Interpreting Your Report
Comments
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Hi @djmammo! I am a 46 year old female and I am hoping you can help me interpret my mammo and US findings. I am confused and a bit worried about the "significantly increased vascularity" although everything else seems to point to a benign mass. Thank you in advance!:
FINDINGS:
Mammography findings: The breast tissue is heterogeneously dense, which lowers the sensitivity of mammography.
There are no suspicious masses in the left breast.
An approximately 1cm, oval, superficial mass is seen along the 5-6 o'clock axis of the right breast, 3-4 cm from the nipple. The mass was not appreciated in 2017.
There are no microcalcifications in either breast.
US findings:
Right breast: High -resolution, grayscale ultrasound was performed, focusing on the right lower inner quadrant. At 6 o'clock, 3-4 cm from the nipple, is a circumscribed, superficial, solid mass. The mass is orientated parallel to the chest wall, and it demonstrates posterior acoustic enhancement. Color Doppler interrogation of this 1.0cm x 0.7 x 1.2 mass shows significantly increased vascularity. This mass accounts for the mammographic finding.
Hyperemic mass along the 6 o'clock axis of the right breast, accounting for the new mammographic finding. Histologic diagnosis by ultrasound guided biopsy is recommended.
BI-RADS: 4a
(My biopsy is Monday at 8am)
Thanks again~~
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Hi I am 31 yo female and have been complaining of breast related symptoms for 2 years. I went this week on 4/30/2019 for a diagnostic bilateral mammo with ultrasound. the mammogram tech gave me results right away that my mammogram was negative. However i went straight back for an ultrasound right after and the ultrasound tech was looking at my left breast about 3:00 - 4:00 position she took some measurements told me shes going to interpret imaging with radiologist and she will be back in to discuss with me in 20 mins. 20 mins later the ultrasound tech comes back in with a male doctor who tells me that i have a small mass in left breast and that they want to get me scheduled for a ultrasound gided breast biopsy which i have scheduled for 5/6/2019.
Radiology reports states
breast composition heterogenously dense which may obscure small masses
findings
On the left CC view there is an equivocal 8x10.5mm oval-shaped assymetric density deep to the nipple toward the 3:00 position.
On the left however 3:30 position 3 cm from the nipple there is a slightly lobular non-shadowing hypovascular 11.4x5.7.4.1 mm hypoechoic focus
IMPRESSION
equivocal mammographic asymmetric density 3 o clock position with ultrasound correlate. while this may represent asymettric fibroglandular tissue or small fibroadenoma options of 6 month foll-up and ultrasound guided biopsy were discussed with the patient. Biopsy is favored to exclude a malignancy. findings and recommendations were discussed with the patient.
BI-RADS category 4 suspicious abnormality biopsy should be considered
So im confused it kinda indicated to me that its a benign issue but why would bi rads go from 1 on prior study done in 10?2017 and d composition to birads 4c and a need for biopsy so fast after. does this mean that they think based off imaging that i have a malignancy and need biopsy to confirm because the birads category and composition doesnt incinuate very good when i have been reading into the different parts of breast cancer wording along with discriptors of reports. Please help me calm my nerves a little bit
Thanks
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Fibroadenomas have a blood supply that can often be detected on Doppler but it usually is not "significantly increased". The other features are more in the benign category especially the enhanced through transmission. Let us know what the biopsy shows.
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Thanks for the reply. That's what has been a bit confusing to me. I don't think my report stated "enhanced through transmission" ? Unless some other verbage on the report means the same thing?
2 questions: 1. What does superficial mean in this instance?
2. Can malignant masses present with benign findings?
I will let you know for sure! Thanks from a fellow "Michigander"
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Unless some other verbiage on the report means the same thing? = . Means the same as "posterior acoustic enhancement"
1. What does superficial mean in this instance? Superficial = near the underside of the skin
2. Can malignant masses present with benign findings? = the short answer is yes, but its not all that frequent. This is basically why it is very common that all new solid masses are biopsied no matter what they look like.
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"So im confused it kinda indicated to me that its a benign issue but why would bi rads go from 1 on prior study done in 10?2017 and d composition to birads 4c and a need for biopsy so fast after. "
That last mammo was 2 years ago. It only tells you nothing developed since the prior mammo. Those results have no bearing on the current mammogram.
"Does this mean that they think based off imaging that i have a malignancy and need biopsy to confirm?"
Not necessarily, anything new and possibly solid is biopsied as a matter of protocol. Ins company will not pay for a biopsy without a B4 or 5. Biopsies are also done to exclude a diagnosis of cancer and most biopsies turn out benign.
If Googling these topics upsets you, then I would advise against it until after the biopsy.
Let us know what the biopsy shows.
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Thanks for the quick responses. ( I promise, I'm not a crazy googler, just love information)
Is it truethat the smaller the mass with higher vascularity, the higher the chance of malignancy? Also, I’ve had 4 previous mammos with no mention of a fibroadenoma. This is a new finding so.... I also read that new fibroadenomas don’t occur in women over 40?
I promise I’m done researching now and going to go work in my garden:)
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I have a history of multiple fibroadenomas (2 bx confirmed, each breast). I found a new lump and went to my Gynecologist who told me she wasn't worried (lump feels hard but mobile, not unlike my other fibros) and sent me for an ultrasound but said I could even wait a week if I wanted to. The US place couldn't schedule me for two weeks, but I didn't see that as an issue based on the advice I received from my Gyno. I had the ultrasound, and the radiologist told me that she considered having me come back in 6 mo, but since the mass is new that I should have it biopsied. I asked her if it looked suspicious and she said "no." So, based on everything I was hearing I was thinking this was probably another fibroadenoma, and scheduled the biopsy at a convenient time about 10 days away instead of asap as I would do for something suspicious (biopsy is this Monday). Then I read the Radiologist's report below about a week later (the place I have the imaging done doesn't post the reports for a week after imaging) and almost fell out of my chair:
RESULT:
Breast DM Diagnostic Bil W/3D Tomo
Breast US Right Limited
HISTORY:
Patient is a 43-year-old female with a history of a new palpable lump at
the right breast. History of multiple cysts and biopsy-proven
fibroadenomas.
Surgical history includes 4 previous biopsies with pathology demonstrating
fibroadenomas and fibroadenomatoid changes. Family medical history
includes breast cancer in mother (age of onset: 56).
FILMS COMPARED:
Prior Images available and compared.
FINDINGS:
Tomosynthesis projections and reconstructed 2D images.Computer-aided
detection was utilized by the radiologist in the interpretation of this
examination.
Mammogram breast composition: The breasts are extremely dense, which
lowers the sensitivity of mammography.
Breast DM Diagnostic Bil W/3D Tomo
Right
A triangular marker denotes the site of new palpable concern posteriorly
at the right upper outer quadrant and this corresponds a focal asymmetry.
There are 2 biopsy clips seen at the right breast. There are multiple
additional partially circumscribed and partially obscured masses present
some of which have been fluctuating in size compatible with cysts.
There are benign-appearing calcifications present.
There is no no evidence of suspicious microcalcifications or architectural
distortion.
Left
There are 2 biopsy clips present. There are multiple partially
circumscribed and partially obscured masses present at the left breast
some of which are fluctuating in size compatible with cysts.
There are benign-appearing calcifications present.
There is no evidence of suspicious masses, microcalcifications or
architectural distortion.
Breast US Right Limited
Right
Targeted ultrasound of the area of new palpable concern at 9:00 6 cm from
the nipple demonstrates a 9.3 x 6 x 7 mm irregular hypoechoic mass with
partially indistinct margins. There is a simple cyst is seen adjacent to
this mass.I am a pharmacologist and definitely no radiology expert, by far. But, seeing "irregular hypoechoic mass with partially indistinct margins" sounds more like characteristics of a malignant mass to me. Now I'm freaking out that I have cancer and delayed the work-up. Am I overreacting? Is there something I'm missing?
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I would be more accepting of Googling if everything I've seen quoted on here was correct. If one sticks to reputable sites the odds of seeing the correct information is higher but one also has to understand what one is reading and not misinterpret it, and I have seen a bit of that on here too.
That being said, the vascularity part is true enough. As far as relation to size it might just be the relative ability to detect the vascularity. Fibroadenomas have a blood supply but its fairly low volume/flow and its probably easier to detect in a large one. The high flow in a cancer can usually be detected regardless of the size of the mass. So I guess statistically that could be a true statement about small vascular masses but its not something we think of/depend on when we read the study.
On the other topic, there is a difference between new and newly discovered. That FA might be there for years hiding in dense tissue until it slowly grows to a threshold size where it becomes visible and /or palpable since they take a while to grow. Many become apparent after some weight loss too. And yes they occur in women over 40.
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That description is enough to warrant a biopsy but not complete enough to tell what it is without a biopsy. There is no mention of vascularity or whether there is posterior shadowing, 2 things that carry weight in making a decision.
Regardless of its appearance, in most practices a new solid mass gets biopsied. 10 days is not a significant delay but 10 months would be.
If this were a cancer, its nice and small. Statistically cancers under 1.4cm have the best prognosis.
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Thanks so much. Have a great weekend
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Thanks so much djmammo! Appreciate your insight.
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Djmammo should I be worried:
MAMMOGRAM FINDINGS: There are scattered areas of fibroglandular density. Full field digital mammograms were obtained bilaterally. Routine 2D and digital breast tomosynthesis images are available. This current study was also evaluated with a Computer Aided Detection (CAD) system. 0.6 cm asymmetry is in the lateral left breast posterior depth, just lateral to the nipple line, 8 cm from the nipple. This is best demonstrated on the cc view. Otherwise, no suspicious calcifications, abnormal mass, or architectural distortion.
BI-RADS Category 0: Incomplete - Additional Imaging Evaluation is Needed. MANAGEMENT RECOMMENDATIONS: Further evaluation with spot compression tomosynthesis, with targeted ultrasound if indicated, of the left breast asymmetry is recommended.
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No. Not yet at least.
There is not enough information available at this point to decide what this density is. When you go back for additional views and an ultrasound you will know more. Since they mention no priors, is this your baseline?
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Your number one job at this point (after you schedule your next appointment) is to stay away from Google. It never turns out well especially if you have a tendency to worry about things in general. No matter what you read it will not change what this thing is and at this point it may not be anything at all.
The only time I condone unrestricted Googling is after you have a diagnosis either benign or otherwise. At this point there maybe treatment options to consider and you may be asked to choose among them and you really should have all the information you can find to discuss with your treatment team.
Meanwhile read this:
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No, not my baseline. I’m 59 and have gone every year since 40. Several years ago I got called back and had an ultrasound, and it turned out to be a cyst. But, shouldn’t they have known this? Could the cyst have grown, or maybe something is hiding behind the cyst? And, this is small in size, right? I
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There is no mention of the prior report so we have to assume this finding is new since the priors, if they had them at the time of this mammogram.
On an ultrasound there is no finding that can be "hiding behind" another but that is possible on physical exam of the breast. On mammo a finding can be surrounded by dense normal breast tissue and this is why standard mammography is done at several different angles and with compression. A "3D" mammo automatically takes images at many different angles.
If the cyst was seen on prior mammograms, if it got bigger they would directly address the finding as "...an increase in size of a cyst previously described". If it was only seen on US they would at least know where in the breast the cyst was located and comment accordingly. And yes 6mm is small.
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Thank you djmammo. I appreciate you taking the time to reply.
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Can someone help me read these results, the words are foreign to me. I went for my annual Mamo this year, returned for a ultrasound and another mamo on left breast. now I have a biopsy scheduled and I am very anxious. What are the chances of the calcifications being cancer?
MAMMOGRAM:
The breast parenchyma is heterogeneously dense which may obscure small masses. Additional spot magnification compression views in the CC, LM and MLO projections demonstrate a persistent 0.3 cm group of coarse heterogeneous calcifications in the
posterior 6 o'clock position of the left breast 7 cm from the nipple corresponding to the central left breast calcifications identified on screening. There is no associated mass or distortion. An additional 0.5 cm group of faint amorphous calcifications
is seen in the posterior upper outer left breast 8 cm from the nipple (best seen on the MLO spot magnification compression view which are not definitely appreciated on prior imaging. There is no associated mass or distortion.
There are no additional mammographic findings of concern. Scattered subcentimeter circumscribed masses are seen throughout the left breast suggestive of underlying fibrocystic change.
Thank you!0 -
There are many different attributes to calcs seen on mammo. Size of each calc, shape of each calc, overall pattern the group of calcs, number of calcs, size of the group of calcs as a whole etc. so you can see there is really very little to go on in this particular report. Did the screening mammo say these were all new or describe them any better?
As a rule of thumb a group of big smooth round calcs are usually benign and small irregular calcs arranged in a branching pattern is suspicious. There are those that are in between these characteristics that can be anything from fibrocystic to ADH.
The good news is they saw no mass so IDC is much less likely. Let us know what the biopsy shows.
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screening report said they were new and it’s a birad 4, thank u for ur quick reply
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Posting this here to see if anyone can help me with some of this. I went in for an US this past week. Radiologist came out and talked to me for a minute, but was extremely condescending and dismissive. I'd simply asked her whether it was looking more like a malignancy or more like something benign. She scoffed at the thought it could be something other than malignant. I freaked out. Told me a biopsy, and not to delay. Then started to say they have a 3-week wait at their place, she thinks. I wanted the specifics to see how bad it was, and went and got my report the next day because the stress had kept me up all night.
Indications: 46 year old female comes for left breast ultrasound evaluation for abnormality noted on recent outside facility screening.
Technique: greyscale and color doppler evaluation of the targeted left breast
Findings: At posterior 3:00 near the chest wall is seen a 1.2x0.8x0.9 cm oblong hypoechoic mass with slight posterior shadowing and no internal vascular signal. This correlates with the mammogram finding. No adenopathy.
Impression: Indeterminate 1.2cm mass in the left 3:00, 9.0cm from the nipple for which ultrasound-guided core needle biopsy is recommended as malignancy cannot be entirely ruled our.
Bi-Rads 4: suspicious abnormality, biopsy should be considered.
Subdivision 4b, intermediate suspicion for malignancy.
So I've spent the last two days stacking the "good" against the "bad" in the report. The posterior shadowing seems to be one of the bigger worries? And the location. But there are a few things that are still questions in my mind:
1. They spent a bunch of time looking at and taking pictures of my lymph nodes. The doc didn't say anything about them. I remembered to ask the tech who said she didn't see anything. Can I assume they're OK if they're not mentioned here in the report? Or how should I go about finding out if they're OK?
2. Near the chest wall has me a bit worried. I keep doctor googling it, and nothing that far away seems good.
3. They won't schedule my biopsy until my GP writes a referral letter. I'm going to try to reach him Monday morning. Since this imaging place is part of a network, is it ok to simply go with "whoever can get me in soonest" or is it really best to go back to the condescending radiologist since she's at least seen me before? Seriously, I'll drive a couple hours if it means a couple weeks less wait time.
4. Anything else I should be asking when I go in for the biopsy?
5. Anyone have these sudden phantom twinges now that you get all worried?
6. Oh, and one view of the mammogram read the mass as 1.7, one read it as 1.4. Can/should I read anything into these different sizes? Was it larger on the mammogram because of being squished?
7. Oh and the network as a breast navigator. When does one ask about using those? when you're just freaking out about the uncertainty, or after a malignancy diagnosis?
Any thoughts are appreciated.
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You are assuming facts not in evidence or as my mother used to say "you are borrowing trouble". First of all realize this may not be a cancer no matter what you read on line. Though not completely described, the buzz words that suggest malignancy to me, are not present in the report. Google if you must but I don't recommend it until you have a path diagnosis and actually have something to research instead of creating anxiety (ask the others in this forum about "Dr Google")
Also keep in mind, that although this is new to you, these facilities have done this very same thing with 100's of people before you. You are not responsible for gathering information, directing your workup, or interpreting your results. You will be told what you need to know if this turns out to be a cancer. If its benign you may only hear from them when its time for your next routine screening.
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1. They spent a bunch of time looking at and taking pictures of my lymph nodes. The doc didn't say anything about them. I remembered to ask the tech who said she didn't see anything. Can I assume they're OK if they're not mentioned here in the report? Or how should I go about finding out if they're OK?
**Nodes are imaged and meticulously measured whether they are normal or abnormal and it is important to include their description in all reports. Abnormal nodes are a significant finding and I have to think if they were abnormal they would have remembered to mention them. I would not assume, but on the other hand if they are abnormal, that will eventually be discussed with you.
2. Near the chest wall has me a bit worried. I keep doctor googling it, and nothing that far away seems good.
**The area just behind the nipple is also rich in lymphatics and cancers here can go to the lymph nodes more than more posterior tumors. Trying to predict outcome relative to position in the breast is splitting hairs. We don't take that into consideration during the diagnostic phase so neither should you. It will mean more to your surgeon if this eventually has to be removed.
3. They won't schedule my biopsy until my GP writes a referral letter. I'm going to try to reach him Monday morning. Since this imaging place is part of a network, is it ok to simply go with "whoever can get me in soonest" or is it really best to go back to the condescending radiologist since she's at least seen me before? Seriously, I'll drive a couple hours if it means a couple weeks less wait time.
**The biopsy cannot be performed until they receive the "order" from your doctor but they may let you schedule it prior to that. You can always tell them you'd prefer a different radiologist as there was a "personality conflict" or similar phrase. Once the mass is identified anyone who does these kinds of procedures can biopsy it.
4. Anything else I should be asking when I go in for the biopsy?
**When you schedule the bx they will ask you a series of questions including allergies and medications, and other things they need to know for things to go well. They like pt's to stop things like Motrin a week ahead of time to limit bleeding, etc.
6. Oh, and one view of the mammogram read the mass as 1.7, one read it as 1.4. Can/should I read anything into these different sizes? Was it larger on the mammogram because of being squished?
**A mass has three dimensions so findings measure differently in different views and on different modalities (physics). There is some magnification with a mammo and also the squishing so if the finding is soft it may appear bigger. I wouldn't read anything into a 3mm difference. The only time that matters is on the pathology report.
7. Oh and the network has a breast navigator. When does one ask about using those? when you're just freaking out about the uncertainty, or after a malignancy diagnosis?
**If this is a cancer they will introduce you to the navigator. They are worth their weight in gold. That is the person who will answer all your questions with a bit more empathy than the doctor you described. They will make sure you see all the right people at the right time and get you all the important information. They replace Google. If its benign you may never be in contact with them.
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djmammo, thanks for the very thorough replies. My rl job is as an analyst, so I'm used to nitpicking things and acting on them immediately ... this is so hard to wait and not to have all the info yet. but thank you for clarifying and answering my questions.
I did hear back from the imaging place ... I'd answered their text message survey saying the doc wasn't helpful. apparently she is a sub doc that isn't normally there and they got several complaints from last week about her refusing to answer patient questions and being dismissive. I'm currently by the phone hoping to hear back about scheduling the next step. knowing it could be days. ugh.
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It seems like if she was so sure it was malignant, she should've rated it 5...
I'm so glad you got a good response back from the imaging place, and I hope things don't take too long for next steps. The waiting is really terrible. Hang in there!
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Had a biopsy on Monday (40y.o) (now Wednesday) and going out of my mind waiting for the call (either way they will call within 1-5 business days). No BIRADS-rating given. Terms like vertical oriented/shadowing terms making me super nervous.
Study Result
Impression
IMPRESSION:
1. Left breast: Suspicious findings. Biopsies are recommended.
2. There is a 0.9 cm suspicious sonographic mass in the 2:00 position, 5
cm from the nipple which appears to lie within the zone of distortion
demonstrated on the tomosynthesis imaging. This would be amenable to an
ultrasound-guided core needle biopsy. Correlation with postbiopsy
tomosynthesis imaging is recommended with regard to the relationship of
this mass to the distortion.
3. There is a 0.8 cm solid retroareolar mass in the 11:30 position, 1 cm
from the nipple. This is of low likelihood for malignancy however
evaluation is recommended. This would be amenable to an
ultrasound-guided core needle biopsy.
4. These results and recommendations were discussed with the patient at
the time of the study. Her questions were answered. The biopsies of the
left breast were scheduled for 5/6/2019.mail on 5/1/2019.
Codes: 4-10-8Narrative
LEFT DIGITAL DIAGNOSTIC MAMMOGRAM WITH TOMOSYNTHESIS AND DIRECTED LEFT
BREAST ULTRASOUND: 5/1/2019
COMPARISON: 4/24/2018, 6/2/2017, and prior.
CLINICAL INDICATION: 40-year-old female who presents for call back for
incomplete left mammogram for nodular asymmetries in the upper and
retroareolar regions.
FINDINGS:
Diagnostic imaging of the left breast demonstrates effacement of the
nodularity in the retroareolar location. There is noted to be a large
zone of apparent distortion in the superior aspect of the breast
posteriorly seen best on the MLO tomosynthesis image #24 of 73 and ML
image #28 of 74. The span of the distortion is approximately 6 cm. A
subtle irregularly-shaped approximately 1.2 cm possible mass is seen in
the slightly upper slightly outer quadrant posteriorly within this zone
of distortion.
Technologist and physician perform sonography of the left breast is
significant for a 0.9 x 0.7 x 0.4 cm vertically oriented hypoechoic mass
with echogenic surrounding tissue and subtle shadowing in the 2:00
position, 5 cm from the nipple. Flow is seen at the periphery, not
internally.
Scanning of the retroareolar region demonstrates a circumscribed oval
hypoechoic mass with internal vascular flow in the 11:30 position, 1 cm
from the nipple measuring 0.8 x 0.8 x 0.3 cm.
Computer-aided detection was used in the interpretation of this
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Here are the results from the additional mag views and US the other day. I do have my biopsy set up for next Wednesday but curious if there is any insight to the mammo report. (Hate the wait!) This is my 3rd mammo so they have previous exams to compare to. These are totally new findings
Magnification views again demonstrates small group of round, ill-defined, amorphous, and lucent centered calcifications at the right upper outer breast. A magnification views these do not definitively demonstrate layering milk of calcium. Targeted ultrasound demonstrates a complicated cyst at the 10 o'clock position 2 cm from the nipple measuring 0.7 x 0.7 x 0.5 cm, with some associated shadowing on real-time imaging. The findings and options were discussed, preference is for biopsy.
Adjacent to this area there is a oval hypoechoic structure at the 11 o'clock position 2 cm from the nipple measuring 0.4 x 0.4 x 0.4 cm, likely oil cyst.
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i am pretty sure the one at 10 o’clock with the calcifications. Not sure if he is doing the area next to it that he thinks may be an oil cyst (I have a calcified oil cyst in the other breast also but he has no concerns with that one
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new here...probably posted in wrong area first!
58 yo fem with "C" heterogenously dense breasts; regular mammo for past 15yrs...no issues til now.
On mammo on April found new asymmetry rt, lower breast.
May: diagnostic 3D mammo followed by US with radiologist @ large med ctr with amazing mammo dept
RAD REPORT: lower, rt outer area breast.
" a subtle palpable area is identified on physical examination at the 7 o'clock position 7 cm from the nipple. Sonographic interrogation demonstrates a hypoechoic area with posterior acoustic shadowing corresponding to the palpable region. Incidentally, assist as noted in the region. Suspicious findings when considering mammographic and sonographic assessment"
Birads 4 ...core scheduled 5/21.
Concerned as I know these terms pop up as not so great, more saying malignancy.nothing else in his report but stated he was going to call PCP immediately. Stressed 4 x need to have core needle biopsy soon.
PCP was contacted by radiologist; her voicemail to me sounded very concerned said that we would talk this week then after the results come in we will sit down and get a game plan. And wondering if the radiologist did not put certain things in his report but discuss certain things with her.....
History of cancer with both parents but not breast cancer.
Steessed!
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Hi djmammo,
Here is a copy of my most recent ultrasound report. I am anxious about waiting another 6 months. I have family history on my dad's side. His sister died of breast cancer and her daughter is currently in treatment for breast cancer. The language of the report is confusing and I would welcome your thoughts. Thank you!
Exam(s): US / BREAST BIL
Reason for Exam: US TO BILAT BREAST OCT 30/2018,6 MONTH F/U RECOMMENDED
EXAM TYPE:
BREAST BIL
HISTORY:
US TO BILAT BREAST OCT 30/2018,6 MONTH F/U RECOMMENDED
COMPARISON:
Ultrasound October 30, 2018
FINDINGS:
Sonographic evaluation of the bilateral breasts. Multiple simple and complex
cysts are again seen scattered throughout the breasts bilaterally, similar to
October 30, 2018. There is a lobular heterogeneously hypoechoic mass without
internal vascularity at the 9 o'clock position of the right breast approximately
1.4 cm from the nipple which measures 1.4 cm.
IMPRESSION:
Multiple simple and complex bilateral breast cysts. Lobular heterogeneously
hypoechoic mass without internal vascularity at the 9 o'clock position of the
right breast may represent a complex cyst or fibroadenoma. Six-month ultrasound
follow-up is recommended.
BI-RADS 3 Probably Benign RESULTCODE-: BR-3
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