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So I think we will start. So this is a little less relevant today because we have, this is the last session. Uh We are hoping to do some more sessions and try and expand, expand the high yield surgeons group. So just keep an eye on social media, keep following us and hopefully you'll hear more about what's to come in the future. Great. And if someone could just confirm that my slides are moving, that would also be great. Just pop in the chat that you can see my slides moving. Mm Perfect. Great. OK, we'll start. So an overview of the session today. So we are be focusing on high yield information to help with exams. So we'll start with basic anatomy of the breasts. Uh We'll move on to breast examination, then we'll have a look at the referral criteria for uh to the breast team and then also the National Screening programs. And then we will have a look at the benign breast pathologies that you need to know about and then breast cancer. So we'll start with the anatomy of the breast. So the breasts are located on the anterior thoracic wall. There are typically two breasts in men and women after puberty, they're a bit more prominent in females than in males and in females. The main purpose of them is lactation which is why they contain the mammary glands. It lies superficially to the pectoralis and the serratus anterior muscles. In terms of surface anatomy, the breast can be divided into two sections, the circular body and the axillary tail in the center of the body. There is the nipple which is made of smooth muscle fibers and then surrounding this is the areola which contains sebaceous glands used to protect the nipple because they secrete like an oily substance used for protection. So I'm sure you've seen this image quite a few times, but this is the internal structure of the breasts. So the breasts are made up of mammary glands surrounded by connective tissue. The mammo glands are similar to sweat glands. They're a form of modified sweat gland and they're formed of a network of ducts and lobules. The lobules contain the alveoli and they are the alveoli are drained by a single lactiferous duct. Each of these ducts then come together at the nipple. The connective tissue has a fatty and a fibrous component. The fibrous con the fibrous components converge to form Cooper's ligaments which attach the breast to the underlying fascia and it separates the lobules from each other. The pectoral fascia is at the base of the breast. It interacts with the pectoralis major as an attachment site for the suspensory ligaments. There is actually a small area between the fascia and the pectoralis major which is called the rectum mammary space. And this is sometimes utilized in reconstruction reconstructive surgery. So, in terms of vasculature, the the lateral thoracic and thoraco crom branches originate from the axillary artery and supply the breasts. The lateral mammary branches originate from the posterior intercostal arteries derived from the aorta. And these supply the lateral aspect of the breast in the 2nd, 3rd and 4th intercostal spaces. And then there's the mammary branch which originates from the anterior intercostal artery, the veins uh then correspond with the arteries and they drain into the axillary and internal thoracic veins. So, in terms of the lymphs of the breast, it's quite important to know and understand the lymphatic drainage of the breast because it's involved with metastatic breast cancer. Um So, the lymph from breast tissue tissue drains into three lymph node systems. The majority of the lymph drains into the axillary lymph nodes. Uh about 75% drains here. The rest, about 20% drains into parasternal and 5% posterior intercostal nodes. And in the picture here, you can see the five groups of the axillary nodes which all ultimately drain into the apical node. There is a separate drainage for the skin and then the nipple and areola. Uh so the skin drains the axillary inferior, deep cervical and infraclavicular nodes and then the nipple and areola drain to the sub areola lymphatic. This is relevant for two reasons. So the first is that some of the signs and symptoms that we see of breast cancer um in the first presentation to the GP are occur as a result of the blocked lymphatic drainage. So the ducts get blocked up and this leads to a backup of lymph inside the breasts. And then this can build up in the subcutaneous tissue. And then because of that, you can lead to uh nipple deviation, nipple retraction, skin changes such as poor on uh which we'll discuss a bit later. So that's the first reason why it's important to understand the lymphatic drainage. The second reason is that metastasis can occur through the lymph nodes, most commonly the axillary lymph nodes. And this can lead to the cancer being spread to other organs such as the liver, lungs, bones and ovaries. Ok. So let's start by having a look at how we do a breast examination. So, breast examinations follow the same principles of every other examination that you'll do. In terms of, you need to have a look and you need to have a film preparation is also uh the same as most other examinations. So you need to wash your hands, don't any PPE explain the examination to the patient and get that consent. The main difference with this is that um you most likely will want to have a chaperone present. So, when I was in GP practice for four months. It was common practice to have a chaperone present for all breast examinations. Some patients might say they don't feel they need a chaperone. But honest as I always would have a chaperone and just explain that's part of your protocol to have a chaperone present. And then in order to start the examination, you need to ask the patient to address from the waist up completely and then ask them to sit at the end of the bed. So I normally ask them to sit on the side of the bed with their legs down and arms by their side. And first, you will have a look at the breasts with while the patients relax with their arms down by their side. So have a look for any obvious um asymmetry. Are there any obvious lumps? Are there any scars, this might indicate previous breast cancer or breast surgery? Any skin changes um including scaling, um erythema which might indicate infection, trauma or breast cancer puckering, which is caused by contraction of the ligaments caused by breast cancer which invades into the suspensory ligaments of the breast. And finally, po on which as we briefly covered earlier is due to lymphatic edema and can indicate inflammatory breast cancer. You just have a good look. Don't be afraid to lift the breasts up and make sure you look all around the both of the breasts. And then I've just included this um image of pod orange. Just cos I think it's quite interesting and it's sometimes can be quite difficult to, um, spot. Once you've initially had a look at both breasts, you can ask the patient to put your hand, their hands on their hips, press into their hips and repeat the inspection fully. This process of them sort of pressing down onto the hips can help to accentuate any skin changes or any puckering or dimpling. In addition, if there is a mass present, it might move with this maneuver. And that might indicate that a tumor is there and it's tethered to the chest wall. And then finally ask the patient to put their hands behind their heads and lean forward and again, repeat the inspection. This can also help to sort of emphasize any abnormalities. Ok. So once you've had a look, it's important to have a feel of both the breasts. So ask them to lie back on the bed. If they have symptoms in one breast, start by examining the other breast. So ask them to put their hand behind their head and lie back. There are a few different methods of examining the breasts um that you might have been taught. But for all of the methods, you need to make sure that you are fully examining the whole breast using the flats of your three middle fingers. And this will allow you to compress the breast tissue against the chest wall. So you can feel for any abnormalities. The method that I was taught at medical school was the clock face method, which is where you start on the outside and you work your way in and you imagine a clock face on the breasts starting at 12 o'clock and one o'clock, two o'clock and you start on the outwards and you palpate all the way in towards the nipple. Other methods include the spiral method, which is where you start at the nipple, you spiral outwards and around all the way to the outside. And then there's also the quadrant method where you break the breast up into three into four quadrants. And you examine each of the four quadrants thoroughly. To be honest, as if the examination is done properly, it doesn't actually matter which method is used. You also need to make sure that you examine the axillary tail. So all the way up into the armpits because the um outer top quadrant is where the majority of breast cancers develop. So just thoroughly examine that area. If you, so you need to feel for any masses. If you do feel a mass, you need to note all of the details so that if somebody was to look at your documentation, they'll be able to know exactly where and what you felt. So have a think about um the location, the size, the shape, the consistency is it mobile is the lump itself fluctuant. So you can um if you do feel a mass, you use your fingers and palpate each side of it and then you can press with your other hand and if it goes up and down, then that can indicate that the mass is fluctuant and then document any overlying skin changes as well. Once you've fully examined and palpated the breast, you need to have a close look at the nipple to assess for any discharge. You can ask the patient to squeeze the nipple themselves. Um And if there is any discharge, just know all the details again. So the color consistency and how much there is and obviously which breast there is and then repeat the examination on the other breast. Once you've palpated the breast tissue, it's very important to examine the axillary lymph nodes. Um So I would get them to sit up again on the edge of the bed. You need to take the complete weight of their arm in your arm. Um So for example, their right arm to your right arm, if you're examining the right um axilla and just uh take their arms like this, tell them to completely relax and tell them, let you take the weight of them and then palpate in the axilla. And I just looked at the posterior, each medial and lateral wall and then the anterior wall to assess for any lump cyst might indicate um any lymph adenopathy and might indicate uh breast cancer or metastasis and repeat on the other side. So, it's time for our first question now. So a 34 year old woman comes to see you in the GP practice complaining of a lump in her right breast, but she's otherwise. Well, you examine her. She has a sym, she has symmetrical breasts, no skin or nipple changes on palpation. She has a firm nodule, tethered to the chest wall. She has no lymphadenopathy. What's the best course of action? So my colleague will pop the polyp and if you just answer the question, um and then we'll go through it afterwards, the polyp. OK. So you should be able to see the poll on your screen. So just answer. So the first option is reassure and send her home, send her home and review in two weeks. Give her a course of antibiotics, routine referral to the breast clinic or urgent referral to the breast clinic under the urgent suspected cancer pathway. So if you just answer, I'm gonna go through, just give you a couple of minutes, ok? Just in the interest of time because we started a little bit late, we will go through. So 6% said a reassurance at home. 13% said b nobody said c 13% said D uh and 62% ze urgent referral to breast clinic under the urgent suspected cancer pathway. So, yeah, the answer is the urgent referral to breast clinic under the suspected cancer pathway. And we'll go through the reasoning for this. Now, So this is the referral criteria based on a nice guidelines. So it is a little bit vague. Um The first two points are pretty clear, but then after that, it's a bit vague. So, referral. So you should definitely refer if somebody is aged over 30 with an unexplained breast lump, doesn't matter any of the other symptoms. If they have a breast lump, you should do a two week rule referral if they're over 50 they have any unilateral symptoms. So any unilateral nipple discharge, retraction or any other changes of concern, just send a referral. The second part is a bit more vague. Uh So it says, consider referring under the urgent suspected cancer pathway if there are skin changes that suggest breast cancer if they are aged 30 years or older with an unexplained lump in the exit. To be honest, in practice when I was in GPI know with a breast lump, um I referred to the breast clinic. Um but you do have to use a little bit of common sense and you know, if you're not sure, just discuss with your seniors, but in terms of exams for higher purposes, the questions are likely to be uh an unexplained breast lump in somebody over 30 or so on 50 years. No, with unilateral nipple discharge, retraction or other changes of concern. Obviously, there are some benign conditions that we will go through later. Um And if the question said, give the most likely diagnosis, it might be something else based on the symptoms and the question. But this is the referral criteria that you need to know. So what happens when you refer someone to the breast clinic? So all patients will undergo triple assessment. So this is a physical examination as we've just discussed imaging plus or minus a biopsy. So, in patients under 35 who are referred, they, the imaging of choice is an ultrasound. Uh this is due to the increased density of the breast tissue in younger people, which makes um mammograms less effective essentially. And then anybody over 35 will be referred to a mammogram for for a mammogram. And then most patients will undergo biopsy which is uh fine needle aspiration or a core biopsy depending on the findings on the um imaging. Um and this allows further histological assessment of the lump and gives us a diagnosis. So moving swiftly on to question 20, hold on. Yeah. So which one of the following correctly describes the NHS breast cancer screening program? So a those aged 25 to 50 screened every three years, anyone aged 50 to 64 screened every five years b age 40 to 7 screen every three years. C those aged 45 to 65 years screened every five years. D those aged 50 to 70 years screened every three years and e those aged 50 to 70 screened every five years, those aged 71 to 80 every three years. So we'll put the polyp and let me just put question two up. So you should see the pole on your screen now. So I'll give you a minute or so. So just give one more minute. OK, I think we'll leave it there just uh in the interest of time. So for this question, the answer was d at one age, 50 to 70 years get screened every three years. So let's have a look at the screening program in a bit more detail. So in England, Northern Ireland, Scotland and Wales. So this is based off nice guidance again, England, Northern Ireland, Scotland and Wales invitations for mammograms will be sent out every three years for women. Patients will receive that invitation within three years of their 50th birthday. So they might get it anywhere up to being 53. Once a woman reaches 70 they're excluded from the screening program. However, you know, if they have any symptoms or they, they want to have um screening, they can self refer to their local breast screening service. Some women may be excluded from this criteria and may have different um screening. They might be eligible for earlier screening and just here listed as some of the criteria uh which warrants referral to secondary care. So they'll be seen in breast clinic and earlier screening might um might take place. So anybody with a first degree female relative diagnosed with breast cancer under the age of 40 if you have a first degree male relative diagnosed with breast cancer at any age, um having a first degree relative with bilateral breast cancer, where the first primary was diagnosed under 50 two first degree relatives or one first degree relative and one second degree relative diagnosed with breast cancer at any age, one first degree or second degree relative, diagnosed with breast cancer at any age and one first degree or second degree relative, diagnosed with ovarian cancer at any rate at any age. And then the the last criteria would be three, first or second degree relatives diagnosed with breast cancer at any age. So essentially, if there's a lot of breast cancer in the family, you might be eligible for earlier screening. Mm. Ok. So let's start having a look at some of the benign breast lumps. So this is question three. So you have a 24 year old female who presents to the GP practice because she's worried about a painless lump that she has felt in her left breast. There has been no trauma to the area. She hasn't had anything like this before she's otherwise fit and well, she's systemically well. So her obs are stable and she's not had any weight loss or any worrying features. She has no family history of breast cancer. On examination, there's a firm mobile, oval shaped 1.5 centimeter lump in her left breast. You see no obvious skin or nipple changes to either breast, you felt nothing abnormal in the left breast, in the sorry that should say in the right breast. Um and no lymph nodes were palpable in the axilla. What's the most likely diagnosis? So, a duct ectasia b, mastitis, C, fibroadenoma, d ductal carcinoma in situ and e fat necrosis. So I will put the, the, the po is up. So just have a go at answering the question and then we'll go through the answers, give you a few more minutes, just give another 30 seconds or so. And then we will go through two. OK, great. So 93% of you said c fibro adenoma and that is the correct answer. Um So we'll go through fibroadenomas now. So, fibroadenomas are caused by overgrowth of collagenous mesenchyme of breast lobules. It is the most common cause of benign breast lumps and they typically occur in people who are under 30 but they can occur in anybody after the menopause. Um Generally the masses get smaller. I think the statistics I read with 30% get smaller, 30% stay the same 30% get bigger. There's typically no need to treat these. They are completely benign. Um But obviously they might cause problems. Um And then in which case, they can be surgically removed. So if they're getting bigger, if they're causing discomfort or anything like that, we generally treat conservatively. Um If causing problems, you can refer to um the breast team Um And obviously, you know, if you're unsure if it is a fibroadenoma, you would just refer anyway because it would, there would be a lump in the breast and it might need biopsying to confirm the diagnosis. So, in terms of the um other answers, so we're gonna go through some of these a bit later. Um but duct ectasia typically has some nipple changes, mastitis. Uh You might see that again, some nipple changes might be painful. There might be some redness, um some swelling around the area. Ductal carcinoma said she just given her age. It's unlikely. However, you know, would probably refer to breast clinic for a biopsy and then e fat necrosis. It states in the question, there has been no history of trauma. So again, this is unlikely. Ok. So let's move on. So we've got another question now. So question four. So we've got a 36 year old female who presents to the GP because she's worried about a lump that she has felt on her left breast. She's noticed it's been there for about six months and she notices that sometimes it gets bigger, especially around the time of her period. She is systemically. Well, on examination, there's a fluctuant mobile mass in the left breast. There's no obvious skin or nipple changes to either breast. You felt nothing abnormal in the right breast, no lymph nodes or palpable in the axilla. What's the most likely diagnosis? So, a ductal carcinoma in situ B breast cyst c breast abscess d, fibroadenoma, e fat necrosis. So we'll put the pole up again and have a girl answering J OK, fine. So we will go through this now. So 21% of you said a 57% said B cyst uh 7% have said an abscess. 14% said fibroadenoma and and nobody said e so the answer is a breast cyst again. It's just the most likely diagnosis. So, you know, you would refer the patient onwards, have a biopsy, have some imaging, but there are some features in the history um which you know, increase the chance of being a cyst. So it's been there for a very long time. She's not got any red flags. She's systemically well, and the change in size is very typical of a breast cyst. So often they get um bigger uh around the time of period. So with the with menstruation, um so just going off that and it's also fluctuant which is typical of a, of a cyst. So that's why that's the most likely diagnosis. But again, you would refer onwards for assessment. So let's have a quick look at brass cysts. So they're very common in patients over 35 typically. Um especially if they are perimenopausal, they're benign, they are fluid filled round, they're generally mobile on examination, they don't adhere to any of the surrounding tissue um which is different from fibroadenoma. So they're normally like a hard, harder lump and then typically they're painful and the, the, you know, the symptoms of these uh cysts get worse around uh periods of menstruation. Um And the diagnosis of a cyst is confirmed by aspirating some of the fluid and having a look at the histology, I don't need to be treated. But again, if they're causing symptoms, you can refer someone to breast clinic and they, they sometimes can aspirate them, um sometimes remove them as well surgically. So, moving on to question five. So again, this is a 28 year old female who presents to the GP with a painful breast. She's four weeks postpartum and she's currently breastfeeding on examination. She has a tender red, swollen left nipple but is otherwise. Well, her observations are stable. You suspect that she has mastitis. Which of the questions below which of the options below? Sorry, are not part of the treatment for mastitis. So, you've got a analgesia b antibiotics if it seems infected, see gentle hand expression to promote drainage. D local measures like hot and cold, compresses and e stop breastfeeding. So we will launch the poll now and just might be a little bit more of a difficult question. Give you a couple of minutes to answer. Yeah, great. So most of you have got the correct answer. I think a few people are going for c now, but the correct answer is in fact, e so um all of the other options are part of the management plan for mastitis. Um But actually, if someone has mastitis, you should, you can encourage them to keep breastfeeding. Um because expressing the milk will help. Um If, if, if you, if they don't express the milk, then that can cause more problems. So obviously give them analgesia if they're in pain, if it looks infected or if they become systemically unwell. I know in this question, the patient wasn't systemically unwell if they, you know, it can lead to them becoming unwell. So you can give antibiotics and again, massaging the area, you can use hot and cold compresses that can help um improve the symptoms as well. But uh it's best to continue breast breastfeeding. So, e is the incorrect answer. So let's quickly go through mastitis which can lead to breast abscesses. So, mastitis is an infection of the mammary ducts. Um and if left untreated can lead to a breast abscess formation. So this is often associated with lactation. And the most common um bacterial causative agent is staphylococcus aureus. They are typically, if they become abscesses, they're typically painful, immobile, subcutaneous lumps which are tethered to the overlying skin, they generally will be warm. Um and they might be red and the patient might also develop a fever. Um They're not always red, but you know, everyone that I've seen has been um when you palpate the area, it might be um tender to palpate as well. The treatment is antibiotics. That's the mainstay of the treatment. If somebody becomes unwell. So if they develop a, a fever and um the infection is just not subsiding, then, you know, they might be um they might undergo incision and drainage of the abscess or percutaneous drainage, uh depending on local guidelines. Um So that would typically be done in a hospital rather than it wouldn't be done in primary care. So the next condition that we're gonna run through is duct duct taia. So this is a blockage of the mammary ducts which is caused by stagnant secretions. Um It typically develops around the menopause um and is actually more common in smokers. Um And the presentation is normally uh sort of greenish or blood stained or brown discharge from the nipple. There may be some other nipple changes, so some retraction. Um and there might also be a lump present underneath the nipple. And you know, the investigation of choice would be an ultrasound of the lump to confirm the diagnosis. But to be honest, if you find a lump and some nipple changes, um you're likely to just refer them under the urgent suspected cancer pathway anyway, um even if you suspect that this is duct ectasia once confirmed, there's no specific management of the condition. Um You can give smoking cessation advice um because it is much more common in smokers. Ok. So, uh moving on to question six. So I have an eighteen-year-old female this time who's come to the GP, she's noticed a lump in her breast. She has noticed it has come on in the past two days. She's otherwise. Well, no past medical history, no history of breast cancer in the family. She does mention to you that she has just started playing rugby and played her first rugby game three days ago. On examination. She has a tender firm lump in the left breast with o with an overlying bruise on the skin. So, what is the most likely diagnosis? So, a ductal carcinoma, situ b, breast cyst c breast abscess, d, fibroadenoma or e fat necrosis. I'll give you a couple of minutes to go through these as well. Ok, great. So 10 of you have answered and you've all got the correct answer. So that is e fat necrosis. So when we go through it, I think you'll see why this is the most likely diagnosis. So, fat necrosis is a condition that occurs after a traumatic injury to the breast tissue. So there's trauma to the tissue, it might even be minor and that leads to fibrosis and calcification, which then presents as an immobile firm lump at the area of injury. There might also be some bruising around the area um and no treatment is required, but of course, you'd have to confirm the diagnosis. So they would likely undergo a triple assessment. Once the diagnosis is confirmed, there's no treatment, things should just settle down on their own, but it's a good one to be aware of. I've seen a few questions, a few F ba s about this. Um So I think it's, it's a good one, especially because if they've had trauma. So in this question, this girl has been playing rugby, um which is a contact sport and therefore highlights that it might be fat necrosis. And then the last one I'm gonna go through is so these are tumors which arise um from the breast stroma. They have the potential to become malignant. So 70% of them are benign, but some of them will be malignant when you first um when you first have them diagnosed, but they also have the uh ability to become malignant. If they are malignant, then they are classified as a soft tissue sarcoma and they typically metastasize to the lungs. Generally, there are in patients 40 to 50 years old to quite young. The history will be a rapid growth of a discrete rubbery breast lump. There might be some pain uh just from compression of the surrounding tissue. And again, if you feel a lump, you would re refer under the two week rule and they'd undergo triple assessment and the biopsy would confirm whether they were malignant or benign. Uh But regardless of that, the management is surgical excision with a five millimeter rim of normal breast tissue uh to minimize local recurrence. So it's a rare cancer or rare benign tumor. Um But just one to be aware of. Ok. So we'll move on to breast cancer now. So there's not lots of different types of breast cancer. There's typically breast cancer, which is invasive or breast cancer, which is noninvasive. So this uh is depending on whether or not it's just staying within the breast tissue itself or whether it has spread um to surrounding breast tissue and up into the lymph nodes and onwards. Um and then cancer can be ductal or lobular. And then there's a few rare breast cancers that I'm just gonna touch on because it's important just to be aware of them, which is inflammatory breast cancer and paget's disease in the nipple. Ok. So we'll just start by going over some of the risk factors. Um So most of these risk factors are based on an increased exposure to estrogen. Um So age obviously, as you get, get, get older, you will have had more estrogen in your body being female, having a first degree relative with breast cancer, having previous breast cancer. Um genetics. So BRCA one, BRCA, two mutations, um any radiation to the chest can increase your risk of breast cancer, not having breastfed and also um lifestyle. So excessive alcohol fat intake, which is pretty similar to a lot of um types of cancer. Um There's so in terms of the increased exposure to Eastern, there's also not having Children or having Children later in life, early periods or early menstruation, late menopause can in the length of exposure to estrogen, having HRT with estrogen and progestogen. Um obesity. So, um obesity increases the estrogen levels. Um because there's more fat tissue and this increases um your sensitivity to your your synthesis of estrogen in the body. There's been a bit of debate about whether the combined pill can increase the risk of breast cancer. Recent data shows that there is a small increased risk of breast cancer. Um if you have the pill earlier in life, um but over time when you stop taking the pill, this reduces your risk back down. Essentially. I hope that makes sense. So let's start by having a look at the noninvasive breast cancers. So the first one I'm gonna go through is ductal carcinoma in situ. So this is an abnormality of the cells in the mammary glands. It's confined to the breast tissue. There are four subtypes, but again, I don't think these are gonna come up in exams, but just so you're aware, there's papillary cribriform solid and there's typically no mass on pre presentation, there might be some nipple discharge and some overlying breast skin crusting. Um and they're typically slow growing. So a lot of these are picked up actually on uh mammograms and on. Um yeah, on mammograms. And the next one is lobular carcinoma in situ. So, again, this is a noninvasive breast cancer and it's um cancerous changes to cells inside the breast lobule left untreated. 20 to 30% will become invasive. Um And again, patients may be asymptomatic, they might have a breast lump. Um It just depends on the size of it really. So invasive breast cancer essentially is the two types that we've just spoken about. But they're, they're more invasive in the surrounding breast tissue. They may have gone into the um lymph nodes and spread elsewhere. So, you've got invasive ductal carcinoma, which is the most common and invasive lobular carcinoma. And then I thought we would just touch on the two rare types of um breast cancers. Um because I have seen these come up in S vs. So the first one is inflammatory breast cancer. So it's a subtype of locally advanced breast cancer may present with an erythematous edematous breast and sometimes it can be mistaken for mastitis or a breast abscess because the area is red, the area is hot, it looks infected. Um But typically the patient will be systemically well. So no fever, they wouldn't be tachycardic, they wouldn't be showing any signs of infection. But again, if someone presented like this, you'd likely refer them under the two week rule. Anyway, so they'd have a, a triple assessment. Um and if they haven't been breastfeeding recently, then that makes the diagnosis of mastitis a little bit less likely. So that's inflammatory breast cancer. And then the second one is Paget's disease of the nipple, which I'm sure lots of you have heard about. So, it's quite a um nasty breast cancer. So it's a malignant form of breast cancer. Um Commonly pa patients will have had a ductal carcinoma in situ and then they sort of spread to the nipple and it can present with an ec eczematous like rash. Um the nipple be inflamed, it might have burning sensation and there might be discharge from the nipple as well and sometimes you can have an inverted nipple. Um The sometimes it's difficult to distinguish between eczema of the nipple and Paget's disease. Um So pagets, the symptoms typically start in the center in the nipple and work their way outwards. Whereas eczema starts sort of on the periphery of the areola and works its way inwards and that sometimes can be used to differentiate between. Ok. So this is our last question of the um talk. So this is a patient who is a 72 year old woman who presents to the GP because she's noticed a lump in her breast after investigations. Unfortunately, she's diagnosed with breast cancer. She has biopsies done which reveal the following. So she is estrogen receptor positive progesterone receptor negative and her two negative as well. So what treatment is she likely to be offered? So I will give you a few minutes to go over. Yeah. Yeah. Ok. So a bit split on this one, I'll give a few more minutes before we go over the answer. Maybe just 30 more seconds as it is 10 to 7. OK, we'll leave it there. So 50% of you have said, oh, it's changed. So 42% have said a and Aso and 57% have said D tamoxifen. So the answer is a anastrozole. And this is because this is the treatment of choice for estrogen receptor positive breast cancer in postmenopausal women. So we are assuming here that a 72 year old is postmenopausal. But I think that's a fair assumption to make. If they were 50 51 52 it might be less of a clear cut answer. So let's go over the management of um breast cancers um including the medication that we just mentioned. So there are medical and surgical approaches to treating breast cancer. Uh There are a couple of things that need to be considered when deciding treatment. So most patients will go for their triple assessment, be discussed at um MDT. And in MDT, they'll consider a few things so that they will have staged the breast cancer using TNM staging. So whether or not it's gone to the lymph nodes or not, uh you know, the size of everything like that, just the the the same staging um for most cancers, then the other thing is the receptor status of this. So this will be um determined from the biopsy most likely. Um So progesterone receptor, estrogen receptor, her two receptor and then some people be triple negative. So this is basically whether or not, they um have the the receptors are present on the cells and it can indicate what type of uh medication the patients might respond to patients who are triple negative. Unfortunately, there are less um options available to them. Um and it can limit treatment options. So the reason we do this is because different uh there are treatments which target different receptors. So we need to know which receptors are present. So which treatment will will work. So, medical management first. So and sometimes there is a combination of surgical and medical management and the management isn't specific to the type of breast cancer. And it's more depending on whether it's invasive or noninvasive, how big it is. And that's why an MDT discussion happens first. But the options for medical management. So there's endocrine therapy. So this is um therapy that targets those receptors that we spoke about. So, tamoxifen is commonly used in premenopausal women who are estrogen receptor positive and it works by blocking the estrogen receptors. As I mentioned earlier, increase exposure to estrogen increases your risk of breast cancer. So, by blocking them and you're hoping to shrink the tumor um and treat the breast cancer. And the second option is aromatase inhibitor. So this is letrozole, anastrozole and estane. Um and they can only be used in postmenopausal women who have estrogen receptor positive cancer and they work by blocking um an enzyme called aromatase which converts androgens into estrogen. So, again, decreasing the exposure to estrogen. There are some treatments which are used in the management of breast cancer such as tamoxifen, um or ovarian function suppression might lead to menopause or symptoms in women or early menopause. And so women need to be counseled about this and about the side effects before starting any of the treatments. If a woman is diagnosed with breast cancer, they should stop any HRT um because of because it might stimulate the tumor and it might interfere with any other um therapies. And then H RT shouldn't actually be offered to anybody with menopausal symptoms if they've got a history of breast cancer. Um um it can be used in exceptional circumstances, but this will be very specialist. Um So another medical management is biologics. So if cancers express her two receptor, then you can use a drug called trastuzumab, which is sometimes also called Herceptin. And this is basically a monoclonal antibody which can target her two receptor and then some patients will undergo chemotherapy. So this is either neoadjuvant, which is where you use the chemotherapy before surgery to try and shrink the cancer. And that makes surgery easier. And it also increases the chance of being able to conserve the breast and not have to take the whole breast away. And then there's adjuvant chemotherapy, which can be used after surgery, which tries to prevent recurrence of breast cancer and increase survival. Um And then there's gonadotropin releasing hormone agonists like gin, which can be used in premenopausal women to help protect their ovaries. Um because um sometimes chemo chemotherapy can lead to premature ovarian failure. Um And obviously, in young people, if they want to have families, then if, if the ovaries stop working, they won't be able to have Children. Um So it's a way of sort of protecting the ovaries and then radiotherapy is also recommended to most patients who have an invasive cancer after a wide local excision. Um It's sometimes also used to treat bone lesions for metastatic cancer as well. We need that. Sorry, I know that it's nearly seven o'clock. I just got two more slides. So the surgical management of uh breast cancer. So again, this depends on the breast cancer itself and the decision made at MDT. But one of the options is wide local excision which um removes the tumor with a margin of healthy tissue around it to try and prevent it from coming back. It's used if the cancer is small. Um And again, it's preferred because it conserves the breast itself. The other option is a mastectomy which involves removing the whole breast and the skin overlying it. It's used typically for larger cancers or cancers uh that are multifocal. So if it's not just one tumor, if it's lots of smaller tumors, um it's impossible to do a wide local excision. And the approach can also, so whether you do a wide local excision or a mastectomy can also depend on the size of the breast because even if a cancer is small, um if, if it's small and there are small breasts, you might not be able to get a margin. So it's actually safer to just do a mastectomy. And then something else to just be aware of is sentinel node sampling. So this is um taking a sample of the node intraoperatively with the aim of ruling out involvement in the lymphatic system. So, lymph nodes are located by injecting a radioactive technetium into the nipple on the infected side of the breast with the cancer. Before theater, it travels up to the lymphatic vessel to the first lymph node. And we call this the sentinel lymph node. So this is the most likely lymph node that cancer would spread to because it will be the first one that it encounters during theater. While the patient is anesthetized, you can also inject a blue dye around the nipple. And again, this will travel along the lymphatics to the sentinel lymph nodes. You've got two ways of identifying the sentinel lymph node. The the sentinel node is removed and it is sent to the lab for analysis. If it shows evidence of metastasis, then a surgical clearance of the axillary nodes is performed. Some hospitals have fancy machinery where you can um send the note to the lab during the operation. So the patient won't have to be brought back and put back to sleep if they do find that the cancer has spread to the lymph nodes and then two more surgeries just to uh be aware of. So, breast reconstruction is quite an important part of the treatment. Um And is discussed with the patient. It's a, it's a massive decision to make and lots of women decide to talk to other women about it. Um And it doesn't have to be performed on the day of the operation. It can be performed at a later date. Um But it's quite all of the surgery is a big surgery. So, you know, it takes a lot of recovery. Oh, and they'll be aware of. Um sometimes women might have their ovaries ablated um surgically or with radiotherapy. Uh because ovaries produce estrogen and estrogen um can as you know, um estrogen can increase the risk of um breast cancer. So this can be done to stop the estrogen from, to stop the ovaries from producing estrogen, sometimes rarely. Um surgical removement of the ovaries might occur. Um And this is most common in women who have the BRCA one or BRCA two mutation. Uh because this mutation can predispose to ovarian cancer as well as breast cancer and that's it. So that's the end of the talk today. 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