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Hi, everyone. Can we just confirm that you can see the slides and hear me? Just just message something in chat. Just make sure that everything's working. Okay? Brilliant. Cool. All right, well, just give it. We'll give it a few minutes. We've had quite a few sign ups to this session, actually, Quite exciting. We'll start in a few minutes time. Once, once people start filtering in, feel free to get a cup of tea or something like I have, uh, in the meantime, but we'll probably start five minutes or so. Right. Okay. I think we've got a good number in here of people here at the moment, so I'll at least start the preamble. Um, hi, everyone. Welcome to the surgical oncology teaching series. If you've been to any of our previous sessions, welcome back. If this is your first time here, what we are is, uh, I along with Antoinette and Charlie heading up this surgical oncology teaching series aiming to kind of take take you all through the surgical management. The six most common cancer types in the UK This is Session five of six. Uh, so far, we've covered renal, prostate, colorectal and skin cancer. And this week we're doing breast cancer. Tune in next week for our last session where Antam. It's taking us through lung cancer, um, to reduce myself. If you haven't met me in my name's Adam. I'm a clinical teaching fellow at Russells Hall Hospital in Dudley. So I'm just post foundation Year two in the UK and taking a year out to get a qualification teaching, which is one of the reasons that I've been inspired to, uh, embark on this teaching program. But yeah, without further a do, we'll start if that's OK on breast cancer. And it's surgical management. Obviously, um, as always, feel free to use the chat function to ask any questions that you'd like to ask. But we'll crack on then. So a little overview slide about what we're going to be covering today. So we're going to be giving a little bit background information on breast cancer. It's epidemiology. It's risk factors talking about the pathology of the most common types of breast cancer that you'll encounter in your clinical practice, as well as any associated genetic mutations linked to breast cancer, which you may or may not be aware of. Uh, We're going to talk about these symptoms and signs commonly associated with breast cancer and take take you through the common patient journey through, uh, presentation through diagnosis and investigations. Um, staging, including specifically the receptor status. We're gonna have a word also on the UK Breast cancer screening program. Then we're gonna focus on the surgical and the management of breast cancer, both the non surgical side of things. The chemotherapy, radiotherapy hormone therapy. Uh and then we'll focus predominantly the surgical management, the techniques, particularly with respect to excision of breast cancer but also reconstruction. The other half of that coin, So little background Breast cancer is the single most common cancer in the UK at the moment. It is an incidence of just over 55,000 cases per year. Almost the overwhelming majority of these are women, but not always bear in mind. Men can get breast cancer works much. Rower uh, one in eight women in the UK will actually develop breast cancer in their lifetime, so it's quite common there. The peak incidence rate is currently in women over the age of 90. We noticed that the incidents in breast cancer over the years has been rising in recent years. Um, there's a number of possible explanations for this. One of them is the existence in the establishment of the UK breast cancer screening program in 1988 almost certainly has contributed to the rise in the number of diagnoses. Also, certain lifestyle factors that will come onto an obit could be contributing to that. But while the incidence is rising, it's encouraging to see that survival rates, as you can see in this blue line in the graph, are actually improving. Five year survival for all types of breast cancer currently across the board is about 76%. But that does still mean that 24% just under a quarter of women who are diagnosed with breast cancer in the UK don't survive to five years. There's much to still, uh, improve on that, so the risk factors of breast cancer so I've divided these into the estrogen related and the other types of risk factor. So firstly, the first thing to be aware of is that breast cancer is strongly positively related to an increase in estrogen exposure. Uh, and the example I've given our of circumstances where women are exposed to more estrogen. So, for instance, newly parity never having given birth. Obviously, during pregnancy and throughout the early post partum period, women have a reduction in estrogen levels, so by not giving birth, they're exposed to more estrogen in their lifetime. Consequently, lack of breast feeding for a similar reason. Because they don't they don't have that suppression of estrogen. Early men are K and late. Menopause obviously increases that the length of time to which they're exposed to estrogen until they hit menopause, as well as taking the combined oral contraceptive pill, which contains estrogen as well as progesterone and obesity. Because fat cells do produce estrogen, obesity is an estrogen related risk factor. The other risk factors are quite non specific for breast cancer. Obviously, female sex is the biggest one there, Um, but then age, genetic family history, radiation exposure and alcohol, which are quite common to other types of cancer. Well, so in terms of pathology of breast cancer, we can categorize them pathologically first by the cell of origin, and secondly, by the invasiveness has it invaded the basement membrane. So the majority of breast cancers, you know, in much like the majority of all cancers arise from epithelial cells, making them carcinomas, the two main ones to be aware of in breast cancer or ductal and lobular carcinoma. The ductal cells line the ducts in breasts, and the lobular cells line the lobules at the ends of the duct. Uh, and ductal and lobular carcinoma we can further subdivide into ductal carcinoma in situ, which is carcinoma, has not penetrated the basement membrane in this noninvasive and then invasive ductal carcinoma. One type you may have heard of his Paget's Disease of the Nipple, which is a ductal, invasive ductal carcinoma that involves the nipple lobular carcinoma again, much like doctor carcinoma, can be divided into lobular carcinoma in situ and invasive lobular carcinoma. A small proportion of breast cancer do arise from the supporting stromal cells, which are sarcoma, as as they arise from mesoderm all tissue so angiosarcoma and your primary stromal sarcoma as the early menarche age. Obviously so sorry, Asia has got a question about that. Obviously, men are K. It ranges from from person to person. Ultimately, the earlier you experienced men are K, the more you are exposed to estrogen, so I don't know if it's reasonable, say that this is early versus that. But a woman who experiences men are k aged 10 obviously is exposed to estrogen much more than somebody who's experiences men. Okay, first at age 13, that's that's the important thing to appreciate. Thanks for that question. So we're on the genetics of breast cancer now. Yeah, sarcoma are from mesoderm. Allow origin so endodermal and epidermal cells. If we think about our embryology, it's not really related to this this topic but epidermal and endodermal cells they tend to produce, uh, carcinomas. And they're the most common types of cancer because they're they're exposed to the outer area into the inner skin. Um, yeah, they're they're exposed to the outer Elements because they line organs, whereas mesoderm allow origin. Tumor's are typically when they're malignant, are called sarcoma, so you can have liposarcomas equipment osteosarcoma as uh, it's not. It's not really in the scope of this has discussed, but I just thought I'd mention that briefly so back to where we are the genetic mutations. So you may have heard of the Braca genes. Um, these are genes that everybody has, but mutations of them occur in approximately one in 400 people and their associated with an increased risk of developing both breast cancer and ovarian cancer. Uh, so the back is our breca one a mutation, and that is results in approximately 65 to 85%. Lifetime risk of breast cancer for a woman and a broker to is between 40 and 85% lifetime risk of breast cancer. Um, we do sometimes offer, uh, screening, uh, of genetic screening for BRCA mutations and women who are found to have known bracket mutations before they develop breast cancer. Uh, may choose, based on their own personal choice, to have what's called a risk reducing mastectomy. It's a preventative treatment, um, to prevent the risk of developing breast cancer. It obviously doesn't eliminate it entirely, but significantly reduces that, and that's a personal choice. So presentation of breast cancer is the most common symptom of breast cancer that is found is a breast lump Now. Obviously, there are a range of pathologies that can cause breast lumps, things like cysts in the breast as well as fiber adenomas. What characterizes a concerning a breast lump that's concerning for cancer is that it will be painless, hard and have the kind of irregular shape that we associate with cancers. It's most commonly in the upper outer quadrant of the breast, but can be located anywhere. Other symptoms associated with breast cancer are an auxiliary lump. This would generally indicate spread to eggs, Ilary, lymph nodes as well as abnormalities of the nipple, particularly unilateral discharge that's often bloody but also changes such as inversion and puckering or abnormal and concerning for breast cancer. They're also sometimes overlying skin changes, depending on the location of the breast cancer and its proximity to the surface of the skin. These can be tethering ulceration of the skin or po'd orange, which we can see in the image down here, which is caused by a Dema around the breast. That gives it this kind of orange peel type, texture and appearance, which is French for Po'd oranges, French for orange peel and then obviously things like unexplained weight loss are fairly common across all cancers. So if a lady presents generally to the G P with symptoms concerning of breast cancer, the G P will refer her along too weak weight referral to the breast cancer clinic, and that the breast cancer clinics will undergo something called triple assessment, which is the term given to clinical examination of the breast as well as imaging of the breast to detect evidence of micro calcifications or any obvious masses, UH, and biopsy of the suspected cancer site, with or without any abnormal lymph nodes. So the imaging, generally a mammogram is done. However, if if it's a male patient, if the lady is under the age of 35 an ultrasound is generally chosen. That's because women under the age of 35 have much denser breast tissue. That's more difficult to visualize on plain film X O, which is what a mammogram is. So in these cases, ultrasound may be chosen in terms of the biopsy. Generally, core biopsy is taken through a core biopsy needle. The advantage of core biopsy over something like fine needle aspiration cytology. F knack is that core biopsy demonstrates can actually give us information about the architecture and arrangement of set. If we imagine the cytology, all we're doing is looking at each individual cell, not how it fits together. Fine needle aspiration cytology, for instance, couldn't tell you whether the carcinoma is in situ or invasive, whereas core biopsy should be able to do that. So that's the advantage of core biopsy there any further investigations. So ultrasound scan of the axilla is commonly done to assess for any kind of enlarged lymph nodes. If these lymph nodes are enlarged, they may choose to biopsy them. At that point for the staging, Emory breast is not routinely done. It's only done in certain cases of invasive breast cancer. The nice guidelines suggest that if there's a discrepancy and findings between the examination in the imaging, then you may choose to undergo an MRI breast to further delineate the anatomy. If the breast density is too high for mammographic assessment or if they want to assess the tumor size if they're considering breast conserving surgery, genetic testing is offered to women who are found to be under 50 and what's called triple negative. Breast cancer will come onto what triple negative means, But generally younger women who present with breast cancer may be offered genetic testing. So like I said, there's a breast cancer screening program currently in the UK The UK currently has three cancer screening programs. Breast, bowel and cervical uh, breast cancer screening program is for women aged 50 to 70 in the UK It's their trials on going to expand this and range, but it's currently still 50 to 70 and what is offered is a mammogram every three years, Uh, and this will be done by two views. Firstly, the craniocaudal view. So top to bottom and then then something called the medial lateral oblique view. And each breast will be, um, we'll have a plain film X ray through both views, So that's a total of four X rays. And that's going to be sent to uh, radiologist who's qualified in interpreting these mammograms, Uh, look for signs of any micro calcifications or any masses that could suggest possible breast cancer. So if signs of breast cancer are identified on the mammogram, what happens next is, uh, the The women can undergo a variety of further tests, and that's there isn't a specific pathway to follow here. It does vary different person to person, but, for instance, if further mammograms are needed, for instance, if the signs are a bit ambiguous that may be chosen and then other things like ultrasound to further delineate anatomy as well as examination and possible biopsy. Uh, and and and obviously the majority of women will have no, um, no abnormal findings, in which case no further action is required and she'll be invited back in another three years. Just a word at breast cancer screening is a little bit controversial in the UK Not everyone is a proponent of it. There are concerns about over diagnosis of breast cancer in situ that may not require treatment. For instance, lobular carcinoma in situ is quite unlikely to progress to, uh, invade the basement membrane and generally doesn't require treatment. So those women may undergo unnecessary investigations and worry. So the staging of breast cancer so much like a majority of cancer. The most commonly used staging system in breast cancer is the TNN staging system, the Tumor Node Metastasis Staging system, which is generic for all cancers but then modified for the particular cancer in question. So word on clinical stage versus pathological stage. So in breast cancer, we make this distinction. The clinical stage is the stage that we arrive at prior to surgery. It's our best guess for what the um what stage of the breast cancer is it? It's based on clinical examination, any imaging and any biopsy results at that time. This is differentiated from the pathological or surgical stage, which has taken after surgery. And based on the histological analysis of the surgical specimen, the pathological stage is kind of the definitive stage that we can establish there. So you may, in certain cases, see, uh, a little C or a little, uh, lower case p in front of the TMM staging in breast cancer and just that's what that means. So, firstly, tumor for T. Uh, so carcinoma in situ is given the abbreviation T i s. This could be ductal a lobular carcinoma in situ. T one is a tumor that's less than two centimeters. T two is between two and five centimeters. T three is more than five centimeters in size, and T four is a tumor of any size that's invading the chest wall and all the skin around the breast. N zero implies that there are no identified lymph node containing cancer cells. Uh, and one generally means there's cancer cells in somewhere between one and three eggs Ilary so armpit lymph nodes, or, if there are cancer cells in the internal mammary lymph nodes, which should a bit more medial there near the breastbone, Um, and two is either 4 to 9 axilla lymph nodes or cancer within the internal memory. Lymph nodes that is caused enlargement of those lymph nodes and N three is either of cancer in 10 or more exhilarate lymph nodes or cancer cells found in the infra super clavicular lymph nodes above the internal mammary lymph nodes. Finally, uh, the M metastasis, much like with all cancers M zero denotes know, distant metastases and M one donuts, distant metastases, breast cancer classically metastasizes to the bone, liver, lung and brain. So, in addition to the TMM staging system, there's a slightly less descriptive but um easier to, uh say numbered staging system stage from 0 to 4. A stage zero is otherwise known as kind of in situ disease. It's not spread to nearby tissue. Early stage breast cancer is denoted as stage one, where it spread to other tissue in a small area. If it's localized, that's between two and five centimeters in size, with some lymph node involvement, or more than five centimeters in size. So that would be a T three. But n zero. No lymph node involvement. Regional spread is stage three. That's where it's larger than five centimeters with lymph nodes involved. Um, but it's and it and it may well have spread to the skin or chest wall, which is obviously, uh, t four, and Stage four is distant metastases. So in addition to staging by TNM, it's also helpful to categorize breast cancers by expression of certain receptors. And these receptors are your hormone receptors. So estrogen receptor and progesterone receptor, and also something called your her two receptor and the breast cancer can be positive or negative for any of these. And if, if a biopsy is taken, we can assess the cells for expression of each of these receptors, and that can be helpful to direct our treatment. So, um, yeah, so a word. And we talked about triple negative breast cancers earlier. So triple negative just refers to all three of those receptors being negative. So no expression of any of those receptors a triple positive breast cancer is positive for Eastern receptor progesterone receptor and her two receptor, um, and the generic term hormone receptor, positive or negative denote it's either positive for eastern receptor or progesterone receptor. And as I said just now, the expression of these receptors predicts response to medical therapies that may target these receptors. So the management of breast cancer, Firstly, we're going to talk about the non surgical management briefly, and then we'll go much more into the depth in the surgical side of things. But as an overview of the non surgical management, there are chemotherapy. Systemic options available. The nice guidelines suggest giving a taxane such as docetaxel alongside an anthracycline with Doctor Robinson with patient's with distant metastases for which a curative option is not available may benefit from something like chemotherapy, for instance, or a patient who does undergo a surgical curative treatment may benefit from adjuvant chemotherapy. Hormone therapy is an option available for patients who are positive for hormone receptors such estrogen receptor. So estrogen receptor positive breast cancer. We can give patient's um medication to reduce the level of estrogen in their bodies. So for men and premenopausal women, we can give them a selective estrogen receptor modulator called tamoxifen. Women who are postmenopausal, um, can't have tamoxifen but can have an aromatase inhibitor such as anastrozole um in eastern positive Eastern receptor positive breast cancer patient's who were positive for her two receptor could benefit from trastuzumab, otherwise known as Herceptin, which is a blocker of that particular receptor. Uh, lastly, radiotherapy is often done alongside surgery. It's typically always done after breast conserving surgery, as it can reduce the risk of recurrence there and in more advanced cancers. It may be chosen even after mastectomy. So coming onto the surgical management, as I said earlier, there's two sides to this. The first is removal of the cancer, and our options Here are breast conserving surgery or mastectomy, and we can also have an accompanying lymph node removal, which we'll talk about in a moment. And the second side of this is reconstruction of the breast following removal of the cancer. This is a sort of in the remit of plastic surgery. It's it's the overlap plastic surgery in breast surgery. So, firstly, removal of the cancer. So what is breast conserving surgery I've used this term? What it refers to is removal of the cancer, along with some, but not all surrounding healthy breast tissue of the affected breast. The margin of excision it does depend on the size of the tumor and the type of tumor as well as the location. Breast conserving surgery is on a spectrum it can come from, so that that that shouldn't say mastectomy. It can vary from lumpectomy through too wide local excision through to partial mastectomy, although correct that on the slides before I upload them, that should be a lumpectomy. Mastectomy is not an example of breast conserving surgery. Um, breast conservative surgery, as I mentioned, is typically followed by, uh, adjuvant radiotherapy lasting approximately three weeks. So one of the disadvantages of breast conserving surgery is a woman in early stage breast cancer, Um, does have to go through radiotherapy and all the associated side effects of that, such as fatigue and hair loss. Um, and it's generally suitable only for your early stages of breast cancer. So the other option that women have is mastectomy. This involves removal of the entire breast affected by the cancer. Um, it often involves subsequent breast reconstruction because women have lost all breast issue there. That's a personal choice, uh, for patient's, and it's generally suitable for later stage. Breast cancers and larger tumor's generally above four centimeters. An average sized breast aren't as amenable to breast conserving surgery because so much tissue would have to be removed anyway, um, it may. Also, a woman may choose it in, uh, early stage cancer for personal reasons, maybe personal, um comfort, Um, and just reassurance that, um, there's a better chance of removing all affected cancer cells or to spare to spare the need for radio therapy. So lymph node removal? Um, so So, um, if there is no evidence presurgery of lymph node spread on our imaging modalities, what's generally chosen is the Sentinel lymph node biopsy, which is typically carried out at the same time as the breast cancer excision. So what happens is the surgeon will inject a radioactive substance or blue dye into the tumour to identify what we turn the sentinel nodes, which are the first lymph nodes in the drainage path of that particular cancer. Those lymph nodes, usually four or more, are then removed and sent for histological analysis. If histological analysis demonstrates no breast cancer, that's, uh, that that can confirm that the breast cancer is indeed Stage n zero. However, if it shows that they're breast cancer has spread spread, then the woman may need further exhilarate node clearance, for instance. Like I said, it's usually performed in at the time of the operation, but it can also be done. I'll just hound guidance. The other option for removal is an auxiliary node clearance. That's if there's evidence of lymph node spread to the exhilarate nodes. The extent of D clearance will depend on the tumor stage, Uh, and after discussion with the patient 11 downside of limp clearance is the more extensive the clearance, the higher the risk of lymphedema of the intellectual arm lymphedema being this build up and swelling of the affected arm due to reduced absorption and transport of tissue fluid as a result of losing all those lymph narrative. Remember, that's one of the functions of the lymphatic system. Um, generally, there are three levels that we consider of auxiliary lymph nodes. They are defined in relation, uh, with respect to their relationship to pectorals, minor muscle. So if they're below and lateral to petrol is minor, that's level one. A Level two clearance would incorporate those level one nodes, but we'll also clear behind petrol is minor, the nodes there, and if they're above and medial to petrol it's minor. Their level three nodes in the level three clearance. We'll do all three levels of of those nodes. So we've had a couple of questions. Is there a different follow up for breast cysts? Well, breast cysts Will, Will. Will, um, they're often, as I understand, they can be related to, um, just the natural menstrual cycle. For instance. I don't know about the specific follow up for that, Um, I'm not sure they're They're always treated and less troublesome, but it's it's kind of outside the remit, the the cancer topic there. Um, curious about reconstruction for men. Sister Trans, We're gonna talk about reconstruction in a moment, so we'll just come on to that now. So breast reconstruction. So the aim of breast reconstruction is to restore the normal appearance of breast, uh, of of the breast following the cancer excision. It's generally needed more so in, say, mastectomies than a lumpectomy. A lumpectomy may well um, preserve overall that the the appearance of the breast and then there may not be any need for for reconstruction. The important thing to embrace about breast reconstruction is it's a personal choice. Reconstructing breast, uh, reconstructing your breast following breast cancer removal doesn't serve a function to the woman. It's it's purely, um whether she wants to have that breast reconstruction. Obviously, a lot of women do feel, um, quite upset after losing, say, an entire breast following a mastectomy and may want a breast reconstruction. But other women may not be bothered by that personally and may choose not to undergo breast reconstruction surgery, so it's not required at all. It often involves more than one procedure, so you could have the initial reconstruction. And then, as the reconstruction begins to heal and take form, there may need to be adjustments made in subsequent procedures. The timing of reconstruction is important. Immediate reconstruction terms. Reconstruction started at the same time as cancer excision, as it often requires more than one, um, procedure. It's not correct necessarily to say that it's all done at the same time as the cancer excision, but it started in the same procedure. Delayed reconstruction is started in a separate operation. Uh, sorry if you said it already. But is radiation exposure concerning screening as well? Really good question and that that it's it's a really valid point. Um, I think the the degree of obviously any degree of radiation exposure does increase the risk of cancer. Um, the national UK. All I can say is the UK screening program for breast cancer has been around for going on nearly 40 years now and that they haven't chosen to repeal it. So it's clearly doing enough. It saves. It's estimated around 1400 lives per year. I think the concerns are more about the over diagnosis and worry, but actually that is a valid point. You know, it's not neutral to expose, um, somebody to, um, x radiate, uh to radiation through mammogram. So, yeah, that that's definitely a consideration that someone may want to take when choosing to respond to screening or not. So, um, Antoinette touched on this, uh, well, not touching this. Antoinette went into much more depth on this principle last week, but as a recap, and if you weren't here, we'll just talk a bit about the reconstructive ladder. So the reconstructive bladder is a term given to the way we order reconstructive techniques by increasing complexity, the simplest procedures beginning at the bottom of the ladder, which is healing by secondary intentions to allowing a wound to granulate. These are the forms of closure, and then all the way up to the top where we get our free, you know, our tissue flats and our tissue transplant plantation. These are the most complex procedures. The reason that the application of the reconstructive bladder is the principal, that closure and reconstruction should be performed by the simplest, effective technique available now with breast cancer reconstruction. It's usually achieved using quite complex techniques through the use of flats. Things like skin grafts, primary intentioned just just won't do. For that. They won't reconstruct the anatomy properly. Is the choice of immediate versus delayed reconstruction guided by the patient or clinical? Good question. Um, so I think there are certain clinical factors. Obviously, we always involve the patient in the decision. If they don't want to undergo reconstruction at the time of the initial, um, the initial cancer excision, that's her choice. And we've never never impressed that on a patient, um, in terms of delayed reconstruction. So, for instance, if what we'll go into is that reconstruction relies on, um, you know it can fail and and if if a patient is really quite unwell at the time of the breast cancer resection, and we think there's going to be too much inflammation around the breast tissue as a result of removing the cancer. Then a surgeon may opt to delay the reconstruction until, um, the the immune system is settled down there and there's there's there's less damage going on there because that could increase the risk of of flat failure. So, uh, the question about reconstruction for menses or trams? Ultimately, it's a question, I suppose, of how much tissue they would lose. Somebody who is, um, genetically mail by sex won't have the degree of breast tissue that somebody who is genetically female and so probably won't have as significant a cosmetic, uh, burden as a result of removal of the breast cancer. Um, yeah, I think. I think that's the main thing to say. That there isn't. There isn't large amounts of adipose breast tissue in somebody who's genetic is genetically mail, and they're probably wouldn't be as significant defect, so it may be less commonly required. Reconstruction will be provided on the NHS. Definitely if if a woman undergoes a large mastectomy, it's not considered a purely cosmetic procedure is quite substantial. So, like I said, Generally, flats are the method of reconstruction in breast cancer surgery. So what is a flap? So broadly speaking of Flap is a unit of tissue that's transferred from a donor site to a recipient site, and a flap is different from a skin graft in that the flap retains its own intact blood supply, so a flat may contain skin and blood supply may contain skin fashion, blood supply, skin muscle and blood supply, or muscle and blood supply. But it's always got its intact blood supply so we can categorize are flaps by, um, sort of location subtypes. In order of increasing complexity, we go from local, which is where the flat is harvested from an adjacent site and just immediately adjacent adjacent donut issue with preserved vasculature and just stretched over the defect, rotated over the defect or stretched out wide over the defect. A regional or pedicle flap is from the same rough anatomical location, but is not directly adjacent. The flap will main attached to its original blood supply by that pedicle, which is then tunneled under or over the skin, and the most complex type of flap is a free flap. Otherwise it's free tissue transfer that's from a distant an anatomical region. And what you need to do is you need to cut off the flat blood supply at its origin and then an estima sit using micro vascular surgery to blood supply at the recipient site. In breast surgery, the recipient site is typically your internal thoracic or internal memory vessels. So, um yeah, so now we're going to talk about some of the main flaps that are available in breast cancer surgery. Firstly, the latissimus dorsi flap. So if you remember the latissimus door, full size one of the large muscles in our back, this is a myocutaneous flap containing skin as well as part of the latissimus dorsi muscle. And the vessels that are used in this flap are the thoracodorsal vessels. This can be a free flap, but it's typically a pedicle flap and is typically chosen as the most common pedicle flap in breast cancer reconstruction because there's less overlying skin and subcutaneous tissue around the skin over the back, as opposed to, say, the abdomen or the gluteal areas. Uh, this typically requires an accompanying breast implant with a synthetic material such as silicone. Um, to give extra bulk to the flat. You may have heard of the term tram flap, so this refers to transverse rectus abdominus myocutaneous flap. So much like the systems Dorsey. This also involves muscle as well as skin. This in this case, it's the rectus abdominus muscles in the medial area of our Antara lateral abdominal wall. The vessels chosen here are your deep, inferior epigastric vessels that supply the rectus abdominus. Um, so this type of flat can be pedicle so we can see the example there where it's been cut at the donor site and then tunneled underneath the anterior, uh, lateral abdominal wall and out onto the affected breast to form a pedicle flap. Uh, and it can also be done as a free flap. Whether we're obviously the the, uh, the blood supply is cut at its origin. Um, it takes there's something called a muscle sparing free tram flap, which still takes some rectus abdominus muscle but takes only a very small amount of that muscle. This reduces the resulting abdominal wall weakness that you can understandably get as a result of losing your part of your rectus abdominus muscle. And so it reduces the risk of, say, hernias. As a result of that, the deep, inferior epigastric perforator flap is otherwise known as the D. Yep, flap. So this is a purely cutaneous flap. It contains no muscle. It's a kind of free flap. It's not a pedicle flap, so it needs to be cut and then re anastomosed using micro vascular surgery. The components of this are just the deep, inferior epigastric vessels, just like the rectus abdominus flap. But it doesn't contain any of the rectus abdominus muscle, so the advantage of this over the tram flap is that there are fewer complications, such as hernia. As no abdominal wall muscle is taken. However, the rectus muscles still needs to be split and accessed in order to retrieve the inferior epigastric vessels that perforate through it. And in addition, because it's a free flat rather than a pedicle flat, it requires quite complex microvascular anastomosis, which is only available at certain specialist centers. The superficial, inferior epigastric artery flap is very similar to the Diep flap in that it contains it's a cutaneous free flap that doesn't contain any muscle. Instead of using the deep, inferior epigastric perforators, it uses the superficial, inferior epigastric vessels because these vessels don't penetrate the rectus abdominus muscle. Then, in this case, in this surgery director dominance, muscle can be left completely untouched and doesn't even need to be split. So, in theory, preserves more abdominal wall muscular strength. The issue with the S S I a flap is that there's a higher risk associated with them in studies of arterial complications. The supposedly, presumably because the superficial, inferior epigastric vessels are smaller, uh, perhaps less less likely to succeed in the anastomosis than the deep, inferior vessels. Um, and so as a result, it's rarely performed. It's only done in patient's who have demonstrated preoperative favorable arterial anatomy. Generally, something like a diet plaque is still preferred, even though it does require splitting the rectus abdominus. In addition, so we've talked about flats from the back. We've talked about flats in the abdominal wall. You can also get flaps from the gluteal regions. These are cutaneous free flaps, um, so that the common ones that we can encounter other superior gluteal artery perforators ESCAP flats or the inferior gluteal artery perforator I gap flats, the only difference being which which gluteal artery perforators do we take the superior, the inferior and then obviously the region in relation to the buttocks that they are harvested from, uh, these again are free fats and connected to the internal thoracic artery and vein. So following reconstruction, there are a number of post operative complications that we need to be aware of and need to monitor for, um uh, with with our patient's. So, uh, seroma is one of them. So seroma is broadly speaking, an accumulation of tissue fluid under a wound following the surgery. The risk of accumulation of this tissue fluid can be reduced by inserting drains. Inter operative Lee. If the surgeon is particularly concerned in that particular patient of the risk of sorrow. HMAS. However, if they don't self resolve, which they usually do within a few days, they may require needle aspiration. Flat failure is the main one to be aware of it as a risk of approximately three and 100. It's more common in free flap than pedicle flaps. As in free flaps, we need to cut off the blood supply and then researcher it was in a pedicle flap. We actually try not to interrupt the blood supply at all and a flat available require return to theater for removal of the necrotic flap. So, as a result, we need to be very carefully monitoring flats post operatively for signs of arterial or venous failure. Now, when I worked at the Kiwi, I was taken through by an S H O on plastics. Um, the different ways that we can, uh, determine whether a flap is failing arterial or venous. So I thought I'd mention that today. So arterial two flats that are undergoing arterial a general generally pale in color because they're not getting arterial blood, they'll have a reduced. So an increased capillary refill time with venous failure. They'll be congested, blue and dusky, and they'll have a reduced capillary feel time. It'll actually be quicker. I'll need to change that later. And in addition usually, um, in terms of innovation, unlike with blood supply, where we need to make sure blood supply of a flap is, um intact. Throughout the healing process, we can cut nerves and rely on growth of new nerves from surrounding tissue. So in the initial area, in the in the initial stages following, it's certainly following a free flat reconstruction, a woman is likely to have no sensation over the affected area. However, over time we hope that the sensory loss does improve, but it doesn't always. They may be left with either tingling parasthesia type symptoms or numbness. So Patrick asked what would be the indications producing one flap over another? Yeah, good question. So for one thing, like I said, Hang on. I can't if I talk about this later, Yeah, talk about choice of flap here, so joint leads us nicely here. So if we flap, they often produce the best cosmetic results. But as I said, they require specialist resources because what we need to do is we need to do microvascular anastomosis, and not all centers are able to do that. And like I said, pedicle flaps generally have a lower risk of flat failure. If there's a patient who we think has a number of vascular comorbidities, for instance, diabetes of peripheral vascular disease and is therefore less likely to top, Um, yeah, just just more likely to have vascular complications in such a patient. A pedicle flat, maybe chosen in those patients' Generally your latissimus dorsi flap is your most common one. For instance, the flat should also ideally be harvested from part of the patient's body that has an excess of skin and subcutaneous tissue. So body type is another important thing. A woman who has quite a flat stomach. Quite a not a lot of subcutaneous tissue around her abdomen may be more suitable for the gluteal flap, because what we want to do is we want to take an area where there is excess skin and subcutaneous tissue, so we can just close that by primary in tension. Whereas if we're taking an area where there isn't much of that, then we have an issue. You face the issue of what to do with the defect that we create there. If there's excess skin and subcutaneous tissue that, then that problem is eliminated, how would flat failure present on brown or black skin? Uh, so yeah, so I mean, it would be just generally what we've got to think about is why. Why is a white person saying experiencing pallor as a result of arterial flat tailing? That's because there's less arterial blood being delivered into this. There still will be a paleness to, uh to darker skin as a sort of arterial flat failure, Um, and congested skin in Venus. Failure has a certain kind of puffy texture as well as the visual appearance of blue and dusky skin, and it's still it's still will. Will will have those qualities, but it's a good question there. So just a summary slide now about what we've covered today. So breast cancer is the most common cancer that patient's get in the UK The incidence rates are currently rising, but the prognosis is improving. At the same time, it's strongly linked with estrogen exposure, UH, breast cancer, most commonly presented as a painless breast lump. But there are other associated skin and nipple changes that can occur with it. The diagnosis, typically by the triple assessment of specialist breast clinics, which involves the clinical examination of the breast imaging either by way of mammography or ultrasound scan and biopsy of the any suspicious lumps. The non surgical management options include chemotherapy and radiotherapy, which are common to all cancers, really, but then, specifically, breast cancer. There are hormone therapy and biological therapy, which are directed by expression of particular receptors. The surgical treatment options comprises surgery to remove the cancer with or without breast reconstruction, and that's depending on patient choice and the degree of defect that's actually left as a result. And lastly, breast construction Breast reconstruction is a personal choice for a patient, and the choice of reconstruction method depends on patient factors such as Do they have excess skin in one particular part of the body? How many comorbidities do they have? And are they likely to tolerate a free flap over a pedicle flap as well as availability of specialist resources? So, uh, these are just references for any further reading for anyone who's interested in breast cancer surgery. Thank you for listening. I think we've got some questions feeling, and I'll try to try to answer them as best as I can. Here we go. Um, since the nipple seems like a common place for this, is there any indication to remove the nipples and leave the breast? Well, obviously, the nipple is a part of the breast, and in the nipple isn't the most common location. Like we said, the most common location is the upper outer quadrant of the breast. However, if there is breast cancer that involves the nipple that actually produces more of a challenge, obviously, because if we need to remove the nipple, that can have a quite quite a significant cosmetic result for the resulting breast. Um, so when you say leave the breast, you're never leaving the breast entirely cause we have to remove the nipple. We'd have to remove surrounding tissue and then have to think about how best to restore, uh, as normal in appearance as we can there. So it would. It would follow the same principles. Generally, um, it's more challenging to do a wide local excision or breast conserving surgery in centrally located breast cancers such as around the nipple. So generally so. It's not. The mastectomy is always chosen, but mastectomy, maybe a preferable option in those cases, Would you generally considered delayed reconstruction in patient's going for radiotherapy? Is it a case by case decision? So, yeah, so radiotherapy is another another, another really good point that I thought about that. That's That's probably another reason that delayed reconstruction would be chosen because obviously radiating the area is going to reduce the, um, reduce the rate of healing. Uh, and so that's what we need we need. We want the optimal environment around the breast to undergo that reconstruction. So that could be another reason that, uh, delayed reconstruction is chosen. Does anyone have any further questions on this? Yeah. So I have Fraser Point. I've just come across many people who don't want to keep their nipples. I'm curious whether that could be a good option. What? You said the location. I mean, we're not going to remove. I'm not sure if I'm fully understand this question, but I'll try as best I can. Um, we're not going to remove an area that we don't need to remove. If it's if it's an upper outer quadrant breast cancer, for instance, we're and it doesn't involve the nipple or the margins that surgeon chooses wouldn't involve in it. But we're not going to just just remove that. Generally, patient's would rather keep them because that's that's one part of the anatomy that's very difficult to restore the appearance of. So if it involved, if if the margin involves the nipple, then then that's a challenge. That then needs to be thought about and addressed in the reconstruction. And if it doesn't then that actually makes reconstruction a little bit easier. Are there any further questions. If not, we can wrap up in two or three minutes time. Could you please go back to the flat failure side slide? Yeah. Um, that's under the post operative complications. Yeah, but do you have a specific question regarding the flat fail? So here this this image, I probably should have said, is an example of Venus flat failure. You can see the dusky skin. Um, that's congested. Um, and as I said, the arterial failure, it should say, increased capillary full time. The venous failure should say decreased capillary refill time. So I will amend that as well as the mastectomy. Um, image before before uploading these slides. Our drains always use post surgery. No, not necessarily. It's just if there are particular factors that either in relation to the patient's own body or in relation to findings observed at surgery, that means the surgeon is particularly concerned that there could be a risk of a seroma. Then then then a drain may may be used. In that case, deflects leave significant scarring. Not if they're ideally, not ideally not. I mean, there will be there will be a scar, obviously, from the removal of the tissue. But if it heals well, if the skin's which is a opposed well, then, huh? Hopefully, our aim is to restore as normal anatomy as we can now. Obviously, we can't restore perfectly normal anatomy. But the goal with the evolution of breast cancer surgery and breast cancer reconstruction, is to get closer and closer to that, so they shouldn't really leave significance going. Is it possible to send the file of the session that was given to Yeah, So what we do is we'd encourage you to fill out feedback forms. They're really helpful to me, Charlie and Antoinette in terms of our future teaching in terms of future of shots as a teaching program. And, um, once you do that, you'll have access to uh, is it called on demand content? Charlie, I'm not sure what it's called, but you should be able to access the slides so I will adjust the I'll make those necessary corrections on the slides, and then you upload them. What is the largest amount of tissue that is safe to use for a flat? Think about reconstruction, the larger breast exactly. So. So this is another patient specific factor is size of the breast. And that's a really important factor in reconstruction. I don't think there's a specific largest amount of tissue, but generally what we have to think about is the defect that we're leaving behind. Um, so you don't want to take a huge amount of abdominal tissue? Only two, then require, like some kind of skin graft or flat for the abdomen. That that that that is sometimes done where you have, like, a sort of stages of flat to flap. And then a second skin graft for that. That that that that can be a That can be a challenge for that. Yeah. Great session, Add. Um, well done. Um, and, yeah, there's been loads of really good questions, which I'm really like, excited to see about. Thanks, guys. For engaging so well, we do have catch up content. Um, we basically just upload the slides. Um, maybe after a few edits or whatever, and I'll be available for you guys. Um, so yeah, don't worry about that. We have the catch up content for a previous sessions as well. If you have been to those, uh, do, please. A complete a feedback form. Put the link in the chat scroll up a little bit together, Um, as it's really helpful. And yeah, um, Adam, Yeah, it's been it's been a great sessions with so many questions, I think I can probably start to think about wrapping up. Yeah, no, thanks. So much of the questions. People seem very interested in this, this stopping in particular which is which is really interesting stuff. Um, it's obviously an overlap of a breast surgery with plastic surgery and plastic surgery is really interesting stuff. I did an elective in it in India in fourth year, so I I find it really interesting. Um, yeah. So next week join us at the same time 6. 30 where we're wrapping up our surgical and ecological teaching series. Uh, saving for the best to last. Antoinette's taking us through lung cancer surgery, lung cancer, which are being one of the most common cancers in the UK, and she'll just be taking us through the surgical management of that. Um so it seems that the number of questions of the questions of by and large stop now. So I think I'll end the session there, and I'll make the necessary adjustments to the slides and get them up. If you would like them, please complete a feedback form. Let us know how you found the session and how we can be doing better as well. Thanks, everyone. Cheers, guys.