12

24:48

o'clock, four centimeters in the nipple.

24:50

There is an irregular hypoechoic mass that corresponds

24:53

to the mammographic finding at 1.9 centimeters.

24:56

Um, she has another mass that's, um, right

25:00

behind it, about 1.3 centimeters behind it.

25:03

Um, so your next step.

25:06

We always look at the lymph

25:07

nodes here at, um, at Cooper.

25:11

Not all places do that, but our surgeons like it.

25:14

So you can see that it's an

25:15

asymmetrically thickened cortex.

25:18

Um, so BI-RADS, what BI-RADS would this be?

25:23

You know, four or five is appropriate.

25:25

Um, and in this case, actually, the one

25:28

behind it was actually, I think it was a cyst.

25:31

It ended up aspirating, but the,

25:33

the main dominant mass was invasive.

25:35

Ductal, the most common type of cancer,

25:37

and that was metastatic lymph node.

25:40

It's always gonna tell you the ER, PR, and HER2.

25:43

Um, positivity.

25:46

This is really important.

25:47

Each patient's cancer is treated completely

25:49

differently based on the ER, PR, and HER2 positive.

25:53

Um, so always wanna look at that too.

25:58

So, like I said, saw compression views.

26:00

Um, it's when you apply more pressure on the, the,

26:04

on the breast to make something either go away or see

26:06

a bit better, see the borders a little bit better.

26:09

It's used for asymmetries and masses.

26:11

It's gonna decrease the amount of superimposition,

26:14

imposition of tissue, decrease superimposed tissue,

26:17

and allows you to evaluate the margins better.

26:20

A smaller paddle will give you more focal compression.

26:24

Um, so if you have something you really

26:26

wanna go away, use a small paddle.

26:28

A larger paddle provides a little bit less

26:30

compression, but it gives you a bigger field of view.

26:33

So, um, it's gonna give you better anatomic

26:36

landmarks, which sometimes you need.

26:40

So if a mass persists on the spot

26:42

compression, what's gonna be the next step?

26:45

So you're always gonna wanna use, um, breast ultrasound.

26:48

So we typically use a high-frequency transducer.

26:51

We actually use 12 or 18 here megahertz.

26:55

You're always gonna wanna annotate the images as

26:59

clock positions and different distances from the nipple.

27:02

You can either do RAD and AD, um, or SAG and TRANS,

27:07

um, depending on how your institution does it.

27:11

Um, I like, I prefer RAD and

27:14

ARAD like spokes of a wheel.

27:15

RAD is along the spokes of a wheel

27:17

and ARAD is anti-parallel to those.

27:20

Um, this is something that we've been

27:23

asked on the boards in the past, so,

27:25

um, I put this as a high-yield fact.

27:28

Um, stock compression views.

27:31

You wanna leave the collimator open, giving

27:33

you a larger field of view in helping to ensure

27:35

that you've included the area of interest.

27:38

Just a little fun fact for you.

27:41

Okay, so case number five, 28-year-old female

27:46

presenting with a palpable mass in the right breast.

27:49

So by definition, you know, when you're

27:50

reading a case, think to yourself, is

27:52

this a screener or is this a diagnostic?

27:55

She's 28.

27:56

What's the first test step?

27:58

Is it gonna be mammogram, ultrasound,

28:02

MRI, or refer her to a breast surgeon?

28:07

Good.

28:08

So everyone got this right?

28:09

So under age 30, if you see something, if you see if a

28:13

patient has something in, they're under 30 years old,

28:16

you're gonna start with ultrasound and go from there.

28:18

Um, so this was actually a case, um,

28:23

that I had when I was first starting out.

28:26

Um, she presented with this kind of cystic looking mass.

28:31

Um, you know, in retrospect I would say that it has.

28:36

Thick internal septations.

28:38

Um, but I thought it was like more of a

28:40

minimally complicated cyst and I gave it a

28:42

BI-RADS three, um, which was not the right

28:45

answer, but I didn't know that at the time.

28:48

So she came back six weeks later because I, it

28:50

grew when I always tell patients when I give

28:52

them a BI-RADS three, I said, if it gets bigger or

28:54

harder in between now and then come back sooner.

28:57

Okay.

28:58

And this is one of those cases.

29:00

So now you can see that the lesion has gotten

29:02

a lot bigger and the thick internal septations.

29:05

Are more evident.

29:07

Um, so now we're worried, um, if we weren't before

29:10

and she has a little bit of a thickened lymph node.

29:14

So in the 28-year-old, um, you know, of course

29:17

we're gonna biopsy this, but when you see something

29:20

suspicious and you've only done the ultrasound,

29:22

the next best step is to get a mammogram.

29:24

Because really you're looking to see

29:27

if this is the tip of the iceberg.

29:28

Are there calcifications everywhere

29:30

and we're just missing it.

29:31

So, always wanna do a mammogram here you can see

29:34

that her right breast, she's got skin thickening

29:36

that we could not appreciate, um, on the ultrasound.

29:41

And you know, it's.

29:43

The right breast looks asymmetrically,

29:45

more dense than the left breast.

29:47

Um, this is where she's feeling that lesion.

29:49

You could see something there.

29:51

So this is now.

29:52

A BI-RADS four.

29:53

It's a complex cystic mass.

29:56

This ended up being an invasive ductal

29:58

cancer in this 28-year-old with metastatic

30:00

cancer in her axillary lymph node.

27:55

She's 28.

27:56

What's the first test step?

27:58

Is it gonna be mammogram, ultrasound,

28:02

MRI, or refer her to a breast surgeon?

28:07

Good.

28:08

So everyone got this right?

28:09

So under age 30, if you see something, if you see if a

28:13

patient has something in, they're under 30 years old,

28:16

you're gonna start with ultrasound and go from there.

28:18

Um, so this was actually a case, um,

28:23

that I had when I was first starting out.

28:26

Um, she presented with this kind of cystic looking mass.

28:31

Um, you know, in retrospect I would say that it has.

28:36

Thick internal septations.

28:38

Um, but I thought it was like more of a

28:40

minimally complicated cyst and I gave it a

28:42

BI-RADS three, um, which was not the right

28:45

answer, but I didn't know that at the time.

28:48

So she came back six weeks later because I, it

28:50

grew when I always tell patients when I give

28:52

them a BI-RADS three, I said, if it gets bigger or

28:54

harder in between now and then come back sooner.

28:57

Okay.

28:58

And this is one of those cases.

29:00

So now you can see that the lesion has gotten

29:02

a lot bigger and the thick internal septations.

29:05

Are more evident.

29:07

Um, so now we're worried, um, if we weren't before

29:10

and she has a little bit of a thickened lymph node.

29:14

So in the 28-year-old, um, you know, of course

29:17

we're gonna biopsy this, but when you see something

29:20

suspicious and you've only done the ultrasound,

29:22

the next best step is to get a mammogram.

29:24

Because really you're looking to see

29:27

if this is the tip of the iceberg.

29:28

Are there calcifications everywhere

29:30

and we're just missing it.

29:31

So, always wanna do a mammogram here you can see

29:34

that her right breast, she's got skin thickening

29:36

that we could not appreciate, um, on the ultrasound.

29:41

And you know, it's.

29:43

The right breast looks asymmetrically,

29:45

more dense than the left breast.

29:47

Um, this is where she's feeling that lesion.

29:49

You could see something there.

29:51

So this is now.

29:52

A BI-RADS four.

29:53

It's a complex cystic mass.

29:56

This ended up being an invasive ductal

29:58

cancer in this 28-year-old with metastatic

30:00

cancer in her axillary lymph node.

32:11

It does not, not, not have thick walls, thick septations.

32:15

Or other discrete, solid-appearing components.

32:17

So if that, if that has any solid or thick

32:21

septations, it's not a complicated cyst.

32:23

The, a complicated cyst could be followed.

32:25

Um, but two or three, depending

32:29

on if they have multiple.

32:30

Um, similar-appearing cyst.

32:33

Um, as opposed, um, I usually say if it's,

32:35

if, if the patient's symptomatic or it's newer

32:37

enlarging, just aspirate it and just make sure

32:39

that it's not bloody or anything like that.

32:43

Complicated cyst is very different from a complex

32:45

cyst and my residents, I always yell at them

32:47

'cause they sometimes use it interchangeably, and

32:49

they cannot be used interchangeably. Complex,

32:54

septations, intracystic masses, or the solid components.

32:57

This is what I mean when you

32:58

say a solid and cystic mass.

33:00

Um, so this is a complex cyst. Malign-

33:03

The rate of malignancy is very high.

33:05

It's 23 to 31%, so it's way above

33:07

the 2% that would warrant a biopsy.

33:10

So tissue sampling is required.

33:13

Um.

33:14

So very important.

33:15

So these are all cancers.

33:17

So this looks like, um, a cyst, but

33:19

you can see that it has, like, some solid

33:21

portions, some that, that did not layer.

33:24

This is really not a smooth, round, circumscribed lesion.

33:29

So already you're suspicious.

33:31

This, these are all cancers.

33:33

So just, you know, is not always a benign thing.

33:36

So you're really looking for those

33:38

septations or solid portions.

33:42

These are all complex cysts that require biopsy.

33:45

So just to reiterate that breast complaints under

33:47

30, you're gonna wanna start with an ultrasound.

33:50

If there's a suspicious mass, you're gonna

33:52

work backwards and get a mammogram, and

33:54

then ultimately you're gonna do a biopsy.

33:56

Um, breast cancer is rare, but it definitely happens.

34:00

We see it often.

34:01

I don't know if it's just our, our population here,

34:04

but we see lots of cancers under the age of 35.

34:07

So a patient's age is not a

34:09

reason to just think it's benign.

34:11

Um, you know, the risk, obviously, that increases by age.

34:14

By the time you're 40, it's 1.5%, um,

34:17

developing cancer in the next 10 years.

34:20

Um, okay, next case.

34:23

So, 48-year-old female presenting for screening.

34:27

Um, so this is her CCV, her MLO view.

34:34

I'm going to point out that this, the tech

34:36

has snuck on a little palpable marker.

34:39

Um.

34:40

I'm just gonna tell you her mammogram's normal.

34:42

But remember, she's screening and she's

34:44

presenting with the palpable area.

34:47

So what is your, so your BI-RADS needs to be a zero.

34:51

All palpable lesions need to have an ultrasound.

34:55

All palpable lesions need to have an ultrasound.

34:57

So if they sneak one on, they're like, if the

34:59

tech is doing a screening and they're like,

35:01

oh yeah, I have this area palpable, they

35:03

should be calling you and letting you know.

35:04

But if it flips by, if you see it in their

35:08

note or you see that palpable marker, you

35:09

have to call 'em back for an ultrasound.

35:12

Um, so in this case we, you know,

35:15

called her back for an ultrasound.

35:17

We did a spot compression that

35:18

if you really don't see anything.

35:20

We do an ultrasound in the area, we don't see anything.

35:24

And the BI-RADS there is gonna be a BI-RADS one,

35:27

no suspicious finding in the area of concern.

35:30

Further management should be based on clinical

35:32

assessment, and the reason we say that is

35:34

not because we're trying to cover our ass.

35:36

We are, but, but really there is a real concern

35:40

for malignancies that are not seen on imaging.

35:43

Um.

35:44

So if a screener has a palpable, you must give it a

35:46

BI-RADS zero and call the patient back for an ultrasound.

35:49

Always do an ultrasound and a palpable management

35:52

of palpable lesions with a negative mammogram.

35:55

And ultrasound should be based on clinical

35:57

assessment, which means that if it's

36:00

suspicious, they may require a surgical biopsy.

36:03

The rate of cancer with a negative

36:04

mammogram and ultrasound approaches 4%.

36:07

So it's not small.

36:09

And these are the cancers that we worry

36:10

about, the ones that we're gonna miss,

36:12

you know, by our standard imaging.

36:14

Um, and, um, you know, if we would send

36:18

'em to a surgeon, they would decide if they

36:20

want an MRI or if they're gonna just do

36:21

a surgical biopsy based on how it feels.

36:24

We have a few cases like that where it

36:25

was a negative mammogram and ultrasound,

36:27

and it did end up being a cancer.

36:30

So case number seven, 56-year-old female

36:33

presents for screening mammogram.

36:36

Um, so here is her CC and her MLO view,

36:42

and I'm going to point out the abnormality,

36:44

which I really think was an amazing call.

36:46

I barely saw it, but the person that was reading

36:49

in, I saw an asymmetry and the CC view here.

36:52

They didn't know where it was.

36:55

And really the point here is what.

36:58

So you're gonna give it a BI-RADS zero, but my question

37:00

to you is, what imaging can you get if you see this

37:04

asymmetry on a CC view in addition to spot compression,

37:08

what can you do to figure out where it is in the breast?

37:11

Already know right now is it's in the lateral

37:13

breast and we're not entirely sure if it persists.

37:16

I think it persists there.

37:18

So if you see something on the CC view, but not

37:21

the MLO view, what views are you going to get?

37:28

Can get rolled true lateral

37:30

tomosynthesis or combination of the two.

37:35

Good.

37:36

I'm happy that it's all over the place, so, so the

37:39

answer, when you see something on a CC Azi, MLO, the

37:44

real answer is rolled and I think that, you know,

37:48

tomosynthesis is kind of getting a way of role getting.

37:51

Rid of rolled views, but I still

37:53

think there is a role for them.

37:55

But in this case, you could do rolled or tomosynthesis.

37:58

So either would be correct, but

37:59

really A and C is the most correct.

38:02

Okay, so this is a question for you.

38:04

So you know it's in the lateral breast,

38:06

and these are what rolled views look like.

38:08

If you've never actually seen one.

38:09

In practice, the technologist has to get rolled medial.

38:14

And roll lateral views.

38:15

And what they're telling you is which

38:17

way they're rolling the superior breast.

38:20

So in this case, they're rolling the superior

38:22

breast medially and the lesion rolls laterally.

38:26

Okay.

38:27

It went from here to here, and in this

38:29

case, they're rolling superior breast

38:31

laterally, and it moves medially, like we're

38:34

seeing it better now within the tissue.

38:37

So just think in your head, so we know it's in the outer

38:41

breast and now is it in the upper outer or the lower

38:44

outer breast and rolls away from the superior breast.

38:48

So what clock positions are you gonna have?

38:51

The tech scan?

38:53

So it is telling you it's in the lower outer quadrant.

38:56

'Cause it's rolling opposite of the superior breast.

38:59

If it rolled with the superior breast,

39:00

you know it's in the superior breast.

39:02

So in this case, it's in the lower outer

39:04

'Cause it's roll, you roll the superior breast

39:06

medially, it rolls laterally and vice versa.

39:09

So we know it's in the lower outer breast.

39:11

So in the right lower outer

39:12

breast, gonna be six o'clock to.

39:15

And there you can see at eight o'clock, there is

39:18

an irregular hypoechoic mass that's suspicious.

39:21

It's gonna be a RAD four.

39:23

And this ended up being an invasive ductal carcinoma.

39:27

Um, and DCIS, you could see that

39:29

it's ER/PR positive, HER2 negative.

39:31

That's usually the most common

39:33

type of cancer that we get.

39:35

Um, so just wanted, you know, this, this

39:38

diagram which we're gonna lose when we

39:40

go, when we, when we show this image.

39:42

Um, but you, this is a great diagram, and it's

39:46

really, if you don't understand this concept,

39:48

take a few minutes to sit and digest it.

39:50

But basically, the tech is gonna roll the test, the

39:52

superior breast medially and laterally, and you're

39:55

gonna see if the lesion moves with it or away from it.

39:57

Um, they must indicate which

39:58

way they're rolling the breast.

40:00

Um, and so like I said, if it rolls

40:03

with it, it's in the superior breast.

40:04

If it rolls opposite, it's in the, um, inferior breast,

40:07

and you're gonna do the, you're gonna do roll views on

40:11

if you see a lesion on the CC view, but not the MLO.

40:14

Okay.

40:15

Um, so what do you do if you see a

40:17

lesion on the MLO but not the CC?

40:20

And this is the opposite.

40:22

So, and when you get it, if you see something

40:24

on the MLO, you're gonna get a true lateral

40:26

view to see if it drops or if it rises.

40:29

Um, and you're gonna do ML. It's better for

40:32

lateral lesions or LM better for medial lesions.

40:36

It's named from the direction

40:38

of the tube to the detector.

40:40

Um, and this helps you tell where it is on the CC view.

40:44

This is a great, um, diagram that's

40:47

gonna show you what lesions do.

40:49

So if you have some on the CC view, I'm

40:51

sorry, if you have it on the MLO view, if

40:53

it's in the medial breast, it's gonna rise.

40:55

So muffins rise on the true lateral view as opposed

40:59

to if it's in the lateral view, it's in the lateral

41:01

breast, it's going to fall on the true lateral view.

41:04

So muffins rise, lead falls,

41:07

that's a great way to remember it.

41:08

So if it's in the medial, it's gonna rise.

41:10

If it's, if it's in the lateral

41:12

breast, it's gonna fall on the ML view.

41:15

Um, so medial lesions go up from the ML to MLO to

41:18

ML and lateral lesions go down from the MLO to ML.

41:22

So again, if you don't understand that concept, take

41:25

a few minutes and just kind of think about that in.

41:29

I promise it'll make sense.

41:31

So just to give you an example, this is a fibroadenoma.

41:34

We don't, we know exactly where it is, but

41:37

this is the CC view, the MLO view and the ML.

41:40

And you could see that it rises, um, from the

41:43

MLO to the ML. So it's in the medial breast.

41:46

So if you didn't know where something

41:47

was, it would tell you where it is.

41:49

Um, so this is a good example of it in real life.

41:54

So exaggerated views are some other

41:56

types of images that you can get.

41:58

Um, if you need to see more lateral or

42:00

medial tissue, XCCL means you're gonna

42:03

pull the, it means exaggerated laterally.

42:05

You're gonna pull the lateral breast tissue out further.

42:08

Um, that's if something's in the lateral

42:10

view and you want to see it better.

42:11

Opposite is XCCM.

42:13

You're gonna exaggerate medially if you

42:15

wanna see the more medial breast tissue.

42:18

Um, okay.

42:20

So 45-year-old male presenting with a lump.

42:23

What's the first best imaging

42:25

test for a 45-year-old male?

42:29

We're gonna start with an ultrasound

42:31

mammogram, MRI, or none of the above?

42:37

Men, by definition, are usually a diag.

42:40

Good.

42:41

So most of you said mammogram.

42:44

For men, actually, 25 is the age.

42:46

That cutoff that you're gonna go from

42:48

ultrasound, um, from start with a mammo.

42:50

So under 25 you're gonna start

42:52

with an ultrasound over 25.

42:53

You're gonna start with a mammogram.

42:56

Um, usually the mammogram is diagnostic.

42:58

Um, when we're talking about gynecomastia,

43:01

the mammogram is usually diagnostic.

43:03

We may not need an ultrasound in this case though.

43:07

Um, so you can see this palpable lump.

43:09

Um.

43:11

When you take a minute and

43:12

look at this image, I'm sorry.

43:16

Um, I didn't mean to advance.

43:18

So the question to you, is this classic

43:20

gynecomastia, or does it need more, more imaging?

43:24

Um, think to yourself for a minute.

43:28

Um, so what's the next step?

43:30

Is it no further imaging?

43:32

This is gynecomastia.

43:34

You need to do an ultrasound to confirm

43:35

gynecomastia, or do an ultrasound.

43:38

'Cause the findings are currently

43:39

suspicious for male breast cancer.

43:43

Good.

43:44

Yeah.

43:44

So, you know, this is suspicious.

43:46

It's a mass. Gynecomastia is not a mass.

43:48

It should not have convex borders.

43:50

It's flame-shaped, it's right behind the nipple.

43:53

Um, does not cause nipple

43:54

retraction like it did in this case.

43:57

Um, so yes, this is suspicious.

43:59

Sorry, it's.

44:03

Yes, so suspicious for breast cancer.

44:05

Um, so you could see if you do an ultrasound, like

44:08

if you were on the fence and you wanted to do an

44:09

ultrasound, um, or the patient's doctor wanted it, you

44:13

could see that this is not a flame-shaped retro density.

44:17

Um, this was an irregular hypoechoic mass, and the

44:19

retro region had another lesion here at two o'clock.

44:22

You can see that these are separated by 2.3

44:25

centimeters, and you've got an abnormal lymph node.

44:28

Um.

44:29

So BI-RADS here.

44:31

I think you all know the answer by now.

44:36

Okay.

44:37

Gonna give you a second.

44:38

Yep.

44:39

So this is BI-RADS 4.

44:40

Very good.

44:41

You're getting the hang of it now.

44:43

Um, so just to kind of talk about male

44:46

breast cancer, gynecomastia is usually bilateral.

44:49

Could be as, it's usually asymmetric.

44:51

Though, both sides are usually affected, one side more than the other.

44:53

It's gonna be a subareolar flame-shaped density.

44:55

Mammo is usually diagnostic; ultrasound can actually be pretty confusing.

44:58

So if it looks like gynecomastia on the mammogram, there may not be a need to

45:00

do an ultrasound, um, to rule out breast cancer.

45:02

It's gonna be.

45:04

Usually unilateral, though the other side

45:05

might have gynecomastia, which we see often.

45:09

It's gonna be a mass with borders, so if it looks like a mass, it needs to be biopsied.

45:10

Ultrasound necessary if the mammo is not classic for gynecomastia.

45:12

When you talk about gynecomastia, there are a few common causes.

45:14

It's usually there's no identifiable cause, idiopathic, um, drugs.

45:17

Commonly we talk about marijuana

45:20

or digitalis, prostate cancer meds.

45:22

Anything that causes a patient to have increased estrogen.

45:25

If they take estrogen for, um, gender differences or liver disease or

45:29

if they have a testicular adrenal tumor, um, also

45:32

male breast cancer, sometimes just the hormone

45:35

levels can cause gynecomastia in the other breast.

45:39

Male breast cancer counts

45:41

for 1% of all breast cancers.

45:43

It's invasive.

45:45

Ductal men don't have lobular, so

45:47

they don't get invasive lobular.

45:49

It's usually a worse prognosis.

45:51

They typically don't get benign

45:53

masses like fibroadenomas or cysts.

45:54

So, unless it's, you know, if there's

45:58

a mass, it probably needs a biopsy.

46:01

Biopsy.

46:01

Alright, post-test questions.

46:03

So, what view should you get if you see

46:06

a lesion on the MLO but not the CC view?

46:09

So hopefully you get this right now.

46:13

Rolls or true lateral, spot compression, or XCCL.

46:19

Oh, no.

46:19

Okay.

46:19

Well, the answer here is true lateral because you're

46:23

gonna wanna see if it falls or rises, um, on the

46:26

AMLO view, um, to see where it is in the breast.

46:54

Okay, so if you don't understand the concept,

46:56

go back again and listen to that part.

46:58

So what about if you see something on the CC

47:00

but not the MLO and you wanna know where it is?

47:03

What are you gonna get here?

47:04

Oh, I gave you the answer, so you should get that right.

47:11

Okay, good.

47:13

All right.

47:14

And then the last one, and I think I messed

47:16

this question up, but if you roll the superior

47:18

breast medially and it rolls medially,

47:20

you know, it's in the medial breast, um.

47:23

I'm sorry, you know it's in the upper breast,

47:25

but I didn't tell you enough information,

47:27

but it's in the upper inner quadrant.

47:29

So, um, you know, just to, the take-home points here are

47:33

gonna be to understand the differences between screening

47:35

and diagnostic tests and the appropriate management.

47:39

Um, screening, you really could only

47:40

give them a BI-RADS zero, one, or two.

47:43

You're not gonna give a four or five off a screener,

47:45

and typically should not give a three either.

47:47

Diagnostic, you can give a BI-RADS one through six.

47:50

Actually always wanna use BI-RADS

47:52

lexicon, ultrasound, any palpable lesion.

47:55

Thank you so much for listening.

47:57

If you have any questions, um, you could email me.

48:00

My email address is rothenrobin@cooperhealth.edu.

48:04

And also, um, if you have Instagram, you could

48:07

follow me and my best friend who are both breast

48:08

radiologists, the booby docs, and then we talk in a.

48:12

So thank you for listening.

48:14

I'll open it up to any questions if anyone has.

48:16

At this point, I often very often get male patients for

48:20

ultrasound evaluation for clinical suspicion in

48:23

case of asymmetry, which I understand is ultrasound.

48:25

No, I think that we really

48:27

need to start with a mammogram.

48:29

Um, you know, I typically, if I get an

48:31

ultrasound only for what they suspect to be

48:34

gynecomastia, I kind of use that as a teaching

48:37

point for the doctor who referred them.

48:40

Really, if they're over 25, they should be

48:42

getting a mammogram first and then an ultrasound.

48:45

Like I said, ultrasound can be confusing, so I,

48:48

really think that it's best to get a mammogram first

48:51

because oftentimes both sides are affected also.

48:54

So they might only feel a lump on the left

48:56

side, but they might have gynecomastia on the right.

48:58

Also, it's important to know, and it's just, you know,

48:58

1153 00:49:02,490 --> 00:49:04,980 I think that people routinely just, you know, click

49:04

an ultrasound for something palpable, but we really

49:07

need to, the correct way is to do a mammogram first.

49:09

Great questions.

49:11

Thank you so much for this case review and for

49:13

everyone in the audience for participating,

49:15

be sure to join us for upcoming webinars.

49:18

You can register for those at modality.com

49:20

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49:22

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49:24

Thanks again for learning with

49:25

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