Answer the Question: “An Imperative for Radiology” “Imaging Re-visited?” - HD

Introduction

Dr. Ted Lyons, a radiologist at the University of Manitoba. This year we just celebrated our 50th anniversary as an ultrasound section. I'm a professor of radiology, anatomy and obstetrics and gynecology. I've been in the field for a long time, and what I'm gonna talk about is how we should rethink the ultrasound examination. The key is, answer the question, imaging revisited. I hope you'll enjoy it. Ultrasound has been done for many, many years, in our lab for 50 years. But is it time now to re-look at what we're doing and what we have been doing? My lecture is to focus on answering the question for radiology. This is an imperative, and really what we're doing is we're revisiting imaging.

Disclosures and Lecture Goals

I'm Dr. Ted Lyons. I have disclosures and I have no significant research support or funds from any committee, from any company. And I don't have any financial interests in a company. My goal for the lecture is to change how you practice and perform ultrasound, unless of course, you do it all already.

Clinical Example: Tender Right Buttock

Here's an example. 72-year-old male with a tender right buttock. And here are some of the standard images, a two dimensional image, a color image showing an irregular collection, and we've measured the size of it. So the question is, how much information are you really getting out of this? When you look at the patient, and I often take images of pictures of patients, and they're saying, what the hell are you doing? But from a teaching point of view, and ideally for companies who are listening, it would be wonderful if we could incorporate into every examination a photograph, particularly if something is superficial and clinically relevant. So here's this 72-year-old, he's obviously got what appears to be an abscess, subcutaneous abscess in the buttock. Now what I'm gonna show you is how to really make a difference with ultrasound. So normally a lot of people would just simply sweep across the area of interest and would see some EMS areas, the area of interest. Does that really add information? I'm suggesting it doesn't add information. What would really add information is to use compression to push down on the mass and to see where the fluid is going. Here you can see this is fluid and it's moving back and forth, and that tells you what's inside the mass and tells you, tells the clinician what you should and could do it to, shows you that that's where the pus is. So just sweeping across the mass just isn't good enough. You need to compress the mass. We call it the squishy tests, because that is what the key is. That's where you're gonna get the information. It's gonna confirm the abscess, the presence of an abscess.

Answering the Clinical Question

So answer the question, what is the question? What's the reason the patient is in ultrasound today? Does she still have the same complaint that was written on the requisition In Canada, we have wait lists, in terms of sometimes days, weeks, and months. And so a patient's pain may in fact not be there. So what is the cause of her complaint or his complaint? Is it a mass? Is it pain? And finally, the sonographer must ask him or herself, did I find the answer to the question? That's critical, and that's different than what we've been doing in the past. Back in the dark ages in the eighties, there was a movement to simply answer the doctor's question. But the question then was pretty simple. Is there a gallstone? Is there an ovarian cyst or not? And so there was a thought that we should focus the examination on just answering the question. Look at the gallbladder. Is there a gallstone or not? That's it. The end of the exam, look at the ovary. Is there a cyst or not? That's the end of the exam. I'm suggesting that that in fact is totally incorrect. That's not the way to practice ultrasound today. There must be a new paradigm, and we have to reinvent our practice to answer the clinical question. If the patient had pelvic pain, the real question is, what is the cause of the pain? So to answer the question, you must always, always, always ask the patient if she has pain or feels a mass ask while you're scanning, does this hurt? Does that hurt? Does this hurt? Does that hurt? Decide then what the tender organ is and what the sight of the tenderness is. And then answer the clinical question. The real question is not the guess that the clinician put down of the pain must be due to tube ovarian abscess torsion. What? Those are guesses. Your challenge is answer the patient's question. What is the cause of her pain? And with ultrasound, you have that capability in any imaging guidelines. Where does it mention the clinical end? It doesn't. And it should. If you look at the A IUM guidelines, it talks about examining the uterus, looking at size and shape, the endometrial myometrium surface. It doesn't talk anything about tenderness. Tenderness is critical. What about on a clinical? What about on the clinical side? What about motion of the end in the endometrial canal or between organs? All of these are clinical issues that are critically important in making the diagnosis, and we don't talk about them. So it should be, it should not be beyond your grass. You should be able to do this now. Technology has come a long way. We're now today in the handheld portable ultrasound equipment. The technology has changed, but examining the patient clinically has not changed. So always focus on the patient and not on the image. This is an excellent comment for clinicians. So often they do imaging studies and they focus the treatment on the image rather than looking at the patient and focusing on the patient.

The Role of Radiologists in Clinical Teams

The key to radiology's continued success, and maintaining ultrasound in radiology, it will only survive if radiologists or ologists are an integral member of a clinical healthcare team and actually are their problem solver. The radiologist has to be an integral member of a clinical healthcare team and be their problem solver. And if they're not, what value do they bring to the game? A radiologist sitting alone in a room reading cases, one after another is productive, but generally they don't wanna be accessible. So accessibility versus productivity, this is the conundrum. And yet the key to the survival of radiology is accessibility. Being an integral member of the healthcare team. Now PAX may be the final straw for radiology. Everybody is so excited that reports are generated within 20 minutes. Is this good or isn't it? With rapid reporting? Why see or consult the radiologist? What role does the radiologist play other than someone dictating the report? I honestly think it's time to close the central reading room and move the radiologists out to the patients and the clinicians in the er, in ICUs, in clinics and wards, they need to have the onsite ultrasound physician or radiologist so that they are then accessible just simply the way it was. Originally, when the film was king, all you had was a film. And anyone who had the film was the person who controlled the entire system. Today, everybody can see everything. And the need to talk to a radiologist to consult with a radiologist is gone.

Commitment of Sonographers

Now, as a sonographer, are you involved or are you committed? Well, what's the difference? The difference is like a breakfast of bacon and eggs. The chicken was involved in the breakfast, but the pig was committed. Are you committed to doing a great ultrasound examination or you just simply want to be involved? As a sonographer, part of your commitment is to talk to your patient, to examine the patient, to ultimately answer the question. Remember that clinicians, many of them are getting their own scanners, like the ER docs, the ob gyne docs, the vascular surgeons. Why are they getting their own machine? Well, they're getting their own machine to answer a limited clinical question. And unfortunately they've not had very much training. So often they're trying to do this with virtually no experience or expertise in the er. The fast scan looking for free fluid, they're looking for all sorts of other things, but they're not doing it very well. Some do it very, very well. Some do it terribly. And then there's a great mass of people in the middle in ob gyny, they're looking for a mass, whether the fetus is alive or dead. Looking at the placenta, they can do all sorts of things. And of course, the specialty ob gyny practices are superb in doing obstetrical ultrasound, vascular surgery, looking at grafts for stenosis, occlusion, et cetera. They're doing a focused clinical exam. 'cause they need that information. They have a clinical question, is the graph occluded? They can do that with ultrasound and we'll do it more and more.

Common Clinical Scenarios

So what is the question? Is it in a patient with pelvic pain? Rule out ovarian cyst, pelvic mass, rule out fibroid. That's what the doctor has asked. Scrotal pain. Rule out tumor, right? Upper quadrant pain. Rule out gallstones. Remember that right upper quadrant pain could be gallstones, but it could be a tender liver from hepatitis. It could be a tender inflamed gallbladder from cholecystitis. Could be a common duct. Stone could be a tender kidney with pyelonephritis or hydronephrosis, or it could be a tender epigastrium that really has no cause identified. Maybe it's gastritis, maybe it's something else. I don't know. We get a lot of patients who have epigastric tenderness and we have no idea. And I've talked to our clinical colleagues and they say, there's a neural plexus there. Maybe that's what the cause. But this is a very common situation and something where we really can't answer the question. Pregnancy and pain, 20 week pregnant. Abdominal pain, we get this all the time, usually at midnight. Query appendicitis. There are uterine causes of pain such as a tender fibroid, abrupt placenta amnio and premature rupture membranes or severely retroverted and impacted uterus. All of those are causes of pain. So if the requisition comes in saying query appendicitis, don't just look for the appendix, answer the question, look at the uterus, see if there are any of these situations. Look in the abdomen. See if there is in fact appendicitis. Could it be an ovarian cyst, a cyst that has ruptured or undergone torsion? Could it be an inflamed right kidney? Could it be pyelonephritis or could it be a liver problem? Gallbladder, pancreas, bowel, et cetera.

Case Study: 10-Week Pregnancy with Pain

Here's a typical case, 10 week pregnancy with pain query appendicitis. You've all seen that requisition. Nice, normal single, live intrauterine fetus. Not a problem there. Behind uterus is a big oblong mass, which is in fact the enlarged right ovary. Well, that's abnormal. Let's look at color. Well, there's no color in that big enlarged ovary. This obviously is a ovarian torsion. The doctor really wasn't sure what it was. And so is asking ultrasound, give me the diagnosis. It could be appendicitis, but it could be a whole lot of other things. And in this case it was ovarian torsion. The strength of ultrasound is the ability to do a targeted clinical exam. You can find the tender organ and that's your challenge. And here's a number of case studies where I'm focusing on answer the question. I've been doing this for about 10 years, trying to get my staff actively involved in this, and every day I have to keep reminding them. And I've got signs all over the room. Answer the question, answer the question. It's critical. So focus on finding the source of the tenderness. What is the painful organ? Remember that from the time that the patient saw the referring clinician, until the time that you see the patient in ultrasound, the pain may be gone or the pain may have been so bad that they gave morphine. And now the pain is totally dulled and not available for identification. But put that down. Make sure that the radiologist knows that there is no pain or that the pain can't be assessed because she has had some morphine. Use cine use cine to find a mass, a mobile mass to separate one a mass from other organs. Is there a hidden mass? Is it too superficial for you to identify squish ability? The squishy test compression characterizes the mass. And finally, what is its the significance of the mass and blind procedures. This is a particular bent of mind, putting needles into places where you have no business going and you don't know where you're going. And we'll talk a little bit about that.

Case Study: Right Upper Quadrant Pain

So find the source of the tenderness. Here's a 60-year-old male goes to his doctor and most doctors, they give the patient 10 minutes and they say, okay, you only have one problem that we can address today. And then the physician writes out a requisition as quickly as possible. So the doctor ordered an ultrasound and writes on the requisition query gallstones. So what is the question? And so often they don't even ask a clinical question. And I try and encourage the clinicians ask a clinical question. But this is where the sonographer has to talk to the patient. Is the clinical question. Are there any gallstones? No, not really. Did the patient present with the question? Hey doc, do I have a gallstone? No, that's not what happened. He said, I have right upper quadrant pain just after eating. That's the clinical question. Let's then answer the question. So right upper quadrant pain, what is the diagnosis? Here? You see a thick walled gallbladder really doesn't have all of the features of an acute cholecystitis. This patient actually has hepatitis and this would fit with a patient with has hepatitis, a big, thick gallbladder. But the gallbladder was non-tender. Again, on the film identify is that vocally tender? That's critical information. It's a thick walled gallbladder that's non-tender. So it's unlikely to be an acute gallbladder. This is secondary to hepatitis. On the other hand, here you have a patient with a big gallstone lodged in the neck of the gallbladder, a thick walled gallbladder that was vocally tender. This is a gallbladder obstruction with a stone in the neck. This is the cause of the patient's pain.

Case Study: 46-Year-Old Female with Pain and Bleeding

46-year-old female with pain and bleeding. She has known adenomyosis with meia and pain. She had a marna IUCD inserted a month ago. The Marna is very good for adenomyosis in that it has levo norge all in the stem and acts locally, not systemically, but she was having persistent pain and bleeding despite nine days of progesterone. So the question is, what is the cause of the pain and the bleeding? So here is the, she's had three previous pregnancies. Here is the sonogram. You can see a retroverted uterus with a centrally located IUCD. And there on 3D you can see the IUCD. The question is, is it in the proper position? It's actually quite a ways from the fundus of the uterus. Is that the way it was put in? Was it put in incorrectly? Is there a reason why it's not right up against the fundus? Well, we sent her away and three days later she came back with increased pain, bleeding, and now fainting. And here you can see the endometrial canal, but the IUCD actually has moved down into the lower uterine segment. This is the only time I've ever, this, the second time, I've actually only seen that the IUCD has actually moved by itself. I don't think that's very common, but you can see the IUCD down in the cervix. And now you can see a very clearly identified mass in the fundus. And that mass has vascularity. And this mass, by all criteria would be a endometrial polyp. That's likely the cause of the patient's persistent bleeding. So there you can see the endometrial canal with the mass, the endometrial polyp. The uterus was tender because the myometrium is heterogeneous and she has adenomyosis. So again, another critical piece of information that I don't think everybody is reporting but should be reporting. These areas of increased echogenicity, these aren't fibroids, this is adenomyosis. So she has adenomas, but we knew that. But she also has an endometrial polyp. So let's treat this patient clinically. She had the IUCD removed. She had a DNC to remove the polyp. The bleeding stopped. Five days later she had the IUCD reinserted to manage the adenomyosis a patient who has intrauterine pregnancy, they're gonna do a therapeutic abortion. They did it. And then she came back with some pain and bleeding. The question is, does she have retained products? And in fact, she has no retained products, but she has an area of increased echogenicity. And the uterus was very tender to palpation. Is this an area of endometritis in this patient? I suspect it is. So the real question is, and must be what is the cause of the patient's pain? What the sonographer should do is go where the money is, look at the requisition, look at the history, talk to the patient, and then try and figure out what is the cause of this patient's pain. Talk to the patient. Ask her what the problem is. She invariably will tell you what the problem is. Then look at the area of concern, palpate the organs for tenderness to see that, if that actually is the patient's problem. And then if they've ordered an abdomen and a pelvis and you've already identified that it's a pile nephritis of the right kidney, how much of the examination do you then have to complete? And that's a whole other issue. But the most important thing is you have to answer the question. Now, can you do the whole examination in a reasonable time and can you afford not to? And what if you were the patient?

Use of Cine Loops in Ultrasound Examinations

Now the other thing that I wanna talk about is CNIs, real time ultrasound and recording of CNIs. There's a lot of sites that don't use or incorporate CNIs into their regular ultrasound examination. Usually the university sites always do and the non-user university sites seldom do. What is the value of the cine in answering the question? Well, I think for all scans, pelvic scans, abdominals, carotids, you should use sins for in the pelvis polyps. One of the best signs to identify an endometrial polyp is watch it move to look at hematomas or hemato metras to see the fluid in there. To look at a cyst and differentiate a peril variant and an ovarian cyst by moving the two apart. Is a mass arising from the uterus or ovary or is it separate? Are there adhesions in endometriosis? The only way you'll see that is the sliding organ sign. So if you do a real time examination and if you record sins, you allow the ultrasound physician to make an independent diagnosis. Now, some people who don't know anything about ultrasound don't want to have to make an independent diagnosis. They rely 100% on the sonographers diagnosis. Well, that's them.

Diagnosing Endometrial Polyps with Cine

So endometrial polyps, the sonographic diagnosis, thickened endometrial stripe vascularity. Remember that in post-menopausal women, you usually don't see vascularity in a polyp. A lack of an endometrial stripe in the center of this thickened endometrium. I don't have it on the slide, but that's a critical sign, a lack of the endometrial stripe. But finally, the myometrium is constantly contracting. And if you watch it, you'll see the endometrial polyp move back and forth. This is a great new sign. You hold the probe on the sagittal view, hold it, and then play it back at a fast speed. And you'll see that polyp move. And I'll show you different examples. So this particular polyp is shown here in the calipers. There's some fluid in the endometrial canal that makes it easier to identify. There is a vascular pedicle. And so it makes this polyp easier to see. But not all polyps have endometrial fluid. Here's an example, query endometrial polyp. 59-year-old patient with postmenopausal spotting. So there you look and you see, there's the uterus, there is an echogenic mass or is this a thickening of the endometrial stripe? It measures 5.8 millimeter as well. It's not really all that thick and it does look different up in the fundus than it does in the lower segment. Is this a polyp? Well, we're guessing, absolutely no feeding vessel. Well, as I told you, postmenopausal women usually do not have a feeding vessel that you can see sono graphically. So that's a good sign that actually isn't here. So what do you do? Well, let's look at the cine. Well, you're looking at the cine, but you don't see anything happening. Why is that? Well, let's just, I know it's a polyp, but now let's look at this sin and let's do the sine again. We'll blow it up and do the sin again. Watch this mass. As I speed up the video, you can see that thing moving back and forth. There is absolutely no question. This is a polyp. This is a great sign, a great sonographic sign. And you're gonna miss it unless you look at the cine. A polyp with good motion at normal speed, you're gonna see nothing at high speed. You're gonna see everything. Alright, so here you can see the polyp there. Is the mass there? Well, not very impressive. Let's just simply turn on the video and let's grab this thing. And now you can see it moving back and forth, moving back and forth. You just do not see that with the normal speed. Another patient, 47-year-old seven weeks, she have a polyp or thickened endometrium. It's 11 millimeters. It's very thick. I don't really see a feeding vessel in a 47-year-old. So likely it's postmenopausal. So let's now look at the video. And when you look at the video, you really can't see anything. But if you speed it up and move it back and forth, you don't see anything moving around. So this is really just thickened endometrium. There is no polyp there at all. Thickened endometrium. Here is a patient who has a mass. Is it a polyp? Well, it's an unusual horizontal end to the mass. There's no vascularity in it. What does it mean? Well, let's look at the video again, looking at it in slow motion, you don't see anything. You speed it up and you can see motion of the blood in the fundal portion. And this is in fact just a hemato omera. There's no polyp, nothing is moving around at all. Just hemato omera here is a big thick endometrium in this particular patient. 33-year-old, lot of vascularity in the mass. This would be of great concern on 3D. You can see this big mass likely filling the endometrium. Let's see if you can see any motion of this thing here. And in fact, you can't. And sometimes the very, very large masses, you won't appreciate significant motion. And this is a great concern for a large neoplasm. Within the endometrium. There's no movement. And in fact, it was an endometrial sarcoma separating two masses shown on sitting the sliding organ sign. So here you can see a mass here and you can see the uterus. Is it arising from the uterus? Is it separate from the uterus? Can you really tell there's vascularity in both? Is it a subserosal fibroid? And you can't separate it from the uterus. Let's look at the cine. And here you can see when we run the cine, we're prying to compress and separate the two masses. And in fact are unable when you press to separate it. So this mass is arising from the uterus and this is a subserosal fibroid.

Finding Hidden Masses

A hidden mass. Find the mass again, it may be right in front of your eyes and you're just not seeing it. So this was a 70-year-old woman and the sonographer came to me and they said, there's a mass, I can't see the mass. I said, did you talk to the patient? Well, sort of. I said, here you can see a little area of something. Is that the mass? I said, let's just go talk to the patient. She says she feels a mass. So I said to the stenographer, did you actually ask the patient? Did you look at it? She said, no. So I went up to the patient and I said, dear, tell me, you said you're feeling a mass. Where is it? And so she pointed to a mass just between the vulva. And I said, show it to me. And she opens it up and there it is. I said, you mind if I take a picture of this? Your face won't be anywhere. And of course I won't use your name or anything. She says, no, go ahead. And there you can see a beautiful little mass that the patient is feeling. Now normally the sonographer would zip right by it, put the probe in the vagina, and of course miss a very, very obvious mass. And how stupid the radiologist must feel if he then tells the clinician, I don't see a mass. Well, I mean, that's just ridiculous. There it is. Just talk to the patient. And here now when we do a superficial scan, you can see the mass. You can see the mass. And in fact the mass has debris within it. It's and if you move it back and forth, it's got debris within it. So it's like a naan cy a bartholin duct cyst in the vulva. It's easy. And the only way you made the diagnosis is 'cause you talked to the patient. It's simple. A labial cyst. Alright, you shouldn't miss that. Another thing that you're gonna miss are ureteric cysts or ureteric diverticula. Here you can see this mass with the vagina. There's a debris fluid level. She's a 42-year-old with recurrent urinary tract infection. On the sagittal view, you can see this mass, but remember it's very superficial. You can see the bladder behind it. You're gonna miss it if you blow by it, putting the probe right in on transfer scan. Again, superficially there is the mass. Very easy to see. And why is it so important is because you can remove them. And this is a cause of recurrent urinary tract infection. And it's a urethral diverticulum urethral diverticulum commonly missed sono graphically. And you can see them on the cystogram.

The Squishy Test: Compression in Ultrasound

And the last thing, one of the last things I wanna talk about is the squishy test compressibility, right? So here you can see swelling of the right hand. Is it drainable? Well, you can see edema in the hand, but does that give you all of the information? If you use a compression test and see what's going on with that fluid, you can see that the fluid is compressing the tissues are compressing. Try and find an abscess. So this tells you a lot more about the quality of the abnormality in the hand than does just the single image. And here you can see no abscess identified. This is just simply cellulitis. Here's another case, a groin abscess. Well, you can see the mass on ultrasound, but you need to get a lot more information. So let's do a compression test. And here you can now see with the you can see the fluid starting to move. There it is there, it's moving back and forth. You know exactly what's going on in there, exactly how much fluid there is. There's fluid over here, there's fluid over here. You know exactly how much you can drain. This aspect of the examination gives you the diagnosis. The rest of it is just fluff.

Blind Procedures and Guidance

So blind procedures, this is a pet peeve of mine. Aspiration of fluid. As far as I'm concerned, clinicians should never aspirate fluid without doing it under ultrasonic guidance. And here you can see, they've taken this particular patient, and she came to ultrasound. They've put needles in left, right and center. And they thought there was fluid there, but in fact it's all tumor. There was a little bit of fluid way up here and it was inaccessible. They thought there was gross societies and they would just put needles in it. But in fact, they got absolutely nothing. They got a bloody tap. And it's because it's all solid fluid.

Lost IUCDs and 3D Ultrasound

So the last area I wanna just talk about is lost I ucds, ultrasound, the 3D coronal view. Very, very important. So the IUCD position, it's really important to determine the position if it's abnormal. 99% of the time. That's the way it was put in it, isn't it? I ucds don't have feet, they don't wander around. Obviously as I showed you a case previously, they can move, but I think that's very, very uncommon. And the 3D coronal view is essential. So this is your typical Marna, IUCD. And one of the ways that it gets in an odd position is that when it's deployed, it has this plastic sheath around it. And then you push the plunger forward and deploy the IUCD into the fundus and there's the stem. But some people try and snug it up. They, once it's been deployed, they push the stem forward. Well, you're not, you think you're pushing it straightforward, but in fact you're not. You're pushing it off to the side very, very typically. And what you'll get is a an image like this. Here you can see the endometrial canal on the 3D coronal view. The stem, the tip of the stem is up here and the arms have been deployed here. And you can just imagine how they've pushed up the end of the stem way up into the right cornua. And that's why you have that unusual position. And here you have a similar view where the stem is now way up on the left cornea. So the explanation is absolutely typical, people trying to snug it up. This is the way it should be. And the only way you're gonna get it there is by putting it in initially into the fundal portion and then deploying it. And one of the ways of seeing it, of course you can see it on the sagittal view and the transverse view. You can see the arms and then you can cut the uterus in coronal view to many different sections. So ultimately you get a 3D coronal view where you see the arms up in the fundus and the stem. And so you know, it's actually in the right position. Now, not all I ucds are a t shape. In fact, this is a very typical IUCD and the patient's name is one syllable. So this is a Chinese woman who came from China who had an IUCD. She had a round a ring type IUCD sitting centrally within the endometrial canal. Here's a different case. And on SVU you can see the two arms of an I-U-C-D-A ring. Here you can see two arms of an IUCD. And here on the other side you can see another one. And in fact you can see three of these. And on 3D you can see these. One, two, 1, 2, 3 I ucds. Well, how is that possible? Well, because of the one child policy, just after she delivered the cervix is rather large and they can throw in as many rings as they want. And this patient had a bico uterus and they put in one on the right horn and two on the left horn. Little overkill. So a lot of the Chinese I ucds are here. You can have a ring without a string. It's a solid ring. You can have a ring with a string and you can have a ring that's made of a spring that has a string. So this one obviously you can remove this one you would never remove. What happens if you have lost string? We get tons of requisitions. Remember there are myometrial contractions. And the contractions not only suck up the sperm from the vaginal vault and drive it up to the fundus and down the tube, but it'll suck up anything. And the string usually migrates into the my endometrial canal. Because of myometrial contractility, the string seldom falls off and it's retrievable with something like a crochet hook. They put it into the endometrial canal, they spin it around, they grab the string and then they pull it out. So misplaced IUCD. Well they're put into wild and wonderful places. They seldom migrate although they can migrate. And IU CDs don't really migrate themselves 'cause they don't have little feet. Should it be removed? Well, a marna, because it's hormonally based, will still work if it is in an abnormal position. One of the other things that are now relatively new, the Essure IUCD, which is a threaded device that's put into the endometrial canal. It should into the fallopian tube. It should extend from the endometrial canal through the myometrium into the tube on both sides. But it's amazing how often we see mal placed esu I ucds.

Conclusion

Well, that's really the end of the talk, but this should be the beginning of your challenge to answer the question. Answer the question, is there a mass? Where is the mass? Is there a tenderness? Where is the tenderness? That's the way you're gonna help the patient. And if you as a female or a male ever have to have an ultrasound, I know that you hope that your sonographer will answer the clinical question. Thank you very much.