Thoracic Lesions: Part 2 (Extrapulmonary)

Introduction

No financial disclosure.
The only one is that I'm sort of nervous speaking
after Mike Fale, but I'll do my best.
Today is the second part of my talk.
As mentioned yesterday,
incidental findings in the chest are abundant,
and I will try to focus.
I covered lung nodules yesterday
and today I will try
to focus on the clinically significant findings that we
encounter, and especially those that are relevant
to the patient's wellbeing.
And I will cover pleural findings,
diaphragmatic mediastinal, cardiovascular and chest wall,
and will try to squeeze all in all of this in 45 minutes.

Pleural Findings

Starting with the pleura, pleural fusions are
really the most common incidental abnormality of the pleura.
And we are all familiar with the underlying etiologies
with what we have to look
as suspicious findings would be noncalcified
or calcified pleural plaques that would
make us think about not benign etiologies
for pleural effusions.
And see clinically significant pleural abnormalities
are relatively rare.
The shape of pleural effusion is helpful to
differentiate between benign and malignant disease.
What are the features that are concerning
for malignant disease?
These are circumferential, thickening that is
beyond one centimeter nodularity,
and a very helpful one is involvement
of the mediastinal pleura as we see in patients,
for example, with mesothelioma.

A common finding in the pleura,
probably also related in some way to obesity,
is the pleural lipoma.
This is a well circumscribed neoplasm has obtuse angles
with the chest wall displaces.
The lung parenchyma has homogeneous fat attenuation,
and sometimes multiplanar reformats are helpful
to differentiate it from lesions that originate
below the diaphragm.
Liposarcomas are very rare and usually very large.
I won't go into these
and you have to get a wide window
when you look at these to be able
to differentiate them from other lesions
and easy then to see how similar they are.
All of these to the subcutaneous fat.

The asbestos related disease or asbestosis.
What we see in this case,
in this scenario is diffuse pleural thickening.
It's important because patients might be symptomatic
with respiratory dysfunction.
Pleural plaques in themselves do not have functional
significance, and typically we see pleural calcifications.
Patients, Calcified pleural plugs in the
diaphragm are very reliable to indicate that this patient has had asbestos exposure.
And as we all know, there is a long latency
between the exposure and the development of those plaques.

Asbestosis in itself is defined as the interstitial
lung disease that is associated with the exposure
and it progresses from the basis to the hilar.
And hilar lymphadenopathy in this case is
usually not present.
Why is it so important to be aware of it?
Because according to the literature,
they have a very high incidence of mesothelioma.
But in spite of the 7000 fold, much more common is
to see lung cancer.
And those patients should be really more discouraged than
any other patient or person to smoke.
Because of the huge difference
that smoking makes in this subsetting
of patients in developing lung cancer.
They also have a significant increase in incidents
of gastrointestinal neoplasms.

And this is a very typical appearance of multiple plaques.
Hard to see on the lung window setting
that these are calcified much easier on
either the bone window or the mediastinal window.
And you can see the calcification on the diaphragm in this patient
and in another patient on the right side easy
to identify them.
Sometimes they sort of blend with the ribs,
like in this case.
But then when we look in the coronal reformats,
it's easy to see how extensive these are.
And again, when I see them, when I don't see them on the
diaphragmatic surface, I'm sort
of not really happy to call them asbestos related.
Notice that the majority of these, or
like 75% are bilateral, a nice differential
to keep in mind that often is
for some reason not considered
by when we read out those studies is prior pleurodesis.

As you know, pleurodesis is performed for both benign
and malignant pleural effusions.
And for patients who present with recurrence,
spontaneous pneumothorax,
and the pleurodesis, the target of that is
to induce an inflammatory reaction in the pleura
and hence obliterate the space.
What then we can see,
and this can remain there for many years beyond the
treatment is high density deposits, often linear.
They can follow the fissure and look like this.
So sometimes quite confusing, sort
of easy in this case since there is no IV contrast.
So one less worry if that's like a hemorrhage
or in another patient with prior lung cancer.
You can see nicely that it also
involves the mediastinal surface in this case.
And if you are not quite sure, you can always
look at the PACS and see
that this patient had a huge pleural
effusion a few days earlier.

So how to differentiate between pleurodesis and other entities?
The main differentials for high density
in the pleural space is previous asbestos exposure healed
empyema or hemothorax or prior granulomatous disease.
Like TB deposits, as I've shown, are linear,
usually posterior basal regions,
whereas pleural plaques in asbestos exposure tend
to be posterior medial and bilateral in the majority of patients.
Caution. One thing to remember, since some
of the patients who've had pleurodesis have underlying
malignant pleural effusions
and FDG can be false positive in these cases.
So one little point to remember.
Prior pleurodesis, if you have positive FDG,
it does not necessarily signify malignant disease.

Diaphragmatic Findings

Moving on to the diaphragm, the most common
incidental findings that we encounter in decreasing
frequency are the hiatal hernia, Bochdalek hernia,
and much less frequently the Morgagni hernia.

Hiatal Hernia

Hiatal hernia are really apparently quite common,
as you can see, over 50% in above 50 years of age.
Of course, it depends on the extent, so it can
include the very small ones and the large ones.
Often symptomatic patients will have chest pain,
heartburn, important to remember
that gastroesophageal reflux can also progress
into Barrett esophagus
and pre-malignant conditions.
Patients might have dysphagia different swallowing complaints.
And very interesting study show that patients
with large hernias also have dyspnea.
So they followed patients
who subsequently underwent repair of the hernia
and realized that they have improved exercise capacity
after the repair.
And that mainly is associated
with the severe compression of the left atrium.

So we can nicely see the hiatial, the defect
or the widening in the hiatus here with a large part
of the stomach within the chest.
But note that if we wanted to look for the left atrial
compression on the axial slices,
it's not very straightforward.
So I'm gonna scroll through this.
This is the left atrium,
and this is the hiatal hernia,
the stomach within the chest,
and really hard to decide if there is in any significant compression.
On the left atrium,
you can see it's a very large hernia, large contents.
However, when we look at the sagittal reformats,
it's much easier to see
that the left atrium is indeed compressed,
and this patient might indeed have a more severe symptoms.
One more good reason that appears in the recent literature
is hiatal hernia may mimic mass within the left atrium in a TEE.
So something to remember that if the
patient has a hiatal hernia that might account
for many other things as well.

Bochdalek Hernia

Bochdalek hernia, we see these quite frequently.
You can see it's different from the lipoma
that I've showed earlier,
because you can see the diaphragmatic defect right here.
They're always posterior
and rather medial,
nicely seen on the coronal reformats
and the smaller one on the sagittal reformat,
most of them are asymptomatic in much younger,
I mean in young, in children and in young kids mainly
because of if there's a lot of abdominal contents that herniates into the chest in adults more often, they're asymptomatic.
They can be both sides. It can be affected.
The majority contain only a little fat,
as I've shown in the last case.
However, they may contain organs
and in these cases might be more complicated.

Morgagni Hernia

Morgagni hernia, even though I'm showing a left sided one a much more frequent on the right,
they're often anterior.
And the CT can, if we know again
that this patient has a Morgagni hernia, this can account
for like a mediastinal widening or a so-called cardiomegaly
because the fat blends with the cardiac silhouette usually
of no really significant clinical importance.
Just something to mention and to know by to accurately name it again, more on the right side.
And if patients are symptomatic they will have cough
or chest pain, very rare to have bowel
or any other organs within them.

Mediastinal Findings

Moving on to mediastinal findings.
So again, back to lipomatosis,
excessive unencapsulated fat within the mediastinum is
frequently seen and disassociated with obesity, as well as
with steroids.
So it could be Cushing from steroid administration.
And this is one such example.
Often it's more symmetric than in this case,
you can see the abundant fat.
And again, you have to window it appropriately to be able
to see the whole extent.
And again, if we know that this patient has mediastinal
lipomatosis, and it's in the back
of our mind, then if we read other like for example
plain films, other imaging modalities, it's easy to account
for the abnormality that we will see on these.

This is very different from a mediastinal lipoma seen here.
So mediastinal lipomatosis is usually anterior.
This is a mediastinal lipoma, a benign tumor,
quite rare one,
and can be, it should be completely homogeneous,
might be symptomatic
and causing in rare cases, even
superior vena cava syndrome and Horner syndrome.
But again, this is not a very common lesion,
just a nice comparison between the completely homogeneous and low density fat in this case.
And compare this to mediastinal liposarcoma
with high density tissue
and a lot of stranding.
Again, both of these are not common,
but the absence of any stranding within this makes it very typical to
for a benign lipoma, unlike the liposarcoma.

Thymus and Rebound Hyperplasia

The thymus, the thymus we always are aware of in children,
and we can see the big thymus on chest x-rays.
And we know they're very active organs in children
where they become very small.
They sort of disappear under stress periods,
and then they rebound when they have recovered.
But thymus can also be
the thymus can be also seen frequently in young adults
and sometimes even in middle aged patients.
So this is a typical normal thymus in a patient
who is 19 years old, typical bi-lobe
and triangular a normal finding in this age group, by the way.
And I would like to just mention this phenomenon
of rebound hyperplasia of the thymus
that we also see in adults.
And this often surprise for clinicians when we
describe that.

So even though, as I've mentioned,
it's very common in children
and adolescents, it's also seen in adults,
though not frequently, the most frequent underlying etiology
for the development of this rebound hyperplasia
of the thymus is chemotherapy.
But it can also occur
after other very stressful events such as major surgery
or severe infection.
The thymic enlargement appears as a mediastinal mass
that would be more prominent larger than the normal thymus that I've just shown.
And in a oncologic patient,
and the majority of patients
with rebound will be oncological patients.
It can sometimes cause a source of concern.
So that's why it's really important for us to be aware of it
and mention to the clinician, to the oncologist,
it might be just a very benign
and temporary rebound of the thymus.

So a 20-year-old man with testicular cancer,
and this is the normal fatty infiltration
with some residual thymus, pretreatment and post-treatment.
And the largest first series describing this phenomenon in adults was actually in young males
with testicular cancer patients with in their early twenties,
which are the typical age group for this tumor.
This is the same patient.
You can see the sagittal the fat
with some residual thymus, whereas the dense soft tissue within the thymus post-treatment.
Another example, this was a 34-year-old female, which
who initially presented with
what we thought would be a pneumonia.
However, it turned out
after it didn't resolve for a long time
to be an adenocarcinoma.
The top slides show her the residual thymus pretreatment
and her rebound post-treatment a few months later.

And maybe the most impressive case I've come upon was this 18-year-old woman with typical findings,
clinical and radiological
of Hodgkin disease in the anterior mediastinum.
And after treatment, all of this resolves.
The lymphadenopathy, there is nothing almost in the
anterior mediastinum.
This is two months after chemotherapy,
and eight months later,
there is this very prominent soft tissue mass.
And the treating physicians were very concerned
about it, and that's why they got the FDG PET CT, which shows increased uptake.
So this wasn't reassuring for them.
However, there were no additional pathological FDG
and no other sites with uptake.
And this is actually described in the literature again
as a so-called false positive.
It's not a false, but it's not, it only reflects the rebound
of the thymus.

Incidental Cardiovascular Findings

Moving on to incidental cardiovascular findings,
This is an interesting article published in 2010.
So the interesting part
of it is the two cardiologists rolled up their sleeves
and looked over 100 consecutive contrast CT studies
that were done to exclude PE,
and they were looking at them through their lenses,
which are focused on the heart
and the vascular structure seen in the chest.
So the PE rate in those hundred studies were about 5%,
a bit lower than usual, but that's what they found.
And then they enumerated the they mentioned
and looked through the incidental cardiac findings,
and you can see that aortic valve calcification was a very common finding
followed by coronary calcification,
cardiomegaly atrial dilation, and so on and so forth.

And then they compared their findings
to the ones mentioned in those reports by generated
by the radiologists.
And only 3% of the reports mentioned any
finding that was pertinent to the cardiovascular
aspect of the study.
And they were only cardiomegaly.
And so they compared it to saying like, look
what the radiologists are interested in lung nodules,
parenchymal findings, effusions,
and they make the case of
how important it was in their opinion, that sort of
to encourage us to mention cardiac findings
and only 3%, whereas they found 78%
of the scans had at least one incidental cardiac findings
that they thought we should mention.
I think it sort of convinced me,
and I definitely look and mention them,
and I'll give you a few reasons why I do that now.

So they stress that
although these abnormalities may not have implications
for the acute clinical management, which was in the reason
for the PE studies, of course, they may have important implication the long-term care,
and just a few examples I won't go into
into all the details,
but we all know coronary aortic wall calcifications
are of course markers for atherosclerosis
and asymptomatic atherosclerosis will benefit with
from treatment with statins and aspirin.
And so hopefully we'll prolong survival and therefore we might help in the prevention
of atherosclerotic events.
Another point cardiomegaly might reflect left ventricular
dysfunction and heart failure.
And these both have poor prognosis
and again, can benefit from treatment.
Left atrial enlargement can cause dysphagia.
I've shown you the other case
before where a large hiatal hernia could
compress the left atrium in this case.
The left atrial enlargement often
as a cause for dysphagia.
And again, this is treatable.
So drugs that can improve the left atrial function
and hence reduce or improve the dysphagia.

Again, as I mentioned on the prior case
with the hiatal hernia, when we look at the axials,
it's sort of borderline.
And if we are in a hurry,
we might not mention the left atrial enlargement.
However, if we look at the sagittal reformats,
look at the esophagus above it
and the compression on the esophagus at the level
of the left atrium,
and then again, there is some air in the esophagus.
So no doubt it compresses the esophagus,
and it's worthwhile looking at it while you look at the
sagittals anyway, for the bones.

Another interesting
and quite frequent finding is lipomatous hypertrophy
of the interatrial septum.
It's while it says it's rare again, if you look for it, you'll see it quite frequently.
I see it frequently in those patients
who have mediastinal lipomatosis,
and then I don't mention it as a distinct lesion.
It is fat in the interatrial septum.
The etiology is not quite known.
Again, obesity is one of the underlying associated factors.
But the more important findings,
more important connections are the atrial arrhythmias
and recurrent pericardial effusions.
It's also more frequently seen in patients with emphysema,
most frequently,
those patients will not be treated
with surgical intervention
unless again, vena cava obstruction
or intractable arrhythmias PET CT.

While a wonderful tool in many instances, again
may be misleading, there is often increased uptake in this area of fat,
and that's likely
because of the brown fat within this lesion
and may be mistaken for a mass.
So this is one example
where you can see the patient does not have mediastinal
lipomatosis, but has this round
or oval shaped fat within the interatrial septum
and another patient with a little bit more fat.
But look at this very prominent sort
of dumbbell shaped lesion within the interatrial septum.
And this patient did have arrhythmia,
and you can see that he has the nice association
with emphysema.
This is his native lung.
This is his transplanted lung, which looks rather normal.

Coronary calcification.
We all know how it looks,
and I don't want to talk about that too much.
Just to mention that when we see we have three coronary, it's all three coronary arteries,
heavily calcified in this 79-year-old male
who we might even not mention it
because we would assume it's sort of a expected finding.
However, this is a recent patient.
I read
and I mentioned, you know, I looked, I said, 38,
that's completely abnormal.
And maybe a month later, I happened to read his CT again,
because now he was post CABG.
So I was sort of delighted that we picked this up
and we pointed it out.
And I think we as always,
we always look at the studies in the clinical setting,
but the clinical setting, one important factor is of course,
the age of the patient.

Chest Wall Findings

Moving on to the chest wall.
So a lot of findings in the chest wall and often easy to overlook when we are concerned with the lungs
and the mediastinum, the diaphragm, there's so much to look at.
It's easy to not mention them or overlook them.
And I think it's not a good practice
to not include it
and not to think about it sort of as an organ in itself.
And even the chest wall is not really an organ.
It's like it consists of so many sub organs.
So just a few findings in the chest wall, the ribs for one
very common finding.
If somebody wants to throw out the name,
it's up there.
Too bad. See?
Alright, my challenge cases don't have that.
And they're alright. You'll get better chances.
Alright, fibrous dysplasia, a common finding in,
in it could look sort of look almost a bit scary, but very frequent finding in ribs.
The normal bone is replaced by immature woven bone.
It's seen in children, young adults,
no gender predilection.
The ribs are the most common site for monostotic form
of fibrous dysplasia.
And the other way around fibrous dysplasia is the most common
cause of benign expansile lesion of the rib,
has this nice bubbly cystic appearance ground glass
enlargement.
And it's associated with many different syndromes.
But that's for other quizzes, not today.

The next patient shows lots of abnormalities in his chest wall.
So I'm gonna point them out.
So first of all, we've got,
and this, there is nothing saying that
what anybody wants to try.
Maybe the mammographers have seen that most frequently,
and I know there are a few in the audience.
Sternalis muscle present.
So he's got a unilateral sternalis muscle.
And this, you know, this even not the mammographer.
So he definitely also has gynecomastia.
And as we go down, we can see the collaterals.
And so these two findings together will be associated
with what we'll see as we scroll down with his cirrhosis.
And so he's got portal hypertension collaterals in his chest wall estia,
and we can give a nice diagnosis.

And this is an example of his sternalis muscle,
which is in this case is unilateral.
And as I looked at through the literature
'cause I thought, should I really include it?
And then I said, yes, it's a nice
finding, why not include it?
And it's actually has a few good reasons why one should be aware of it, of this anatomical variant.
And it's maybe sort of importance.
One is because if we know it's there,
and in my imaginary PACS,
every time I would read a relevant study,
there would be a little star coming
and saying, you know, this patient has a unilateral left
or right sided sternalis muscle.
And if this was a woman and she underwent mammography,
then it would hopefully avoid a pitfall saying, oh,
this is a mass in the breast.
Alternatively, there are some surgical benefits
because if a patient needs reconstruction
surgery of head or neck cancers
or anterior chest wall, or
because of breast surgery,
the muscle is very helpful apparently for plastic surgery.
So even though we might often sort
of dismiss those findings,
because we don't want to write like a whole long report, some findings I find are really maybe just
worthwhile mentioning another congenital anomaly of the chest wall.

And this one, I'm fortunate I didn't put the answer anybody wants to try.
So we've got rolling.
Yes, very good Poland syndrome,
rare congenital malformation of the chest wall.
It consists of a unilateral, partial
or complete absence of the pectoralis muscles,
sometimes even more extensive.
Also, hypoplasia of the subcutaneous
or breast tissues, absence of ribs sometimes.
And also rib upper extremity and hand abnormalities.

And so moving from the congenital abnormalities
to the pathological conditions in the chest wall.
So I've already mentioned gynecomastia,
and this is defined as benign,
excessive breast development in male individuals.
And apparently it's a very common finding and can probably be a huge concern for the young men
because look at the percentage who are affected by that.
This is the list.
I'm not gonna go through this of gynecomastia,
and I barely made it into to squeeze it into this,
and I'm not gonna read through this for you.
Almost the same length,
and this is probably even more important, are the many,
many drugs that are associated with gynecomastia.
And many of them are drugs that are very commonly used such as amiodarone and cimetidine
and spironolactone
and ketoconazole and many others.

And this is probably important
because if a patient gets a CT done for any other reason,
and he might not mention to his doctor
that he suffers from gynecomastia, it might be worthwhile
for us to mention that
because maybe this drug can be switched with one
that doesn't cause that for that patient.
So just trying to summarize the those lists
that I've shown you, liver disease, at least in my practice,
is probably the most common cause for cirrhosis.
Drugs, as I mentioned, are too many to count
and really an important underlying reason for that.
And estrogen levels when they're increased,
testicular cancer and so on and so forth.
The typical patient will be a patient
that has an underlying cirrhosis
and really prominent gynecomastia.
Again, very small error that we can make is
by not looking at the gender and the age of the patient.
So make sure you look at the gender
or else you can just dismiss these prominent breast tissue in this male.
And again, if we scroll down, we have at,
we can make the whole picture fit nicely into the
all the pieces of the puzzle into one nice picture.

And not infrequently do we see also unilateral gynecomastia.
So that's shouldn't raise the possibility of breast cancer that wouldn't look like that.
And finally probably one
of the more important incidental findings
that we do not want to miss and is often overlooked.
And again, I will be very honest
and say that since I've started looking for finding nice examples for this talk,
I look at the breasts much more carefully than I used to.
And the rate of incidental findings
that I've found over the last few months has increased
so dramatically that I'm sort
of embarrassed, but don't tell anybody.

So this is really an opportunity for detection of findings
and as I've said, it might be the most significant
incidental, so-called incidental finding
that you would look at, you would find.
And a few studies that have recently been published mentioned that up to 30% of those incidental findings
that one finds on CT will be malignant.
So huge percentage.
And they were trying to characterize
what features should raise the possibility
of malignancy and speculation
and irregularity were the main ones.
Unlike mammography, calcification patterns
do not appear to be helpful.
Size does matter, but only to a little, to a certain degree
because malignant lesions tended to be larger
than the benign ones.
Of course, there is overlap. Also age matters.
The older patients in their sixties tend
or seventies had the larger incidences,
greater incidences
of cancer than the younger age population.
And these are the underlying pathologies
that this one study found.
So a third of the patients with incidental findings
that were worked up were malignant and they
and other researchers have stressed the importance
of the axillary lymphadenopathy in these patients.

A particularly important finding that we should mention,
and I would like to stress
that many studies do not include the entire breast, such
as like coronary calcium scoring
and other coronary studies which are quite abundant out there.
So when you don't have the breasts in a woman,
but you do have a large prominent
enhancing lymph node in the axilla, do mention that stress
that and recommend mammography
because most likely the patient
who undergoes those studies are probably
passed her 40 years.
So if she hasn't had a recent,
I usually say if there is no recent mammography,
consider mammography since this might be an important finding that is correlated
with breast cancer.

And so this, I assume none of us would miss
a large lymph node,
but imagine the breast wouldn't be associated
or would be cut off for some reason.
If it's a single large lymph node, it really is important
that we mention it and mention that it might herald breast cancer.
This is a young woman, she's 37,
and when she was even younger than that,
eight years earlier, she had a fibrosarcoma in her thigh.
So she undergoes annual scans to look for lung metastasis.
So needless to say, we look very carefully.
I've shown you the MIPs yesterday.
So in this case, of course, we look
for the lung nodules on purpose.
We do not want to ignore them,
however, we don't look as carefully at her chest wall
and definitely not at her breasts.
I had the whole study, if you scroll through it,
this would be a bit more obvious compared
to the left breast, but I didn't want
to take more time.
But this is 2006.
She's 37 years old, then she comes back a year later.
Look at the left breast, look at the right breast.
She's now 38 years old. She's now 40 years old.
And when she's 41 a year later, she palpates a tender lump pain, tender lump is firm.
And she has multifocal disease in exactly the same
location as we see it on the CT.

So just to show it one more time,
different patient had itchy rash
for a few years and was diagnosed with Sezary syndrome,
which is sort of a lymphoma
that involves the subcutaneous tissues.
You can see those nodules in her.
This is a PET CT, part of a PET CT.
You can see the nodules in her skin
and you can see the nodule here and two nodules in her breast or chest wall.
This one is a bit larger, a bit more speculated.
And when we get the PET CT,
this ended up being DCIS in the left breast.
So we really need to have a high index of suspicion.
We do not want to miss these.
And what would we say about this patient?
Would we say that just asymmetric,
maybe we would overlook it
or maybe we would say patient post mastectomy?
I always encourage you to look at prior studies.
Always look at the patients.
If you have access to electronic file, it's
so helpful and really gratifying
to avoid embarrassing mistakes in this case.
Right breast is really much
more prominent than the left.
She did not have a mastectomy before she undergoes PET CT.
And this is biopsied
and she has B-cell lymphoma in her right breast.
This is pretreatment,
and two months later she's post-treatment.
And look at this breast tissue.
Now it's completely symmetric.
Now with the left normal breast.

Tiny hyperdense lesion, I hope it shows,
I think you can see it right here.
It's a patient who has had a previous ovarian cancer.
Again, in these patients, needless to say, we will look
for lymphadenopathy very carefully in the mediastinum.
We will look for the lung lesions.
Will we inspect the breasts very carefully?
It probably depends on our routine
or on how much,
how many more studies are waiting for us.
But a good routine would be to include these no matter
how many additional studies we need to read.
And this ended up being metastasis from her ovarian cancer.

Summary of Incidental Breast Lesions

So incidental breast lesions.
To summarize these, there are no certain radiological
criteria to safely differentiate between malignant
and benign breast lesions.
Therefore, all breast incidentalomas should
be further evaluated.
We shouldn't look away, we shouldn't make diag like we shouldn't think.
The patient will just be worried.
No, we shouldn't.

Overall Summary

And to summarize the whole talk,
there is really plethora of incidental findings
and I hope I've stressed the ones that I found relevant
for the patient's wellbeing, the cardiac
and the hiatal hernia, for example.
It's a wonderful opportunity for documenting findings
that this patient has
and might account for findings in additional imaging
or other events in his medical career
and the opportunity for detecting breast cancers.
And I thank you very much for your attention.