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UU Surgical Series: Session 3 - Breast



Join Michael in session three of the Ulster University Surgical Society's revision series as he presents an overview of breast anatomy and common breast conditions. In this session, he provides a thorough explanation of the glandular and connective tissues, the structures of the breast, its blood supply, lymphatic drainage, and its important relevance in cancer metastases. Michael also touches on the axillary anatomy and its significance in surgery. In addition to anatomy, the session delves into common scenarios such as a patient presenting with a change in the breast. It discusses the relevant history to elicit, the examination skills required, and the conditions to be wary of. The session ends with an engaging review of potential exam questions, enabling participants to apply their learning. Great for revision, this session is a valuable resource for medical professionals facing two-year exams. Please note: The teaching in this session is student-led and is intended for educational purposes only rather than professional medical advice.
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UU Surgical Series: Session 3 - Breast

Welcome to session 3 of the series where we will cover the fundamentals of breast core conditions found in the T-year (2nd year) curriculum.

This session provides an overview of breast and axillary anatomy and covers the 'need-to-knows' for the surgical core conditions that can come up in exams.

This is a pre-recorded session that can be accessed at any time. Going forward, we hope to use this format for our revision materials, with the intent of making the series as accessible and convenient as possible!

Once you've accessed this resource, please give us your feedback so we can tailor future sessions to your revision needs.

We hope you enjoy!

Ulster University Surgical Society

Disclaimer: The UU Surgical Series is a peer-led revision series for educational purposes only. The design and delivery of these materials is carried out by medical students and, as such, should not be taken as professional medical advice. Whilst the materials have been designed as accurately as possible, it is possible that some materials may be out-of-date by the time the content is accessed.

Please note: These slides are property of the Ulster University Surgical Society - please do not distribute.

Learning objectives

1) Understand the intricacies of breast and axillary anatomy including the main structures, such as the secret lobules, lactiferous ducts, suspensory ligaments, and the nipple-areolar complex. 2) Examine and explain the blood supply and lymphatic drainage of the breast, and be able to identify the leading arteries and node groups. 3) Recognize the important anatomical spaces in the axilla and be able to recount the core contents, including the axillary artery and vein, axillary lymph node groups, the brachial plexus, and the short head of the biceps and coracobrachialis. 4) Develop an understanding of the primary symptoms and signs associated with breast changes that might indicate a pathological condition, including lumps, pain, nipple discharge, or skin abnormalities. 5) Acquire the fundamental skills needed for breast examination, in a sensitive and professional manner, and be able to discern and interpret findings such as masses, skin changes, asymmetry, and nipple abnormalities.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, happy new year and welcome to session three of the Ulster University Surgical Society's revision series. My name is Michael. And in this session, we'll be covering breast anatomy and some of the breast core conditions for the two-year exams. Just a quick disclaimer before we get started that this series is designed and delivered by students. Um It shouldn't be taken as professional medical advice and it's for educational purposes only. Whilst the materials we've designed have been done so as accurately as possible and with good sources, it's possible but that some of the materials might be out of date by the time this content is accessed. So it's worth keeping that in mind. So without further ado, let's get started. So the learning objectives of today are to review the fundamentals of breast and axillary anatomy, then we will review the definition presentation and management of the common breast conditions that will come up in exams. So some of the breast cancers, some of the benign breast diseases and a couple of other things as well. And then there are a couple of SBA S to practice at the end. So the good thing about the breast topic is that it's really quite simple and the anatomy isn't too complex. And if you know a couple of things, you're likely to be able to answer most questions on the exams. So let's kick off with anatomy of the breast. So the important structures in the breast that you need to be aware of are listed here. You've got your secret lobules, your lactiferous ducts, your suspensory ligaments and the nipple areolar complex. So you can kind of divide the breast into glandular tissue and connective tissue. So, in a female breast, there are approximately 15 to 20 secret lobules. And each one of those will consist of alveoli and these alveoli contain milk producing cells. Those alveoli are drained by a system of lactiferous ducts and those ducts all converge at the point of the nipple. So that's, that's the glandular tissue in a nutshell. The connective tissue then is it forms around the glandular tissue? Ok. As a fibrous stroma of connective tissue. So this forms, it consists of the suspensory ligaments. You'll also hear them referred to as the ligaments of cooper. And these help the, secure the breast to the dermis and they separate the individual lobules of the breast. I like to think of the suspensory ligaments almost as like a a scaffolding in the breast. And then posterior to all of this tissue, you have a layer of pectoral fascia which separates the breast and the glandular tissue from the pectoralis major muscle. Ok. And those are, those are the basic structures and if you know that you're doing quite well. Ok. So let's think about the blood supply to the breast. First of all, focusing on this diagram on the left here, the breast receives arterial blood supply from different directions. Let's focus on the medial side of the breast first. So medial, remember meaning closer to the midline. Most of the medial breast is supplied by this artery here. The internal mammary artery, this is also known as the internal thoracic artery. Ok? You can use those names interchangeably. And it's a branch of the subclavian artery up here. Looking to the lateral side of the breast, you have a couple more blood vessels. You've got the lateral thoracic and the thoracoacromial which are both branches of the axillary artery. And then if you imagine your intercostal arteries, these have little perforators that will come up and, and have some blood supply to the breast too. Ok. So these are the main ones you need to be aware of. Then we move over to lymphatic drainage of the breast. Now, I usually don't tend to worry too much about learning lymphatics. But in the breast topic, lymphatic drainage of the breast is really important. Ok? Because it's, it's very relevant for cancer metastases. And it's, it's one of the things that can come up in exams. Ok. So the lymphatic drainage of the breast is via three node grips OK. Now, most of the lymphatic drainage comes from the axillary nodes. OK. About 75% to the auxiliary nodes. If you can remember that you, you're doing quite well. Some of the other groups that are involved are the parasternal nodes and the posterior intercostal nodes. But remember most of the lymphatic drainage of the breast is via the axillary nodes and that can come up in exams. Now, that's in reference to the breast tissue itself. Ok. The skin also receives some lymphatic drainage. So the skin will drain via axillary inferior, deep cervical and infraclavicular nodes. And then the nipple and areolar complex has a subareolar lymphatic plexus. OK. As you can see if I turn on my pointer sort of circumnavigating the areolar. I think if I want you to learn one thing, it's this OK. That 75% of the breast tissue itself is drained through the axillary nodes. Ok. So we've covered the fundamentals of breast anatomy and given a quick overview. And I think that's probably all you need to answer your, your questions on the exam in this topic. Though, there is another important anatomical area and that's the axilla and it has an important application when we come to talk about surgery and we'll, we'll move on to that a little bit later. But um these things can come up in anatomical questions in the exam as well. So a couple of important things to know about the axilla are the borders on the contents. So what is it? It's, it's a space at the junction where the upper limb meets the chest wall. And if you to, to learn the borders of the IL, you have to think a little in the 3D. So we'll look at that now, anteriorly in this space, you have the PEC major and minor muscles coming across this way at the back of the posterior border. You have the scapula, otherwise known as a shoulder blade. You have the terra major muscle and the latissimus dorsi muscles on the lateral border of this pyramid shape is the intertubercular sulcus of the humerus on the arm. And on the medial side, you have the chest wall or if you're thinking more specifically about it, you have on the medial side, the serratus anterior and that's that serrated saw shaped muscle that hugs the chest wall. That's where it gets its name from then because it is a pyramid ship. It has a point at the top. This is the apex of the axilla and that's made up by a couple of structures. You have the lateral border of the first rib here, you have the back, the superior border of the scapula or the posterior sort of inferior border of the clavicle up here. OK. So those are your borders, then it can be helpful to think about what actually moves through this space. What are the contents of the axilla and sometimes it's just about rote learning them. But if you're ever on placement and you see some axillary surgery, it can be useful to ask the surgeon to point out these structures to you. So typically you have the axillary artery and vein together, you have the axillary lymph node groups, which we discussed in the last slide, you have the brachial plexus. So that plexus of nerves that goes on to supply the upper limb, you have the short head of the biceps breakout and then the kraco brachialis as well. So that's an outline of some of the important anatomy that you should be aware of when it comes to this topic. But now I want to move on and just before we dip into some of the specific conditions that patients might present with, I want you to just think about what would you do if a patient presents to you with a change in the breast? Ok. You imagine you're a GP or you're somewhere in the community and a patient comes to you and says something is different about my breast. Where, where might you start? So similar to any patient interaction, you're going to elicit a history and perform an examination, aren't you? And a change in the breast might mean different things for different people. So somebody might complain of breast lump or maybe a painful breast. And if either of these two things come up, you're going to ask specifically about some of these things. So ask about any previous lumps, a history of cancer, maybe a family history of cancer, ask about any skin changes that are associated with the lump. Ask if the lump or the pain is different at different times of the month. If there's any relationship with the menstrual cycle. Ask about the number of pregnancies and you also ask about the age of menarche and menopause if it's applicable and the reason we do this will become clear later on when we talk about some of the risk factors for breast cancer, ask about drug use in particular. Are they on HRT hormone replacement therapy? Then you can ask about breast trauma, you know, have they taken a knock to the breast and then you'll ask about the breastfeeding status. So maybe it's, it's a new mum. You'll, you'll ask, are you, are you feeding by breast? So it could be a breast lump or breast pain. It could also be a change to the nipple. And in that case, you'd be asking about discharge particularly, you know, it could be skin changes. But quite a lot of the time nipple discharge is something people will come to their GP about. So you'd ask about amount of discharge. What color is it? What's the consistency of it? Is there blood in it? These are really important questions. So you've taken your history and now you're going to move on to examining the breast and the normal pillars for examination are your inspection, palpation, percussion and auscultation. The most important things for a breast exam are the inspection and palpation parts. So what are you looking for? You want to inspect both of the breasts and you're looking for obvious masses, any abnormalities to contour and shape asymmetry? So does one breast look vastly different from the other? You want to look at scars that might indicate any previous breast surgery changes to the skin. You know, is there ulceration, is there dimpling? Is there tethering, which would suggest maybe there's an underlying malignancy under the skin or look at any changes to the nipple. So is, is the nipple dry, is there discharge or maybe it's retracted and it's actually going in towards the patient and you want to inspect the breasts with a patient, first of all, placing their hands behind their head and also with their hands on their hips and almost tensing inwards. And what that does is tenses the pectoralis major muscle underneath and if there's any tethering or skin dimpling, tensing the muscles in that way can accentuate these. So, so what does that actually look like? We'll have a look at pictures A and B here and see what you can notice. It can be quite subtle but well done. Have you noticed some of this skin dimpling? Alright. And when you see dimpling of this, it's suggestive of, of carcinoma. Ok, or an underlying cancer. And usually what happens is there's some sort of invasion near the skin and maybe it's, it's almost dragging the skin down with it. So when you see these things in examination, it's usually not as good a sign picture. See here, a couple of things to look out for. This is an example of nipple retraction. Now, there's a very obvious ulcerating mass in the lateral breast here, but um maybe more subtle that you might miss on first glance is the retraction of the nipple. So these are just some of the things to look out for. So once you've completed your inspection, you're going to palpate the breasts and you're going to examine both sides comparing like for like. So to do this patient positioning, you will ask the patient to lie supine with one hand behind their head and usually on the side to be examined. So you want to examine each quadrant of the breast from the outside and towards the nipple and including the nipple, you will examine the axillary tail and examine the axillary lymph nodes as well. So in the same way as you might have been taught to examine the cervical lymph nodes, you also examine the axillary lymph nodes. OK. There are different ways to do this. There are different patterns, ok? And it doesn't really matter which one you use in, in practice or in an exam. But it is important to cover all areas and examine both breasts. So you could do a circular motion, you could work inwards like a clock face or you could go in a vertical pattern, right, just to cover all the areas. Now, if a patient presents with a change to the breast that is in any way suspicious or they have risk factors for breast cancer, they're going to be referred for specialist assessment. Ok. And the way that these patients are seen is at a triple assessment clinic, sometimes called a One Stop One Stop clinic where they will receive three different types of investigation. So they'll have the clinical radiological and pathological. The clinical is like a repeat of what you maybe in general practice might have already done. So typically a breast surgeon will elicit another history and examine again. Then there's a radiological input. So in women of under 35 years or male patients, they'll tend to be ultrasounded. And that's another important point, males can get breast cancer um and about 1% of breast cancers are males. So that's really important to remember those patients over 35 are likely to be offered a mammogram. So this is the imaging part of the triple assessment. And then if required, there will be a pathological input as well. So a core biopsy of the lump or lesion will be made and it'll be looked at under the microscope by a pathologist to try and identify the presence of any cancer cells. If say the lesion is a cyst and it's, it's a fluid filled lump. Then you can do what's called an FNA, a fine needle aspiration. And this is almost like an investigation and a treatment all in one. It's where it'll be, you stick a needle in, you'll draw out some of the cells and that will reduce the size of the lump because you're, you're drawing the fluid out of the cyst. But then those cells can often also be sent away for analysis under the microscope and you can find out what they are. So virtually all patients presenting with a change to the breast are going to be investigated in this way. So now let's tuck into the core conditions and the way to sort of split them up for your exams is benign, breast conditions and malignant breast conditions. We're going to start with the benign stuff. Now, the purpose of this section isn't to explain every element of every condition that can present in the breast. There's too many and that would be beyond the scope of this. But what is important is to be able to identify or provide a list of differentials based on how the patient presents and to be wary of things that might make you suspect something cancerous over something benign. There are loads of benign conditions that could present just as a lump. And we're gonna focus on defining some of these and describing how they present. Now, just remember that the investigation for all of these is typically the same. It usually involves triple assessment. Um But let's talk about the ones that come up commonly in exams and that are probably the most important to know. So let's kick off with the fibroadenoma. So this is the benign tumor of stromal and epithelial breast duct tissue. It's the most common benign growth in the breast. It typically occurs in women of reproductive age. Um You'll find women in their twenties and thirties presenting with fibroadenomas and some of the key features on examination or indeed in exam questions that will make you suspect a fibroadenoma over anything else is that it's highly mobile. Sometimes people will refer to this as a breast mouse because it moves around as, as you palpate. It, it's usually well defined with smooth edges. So it feels like not like a jagged lesion, more of a smooth ball and it's usually quite firm as well. It doesn't, it's not fluctuant. So these are benign um and usually are just discovered during a self examination. And the management of these is they're, they're harmless. They're often left in situ with a follow up every now and then just to make sure it's not growing or it's not suspicious. But typically if, if it's the patient's preference or if the lesion is getting quite big and it's maybe over three centimeters, it can be excised surgically. Ok. We're moving along to something quite similar. This is a breast cyst and this is in the core conditions, list and cysts form when the lobules of the breast become distended due to a blockage. Ok. And you can see a little picture there. They could be individual cysts, there could be multiple cysts and they're typically, again, quite like, um, a fibroadenoma, they're smooth when you palpate them, but they can often be quite tender, quite sore when you palpate them in the exam. And patients might present saying I, I've got a, a painful lump in my breast. The management of these again, sometimes these will go away on the road, they'll resolve spontaneously. And if they're quite large, they can be aspirated. And remember talking about when these patients come to the triple assessment clinic, they might, the surgeon might just pop a needle in there and draw some of the, the fluid out and that could resolve symptoms. Ok. Now, here is a breast condition that is quite common. This is mastitis and I've added abscesses onto this page as well because um mastitis can often lead to an abscess. It's not the only thing that can cause a breast abscess, but they're, they're often related. So, what is mastitis? It's inflammation of the breast tissue and it's it, these can be categorized into a lactational mastitis or nonlactational mastitis. So, a lactational mastitis would occur when maybe a new mum is breastfeeding. And typically during the first three months, they can, because they are, they're using this ductal system so much or potentially there's a blockage, you can have irritation and, and inflammation in the ductal system and that will present as tenderness, um, swelling if there's a blockage and overlying erythema. So you can see on the right hand side, this is the sort of skin erythema you'd expect to see with classic mastitis. And if they're unwell, they, they might have systemic signs of infection too, so they could have a temperature as well. That's lactational, there's also nonlactational types. Um you can have staph a infections that's the most common cause. And those, those are the ones that might lead to an abscess. An abscess is just a collection of pus and infective material. So this is kind of what an abscess looks like. It's more of as you can see. Whereas the mastitis is, is widespread erythema, an abscess, you can see a very clearly defined area. The management for these is mostly supportive. Ok. So quite often, um mastitis can be managed with pain relief and a warm compress and continued breastfeeding. This is a really important point. A lot of new mums will come presenting with mastitis because they've started breastfeeding and there's inflammation there and because it is sore, what often happens is that the breastfeeding stops, but it is important to encourage those that are breastfeeding to continue doing so because by expressing breast milk or by breastfeeding, it actually clears the ductal system. And if there's a blockage there, that might help just keep things moving and, and clear the clear the blockage. If you're really worried about an infection or if, if the patient is really systemically unwell a temperature, maybe they've got an effective blood picture. You would, you would consider antibiotics. In the case of an abscess. I say the abscess is only going to grow if the, the pus collection gets bigger and if it gets serious, you, you might require an I and D OK. This stands for incision and drainage where a surgeon would take a knife and would make a small stab incision and drain the pus. And you'd probably send a sample of that pus off to the labs just to culture it, find out what the bacteria is causing the infection and treat appropriately with antibiotics. So this is something really common and something that can come up in exams, things to think about if it's tender, swollen red, maybe there's a temperature running. One of the things you really want to think about is mastitis. So I've included fibrocystic change in the benign breast disease section. Although it's important to remember that this is considered now a variation of normal rather than actually disease. What it is is changes to the breast in response to female sex hormones. So, estrogen and progesterone can cause changes in the breast and they're most pronounced during the menstrual cycle because that's when the the pattern of these hormones are changing and it can cause breast structures to become fibrous fluid filled. And patients might come saying, do you know, maybe a week before or during my period? I um I'm feeling like my breasts are lumpy. Ok. They feel like lumpy breasts on examination. You might, you might feel it, they might feel a little bit lumpier and firmer than you would expect. They could be tender. Sometimes they're not, they just feel unusual and actually this isn't, this isn't illness. It might bother the patient. But what you find is that um some patients will say, you know, it annoys me during that period of the month, but actually the rest of the month, it, it doesn't bother me and I don't notice. So management for these patients tends to be supportive. Again, they'll use a supportive bra and if it's really bothering them, they might have, they might use nsaids if there's any evidence of inflammation or if they actually want to change how their hormonal cycles work, they might have some hormonal treatment. But most of the time this is a supportive management. So the next condition I want to talk about is fat necrosis of the breast. And I've included this because it's quite easy to ask about in exams. What it is is localized degeneration and scarring of fat tissue in the breast. It will present as a lump and, but it, you know, it mightn't be noticed at all and it might just be picked up on routine screening. Approximately 60% of the cases are due to previous surgery or radiotherapy. Ok. Consider, consider surgery as almost like trauma to the area when you are cutting away or, or burning fat. Sometimes there's some scarring that's left over and that'll, that'll feel a bit lumpy and then sometimes it could be due to breast trauma and this, this comes up in exams. I find or past paper questions where there's maybe a history of breast trauma or they've, they've taken a knock or do you know they were maybe punched in the chest. And then shortly after they started feeling this lump in the breast, um some of these patients might also present with fluid discharge, skin dimpling pain and it can actually mimic malignancy quite well. So as you can imagine if these patients present with an unusual lump, they'll be assessed via triple assessment like everybody else. But actually, there's, there's not much you need to do for a case of fat necrosis on the left. Here is an example of, of what it looks like in mammography. And these patients are given simple pain relief and reassurance to tell them that there's nothing to worry about. So this one's really easy to ask about in exams and it's worth remembering. So there's so many more benign conditions I could talk about. But one last one I want to add in is a galactocele which is a milk filled cyst that forms due to a blockage in one of the lactiferous ducts and similar to lactational mastitis. These typically occur in breastfeeding women. Um and often happens after a period of no feeding. So maybe a mother has, has decided they want to feed for a while and then they take a break or they stop, but milk is still being produced. And quite often you can, you can get a blocked duct and there's a backflow of milk and that forms into a milk retention cyst. So on examination, this will be a fairly firm and quite mobile lump differentiating this from mastitis is that this galactocele is typically not very sore, it's painless and sometimes you can palpate it under the aerial. Look as if you imagine that's where all those lactiferous ducts converge and exit the breast. That's where you might feel it again. Management for these patients is usually supportive, they might resolve on their own. But sometimes if a fluid remains stagnant and starts to build up in an area and makes a cyst that becomes a harbor for bacteria, a nice warm environment for them to incubate and an infection might grow out from that. So if that's the case, it might present closer to a mastitis and you'd be looking to administer antibiotics. So these are some of the important benign breast conditions to be aware of. And we haven't mentioned all of them. But I think if you know the ones we've covered, you'll be able to answer the majority of your examination questions before we move on to malignant breast disease. I want to thank you if you've made it to this point in the video. Thanks for sticking with me. Why don't you take a quick five minute break to grab a cup of tea or coffee, stretch the legs and then join us back for the second half of the presentation. So now we move on to malignant breast disease, which is another section of the core conditions in two year. And whilst again, we're not going to cover every type of breast cancer, but the ones we will talk about are the ones that you need to know for medical school. It's worth just noting that in Ulster University, there are I OD investigation of disease sessions and during your surgery placement, you will have an IO session on breast disease and I would encourage you to use that session to supplement and support the learning from this session. Um As the IUD will cover some things that we won't have time to cover in this presentation. Ok. So before talking about the individual cancers, let's talk about risk factors that apply to all types of breast cancers and things that you'd be looking out for in the patient history that would make you suspect cancer. So starting on the left is estrogen exposure. And these are why you ask questions like early menarche, late menopause because if you have an earlier menarche and a late menopause, you have a longer lifetime exposure to estrogen, same with H RT. Some H RT regimes include estrogen. So it's important to ask about that. And obesity is an important thing to note as well. Peripheral adipose tissue creates estrogen. And that's just another exposure to estrogen that that people might have naturally female sex is, is a risk factor. The incidence is, is much higher in females than in males. Only 1% of breast cancers are in male patients. The other 99 in females, older age, again, whether this is associated with altered cell cycle mechanisms or maybe it's a result of longer estrogen exposure. Previous breast disease is an important thing. Yeah. And that's why we ask about any previous history of cancer. We also ask about family history of cancer. Other general risk factors include smoking and alcohol consumption and then some genetic things like BRCA one and BRCA two gene mutations. Ok. These genes are responsible for um protecting against breast cancer when there are mutations or these genes are faulty, then that leaves the individual susceptible to, to breast cancer. So these are just some of the general things that it's, it's worth learning. So I want you to think back to the start of the video when we discussed the anatomy of the breast. Hopefully, you'll remember we discussed ducts and lobes and this is an easy way of putting breast cancers in two buckets or categories you can have cancer in the ducts and cancer in the lobes. So, starting with ductal cancers, two types to be aware of. The first is DCIS, this stands for ductal carcinoma in situ. This is cancer that's confined to that duct. It hasn't spread beyond that duct. It hasn't invaded through the basement membrane. It's just within the confines of the duct and I'll get you a little vis visualization of that. Now, so here's a normal duct, the lumen of a normal duct with DCIS, ductal carcinoma. In situ, these cancerous cells are confined within the duct. This comprises about 20% of all breast cancers. It's actually mostly asymptomatic and it's picked up through screening programs and the the normal treatment of this is through an incision and it usually doesn't warrant total removal of the breast tissue. The other type to be aware of the other type of ductal cancer to be aware of is IDC. This is invasive ductal carcinoma. So this is cancer that has originated inside the duct. It's maybe started as a A DCIS, but it's invaded outside the basement membrane of that duck. Here's what that looks like. This is the most common type of breast cancer. Ok. Approximately 70 to 80% of breast cancers are invasive ductal carcinomas. Again, they're mostly asymptomatic. It's often picked up through screening and because this is an invasive cancer, it's starting to spread. These are, these are associated with a worse prognosis. So, those are, are ductal cancers. Now we move on to our lobular cancers and if there's ductal carcinoma in situ and invasive ductal carcinoma, then you guessed it there is lobular carcinoma in situ and invasive lobular carcinoma. And the definitions are largely the same. So L cis is when the cancer has originated in the lobe but still confined to that lobe and it hasn't extended beyond the basement membrane of the lobe. It's rarer than D CS, but L CIS is, is associated with a greater risk of invasive cancer. Um So it's rarer but but commonly more deadly, usually asymptomatic and is, is usually diagnosed as an incidental finding during a biopsy. Um So that's in situ and again, you can have invasive lobular carcinoma where the cancer has likely started as an L CIS within the, within the, the borders of the lobe, but has invaded beyond the basement membrane has spread, spreading elsewhere. And quite often by the time these are picked up, the tumors could be quite large and might if, if they are surgically treated might require more extensive surgery. So thinking about cancers as ductal and lobular and also as in situ and invasive. These are, these are a really helpful way to, to categorize these cancers in, in your mind. So I think if you're aware of ductal and lobular carcinomas, that's, that's enough for this session. I haven't talked about some other things like inflammatory breast cancer. Um because I think ductal and lobular are are the main ones to be aware of. This is one last thing I wanted to include in this section. This is called Paget's Disease of the nipple. Now, I just want to emphasize that Paget's disease of the nipple is not cancer. It is a condition that's highly suggestive of cancer and highly associated with underlying malignancy. So if 100 patients came to you with Paget's disease of the nipple, approximately 85% of those are likely to have underlying cancer. So, again, not a cancer in itself, but highly associated with cancer. So, so what is it? It's when there's roughening, scaling and ulcerating um change to the nipple, it can be itchy, red, sore, the skin can be thick, there might be discharge. Um and, and because of these features, it can, it can present to the GP and it, it, it is often mistaken for a case of eczema or dermatitis. But really, when you see cases that look like these, you, you need to send them like everything else to the triple assessment, will they be biopsied? And those cells will be looked at under the microscope. And you might actually, if there is an underlying malignancy, you might actually pick that up through, through that referral. So to manage these patients is, is usually of with the treatment of the underlying malignancy. Um and, and because you can see from these pictures that that underlying malignancy has has started to involve the nipple and the areola. Often those need to be surgically removed. Ok? And you can't leave any residual cancer cells in, in that area. So not a cancer but something to be aware of as this may be a presentation of cancer. So I want to talk a little bit more about the management of these breast conditions. And I want to make a note that it's not always surgical whilst breast is a surgical specialty more. Now, we're moving to non surgical options as well. It goes without saying that all breast cancers, no matter what type or, or how severe they are they should be treated. Following discussion in an an MDTA multidisciplinary team meeting, a breast MD team might include oncologists, breast surgeons, radiologists, pathologists, breast cancer, specialist, nurses, and what's discussed is the patient factors and preference and the tumor factors. So talking about the size, the biology, the focality and the spread of the tumor and with all that information and with all that professional input, you determine the most appropriate management plan. So a handy way to break down cancer management is into non surgical and surgical. So we'll talk about non-surgical first, but to understand that we need to understand what makes cancer grow and this is where we come across this concept of hormone status. Now, different cancers will respond to different hormones. You might hear of an er positive cancer. Ok, an estrogen, positive cancer. What that means is there are estrogen receptors on the cancer. When estrogen binds to these receptors, the cancer gets bigger. All right. And that's why we discussed earlier about some of the things you would ask in the history and how that's why estrogen exposure is, is a risk factor for breast cancer. So, er positive is, is just one example. But other ones that you'd need to know for exams are pr positive that's progesterone and it's the same, it just respond, the, the cancer grows in response to progesterone exposure. There's her two positive. Um when the individual has too many copies of the her two gene which causes overproduction of her two, which is a growth promoting hormone. And that's what causes the cancer to grow. If you've got hr negative, that's when the cancer has no hormone receptors and it, it doesn't respond to any of those hormones. That sounds like a good thing. But actually when you can identify as a, a cancer to have a, a hormone receptor that, that helps you target, target the, the cancer. Actually, when it's an hr negative cancer that is more difficult to treat. So, briefly, touching on some of the non surgical management options for breast cancer. Again, I find it helpful to put these things into buckets. So for nonsurgical options, you have endocrine options, immunotherapy and you've got chemotherapy as your main ones if you know these, that's enough. So for example, an endocrine treatment let's say you have an er positive cancer. What you want to aim to do is to compete or antagonize the estrogen receptors on the surface of the cancer. So, premenopausal patients will be offered this drug, a selective estrogen receptor modulator. An example of that to remember is tamoxifen in postmenopausal patients, they will likely be offered an aromatase inhibitor. And I think one that's easy to remember is anastrozole and quite often in an exam, you might be presented with a patient with an er positive cancer. They'll give you the age of the patient and they'll ask you to select the best medical option for the patient and you'll, you'll probably suggest one of these two immunotherapy then. So these are newer drugs, monoclonal antibodies and they'll target specific receptors. So, for example, you have a woman with a, her two positive cancer. You can use this drug Herceptin. That's an easy way to remember it. Her two Herceptin, that's the brand name. The drug name is trastuzumab. And that's another option for when they've identified her two positive. Then the third option is chemotherapy. Now, more often than not chemotherapy is offered to breast cancer patients before they undergo um surgical excision of the cancer. What chemotherapy does is shrinks that tumor size and it's smaller for the surgery. Sometimes it might be given alongside a couple of these other options or maybe for a little bit after surgery just to target any residual cells in in order to try and prevent recurrence, this these buckets aren't hard and fast, do you know? And they are different combinations for different patients? And that's why I go back to this, this important point. All treatment options are discussed by the MDT and and plans are personalized to patients because it depends so much on the patient wishes. Um the patient's physiological baseline age and and what type of cancer they actually have. So these are just to introduce these, these buckets of non surgical management options and treatments personalized between them. So that's a very brief overview of the non surgical management options. But we are a surgical society. After all, we love talking about surgery. So let's have a think about what surgical options there might be. So one option might be breast conserving surgery. Ok. One of the popular operations you might come across are wide local excisions. This is very common and this is offered to those with maybe a smaller or a localized cancer that hasn't spread somewhere else. So, a wide local excision involves removing only the cancerous part of the breast and usually takes a, a very small margin of healthy tissue around that just to make sure that all the cancer has been removed. This um sometimes called a lumpectomy and it just involves taking a core of that cancerous tissue away and leaving the remainder of the breast. Another option is Mastectomy, which is removing the entirety of the breast, this would be indicated in cases where the cancer is more widespread. Maybe there's a high risk of cancer recurrence or actually, sometimes patients might just decide that in order to reduce the risk as much as possible, they may, they may opt to may be their preference that the entire breast goes. So they will get a mastectomy. More recently, mastectomies can be performed in a way that spares the skin and the nipple. So only the underlying tissue is removed. And the point of this is that later on after the initial treatment phase, that breast reconstruction could take place. And lastly another type of surgery to be aware of or some of the axillary procedures that often go on at the same time as the mastectomy or the wide local excision. So earlier on, we had a think about the lymphatic drainage of the breast and that is significant because we know that cancer cells travel in the lymphatics. So if there's breast cancer, when that cancer decides to spread and metastasize, where's the first place it's going to go, it's going to travel into the lymphatic drainage of that gland, isn't it? So we decided that the auxiliary nodes drain 75% of the breast. So this is where you might find metastatic cancer. Two common auxiliary procedures are sentinel node biopsy where if you've examined a patient and you feel maybe a slightly lumpier node that's suspicious. When you're examining the patient, you might remove that first node and send it for analysis. And if it's looked at under the microscope and there are cancerous cells there, you might, you might come back and take the rest of the nodes. In that case, you might perform what's called an axillary node clearance. So if you've identified that there is cancer metastasis through the axillary nodes, the safest thing to do is to remove that entire chain common complication of that is is lymphedema. So if there is no lymphatic drainage that that fluid can collect in the arm even years after the procedure, and you'll have an edematous arm. There are other surgical techniques. But if you are aware of these three main categories, that will be enough for your exams. So I've included a bit more information here purely out of interest for those that know me well, um you know that I am hoping to train as a plastic surgeon. And one of the things I I'm really interested in and passionate about is is learning about surgical history and how far we've come. And I think having an appreciation of the history of surgery can allow us to further appreciate how, how far we've come and development still to come. So the picture on the left here is from a, an illustration book that I was given as a gift for Christmas. It was an illustrative history of surgery. And the purpose of this is just to discuss actually how far we've come in terms of breast surgery. So before when a patient had breast cancer, one of the procedures that was done was a radical mastectomy. Pretty brutal procedure. This is where all the breast tissue is removed and the underlying pectoralis muscles were taken along with it. That was because there was suspicion of residual cancer in the muscle underlying the breast. And unfortunately, you, you resulted in some, some results that weren't as cosmetically pleasing. And whilst the cancer was away, you, you can see in this patient, for example, that the underlying ribs exposed, there's no muscle there and it leaves the patient with, with quite a concave chest. And whilst the cancer is gone, it can be quite psychologically difficult for patients because the breast um plays an important role in in the the contour and shape of of the female profile. So newer techniques evolved and in 1948 they came up with the modified radical mastectomy where they would take the whole breast and the pectoralis muscles were spared. And whilst there wasn't such a concave appearance, you were still left with some, particularly in large patients, you would be left with, with a cosmetic result that really emphasized the excess skin and adipose tissue there. And this, this procedure was, was quite brittle. And you can see from 1948 that's, that's actually not that long ago um that we were still doing these procedures. So thinking about where we come from in terms of breast surgery. It's so interesting to look at what's happening in the present day where there is more of a focus on reconstructive surgery. Now, I would like to preface this by saying cancer treatment always comes first and cancer treatment should not be compromised for the sake of cosmetic result. But let's have a look at some of the things that are are options for patients today in terms of reconstruction. So some of the things you might be aware of are the implant, the implant based reconstructions where you can use tissue expanders and um saline or silicone implants, plenty of options for, for size and shape. But even in some circles, these methods are being considered out of date now and we're moving more towards autologous based reconstruction, autologous tissue meaning from self. So this is where the the surgeon kicks the patient's own tissue and rearranges it to, to reconstruct the breast profile. Here's an example of one of those a latissimus dorsi flap where they, they release one end of the latissimus dorsi from the back, swing it round to create a breast profile on the front of the chest. Another example is the deep inferior epigastric perforator, the Diep flap. This is an example of a free flap reconstruction where a portion of the patient's abdominal tissue is raised on its vascular pedicle. It's brought up to where the breast used to be and the vessels are anastomosed with the internal mammary artery in the chest, then this this tissue flap when it's reperfused can be molded and shaped into a new breast and the patient's left with a scar across the middle because this operation is not only a breast reconstruction, but it's an abdominoplasty at the same time, otherwise known as a tummy tuck. So for this operation to be an option, patients actually require a little excess tissue in the abdomen. It would be quite difficult to perform this on skinnier. Patients want to emphasize very strongly that you don't need to worry about learning this stuff. This was just for personal interest and uh something I thought would be would be interesting to include. Well, folks, thank you so much for sticking with us. That is all that I wanted to cover with you in this session. I've just made a note of some of the things we didn't cover that are important to learn, but that are included in the breast surgery I OD session whilst you're on your surgical placement. So um I'd encourage you to engage with those those sessions to, to learn some of this stuff that includes tumor staging and grading. Um do read up on the TNM staging system. Some of the other rarer breast conditions II didn't include um such as mammary duct, ectasia intraductal papilloma and maybe things like inflammatory breast breast cancer, which are less likely to come up in my opinion, but um might be interesting to read up on or you might come across pa past paper questions on them, but we focus today on the main ones and last but not least is the breast screening program. So, whilst the focus of today was on the core conditions, it's useful to familiarize yourself with the NHS breast screening program, which is also covered in the I OD session. And there are a few questions and exams that might come of that. So do do have a look at those. So as promised to finish off the session, I've included just a couple of SBA S for you to practice on and test your knowledge. So have a think about this question. So a 40 year old premenopausal female presents with a breast lump that is tender firm and irregular in shape on examination. The patient has a previous history of breast cancer which was successfully treated by wide local excision two months prior. She's also been receiving radiotherapy. What is the most likely diagnosis? So why don't we pause the video now and have a think about your answer. Ok. So the most likely diagnosis for a patient that has an irregular breast lump with a history of recent surgery and recent radiotherapy. In this case, the most likely diagnosis is b it's fat necrosis of the breast, well done if you got that right. But why is it not the other options? So you have a fibroadenoma? Well, remember we said that fibroadenomas tend to be regularly shaped. They're like firm, well-defined smaller balls and they're, they're highly mobile. This lump is irregularly shaped. So it's less likely to be a fibroadenoma. And the, the breast cancer history, the surgical history and the radiotherapy make it less likely to be a fibroadenoma recurrence of lobular carcinoma is a good thought and it's something that should be in the back of your mind if a patient presents with a lump and they have a, a personal history of breast cancer, however, they've had a recent surgery and it's likely that that lump of tissue from the wide local excision has been sent away. Looked at by a pathologist again, has been confirmed that it's ok. And that's, that's why c probably isn't the most likely diagnosis in this case, deep breast obsess whilst it sort of fits with the tender picture, a breast abscess would probably have some overlying erythema and skin changes. And if it's at the point where the patient has an abscess, there is likely um some systemic signs of infection there too, like a temperature and generally feeling unwell and fibrocystic change is less likely because quite often you'll have just a general feeling of lumpy breasts but doesn't really fit in with the tender or the, the pain. Um that, that fat necrosis would bring so well done if you got that right. I think there are other options that this could be and it's good if the if you've considered them. However, given the, the recent surgical history and the the radiotherapy fat necrosis is the correct answer well done if you got that right. Ok. Question two. A 28 year old woman presents to her GP complaining of a tender lump in her right breast. She has recently given birth two months ago on examination, the patient's breast has a firm and defined mass in the subareolar region. It is mobile tender and approximately two centimeters in diameter. Physical examination of the left breast reveals no abnormalities. The patient describes severe discomfort so much so that she's had to stop breastfeeding. What is the most likely diagnosis? Pause the video again and have a think about your answer. Ok. So the most likely diagnosis for this patient is ea galactocele well done if you got that right. If you remember a galactocele is a milk retention cyst that often comes in breastfeeding patients. So this lump is firm. It's well defined and it was palpated in the subareolar region. Well, this one was a little bit trickier and let's talk about why it wasn't the other option. So the first one, mastitis, mastitis was an appropriate differential here. Um you had a, a tender lump in the right breast um which is unilateral, you have a breastfeeding female. Um But however, if you think back to mastitis, you would expect some skin change and maybe widespread erythema. But in the question, the mass is well defined. Um So it doesn't really fit with, with mastitis. Now, if you said fibroadenoma, that was also a good differential as we're talking about a, a firm and well-defined mass. However, it's less likely given the tenderness and the, the severe discomfort described by the patient and the clues in the question are around the, the breastfeeding and the recently given birth. So that makes this less likely a ductal carcinoma in situ is a good thing to suspect. And realistically if, if you were suspicious, these patients would be referred to the Triple Assessment Clinic just to make sure. But if you remember D CS, most of the time is asymptomatic isn't really associated with, with discomfort or tenderness in the breast sometimes is, but most often it's asymptomatic and it's picked up. So, compared to the other options, that wasn't the best option given the information you had. Again, a breast abscess, not a bad differential of a tender lump in, in one breast. Um And do you know when starting breastfeeding? It's, it's not unreasonable to suspect the introduction of an infection into the breast that might lead to an abscess. But I think the description of a tender lump that's well defined and is firm um is, is more in keeping with the galactocele and the patient doesn't have any systemic signs of, of illness or like fever. Um So that makes a breast abscess less likely. One thing to remember is that galactoceles may very well lead to mastitis and then a breast abscess. But it wasn't the right answer in this case. Question three. After a review at a triple assessment clinic, a 57 year old female is diagnosed with a three centimeter lobular carcinoma in situ. After further investigations, it is determined that the patient's cancer hormonal status is er, positive. Which of the following treatment options might be offered? First line. Why don't you pause the video and have a think about the choices. Ok. So which of the following treatment options might be offered? First line in a female of this age, 57 years old is, is old enough that we can assume the patient is post menopausal. And we are thinking about what might be offered first line. So typically surgery might come later down the line. But what might be offered first in the patient of this age? The answer is a, an astro zole an aromatase inhibitor. Well done if you got that right. The key thing in this question was recognizing that anastrozole is an option for er positive cancers. So is tamoxifen. So if you narrowed it down to one of those two well done, the deciding factor then is the patient's age. And with a postmenopausal patient, we would offer them an aromatase inhibitor first such as an trao well done if you got that right. Well, folks that brings me to the end of this session on breast core conditions. Thank you so much for watching. I hope that it was a useful recap and it's going to benefit your revision. Please do fill out your feedback on this session. Take 30 seconds to do so on med all. And our next resource which is also prerecorded will be released on Wednesday the seventh of February. And it's going to cover the urology core conditions. I hope that you'll join us again for that. Hope this format is working for you. The idea is that it's accessible to everyone and that these materials can be accessed by you at a time that is convenient or useful coming up to exams. But until the next one, it's Cheerio for me and I hope to see you then.