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Hello. Hi, everyone. Welcome to the breast session today or the session on breast surgery today. Um If any of you can hear me, please shout out in the chat. So I know that you guys can hear me. Okay. Perfect. So we'll give it a couple of minutes before we start. We sort of have uh heavy ish session today, I guess just because there is quite a bit to cover in breast surgery. Um but it should be all good. So let's just give it a couple of minutes. Um I've just uploaded the slides and the video for the ophthalmology session. So hopefully you guys can see that once this session is over. Hopefully, hopefully it should be up by now. Yeah. Okay. Right. It's a nice day. Um Got quite a nice topic in store for us today. Um And you guys have a lot of, you have probably done this before, but in case you guys haven't, I'll just run through an overview of this session. Um So we've got MCQ questions and a bit of my own question sort of taken from passing it to cover major themes. And then as usual, you guys will interact using the polls. So I'll release some polls after each question. So you can have a try and then we'll discuss and go through the explanations for each question together. Um Of course, you can talk through the chat, ask me any questions in the chat. Um And again, thank you so much for, for your time today. So let's get cracking. Um, uh, hold on right. So quick. Anatomy recap. Okay. So, um there are two breasts on each person. Uh and the breast usually consists of the nipple at the very top, the areola and then within the breast, it consists mainly of fatty breast tissue with the ducks and the lobules, which is where milk is or you know, breast milk is produced in the lobules. Okay. Underneath the breast tissue, you have the pectoral muscles, the pectoral muscles and then the chest wall. Um So presenting complaints in breast disease. Um Can you think of what people would most commonly present with or some of the things that people with breast disease can present with type it in the chat if you know. Yeah, breast lump, yeah, lump pain and discharge. I would say those three would be, would be the top ones. So a breast lump pain, nipple changes or nipple discharge, skin changes. Uh and constitutionally what I mean by constitutional like weight loss, fever, fatigue is what I mean? Okay. So what would you, what would you ask about a lump say a patient comes in presenting with the lump. What would you ask them? Mhm. Yeah. Mastitis is one of the, one of the things we will be talking about today, but essentially with a lump. Yeah. How long they've had it for? Um, basically what I use for lumps is I use Socrates for lump as well. So where is it? When did you first notice the lump? Um What was the character of the lump? Okay. Is it soft or hard, smooth or irregular radiation? So does the lump move or is it fixed to the skin or the surrounding structures associated symptoms? Um Yep, Charmaine. So cyclical would be under time course. How has it changed over time? Is it there all the time? Uh If it's pain, if I hope that's what you mean by cyclical cyclical pain? Um Very good family history. Um e exacerbating that the lump appear after an incident like a trauma. Um I'll explain later why that's relevant. And then if there is pain severity of the pain. But yes, family history of breast cancer. Um Okay. So let's say if a patient presents with pain, you basically just Socrates, the pain and Charmaine mentioned it before. They're cyclical pain and non cyclical pain. So, cyclical breast pain is worse during ovulation uh in menstruating movement and it's always usually not sinister if it's cyclical pain is almost always associated with menstruation. Non cyclical pain can be things like injury and trauma, musculoskeletal pain, mastitis and something else you definitely shouldn't miss called inflammatory breast cancer, which is rare, but it's something you must rule out for any patient's presenting with pain in their breasts. Okay. Question about nipple changes or discharge. So you have to make sure you ask about the color. How much discharge is it in one or both nipples? Is there nipple inversion? Is there or is there exematous changes in the nipples? Okay. Um Question about skin changes. You you should ask about erythema, ulceration, dimpling. There's a, there's a, there's another word for dimpling. Does anyone know what it is? It's a French word. M breast in, in breast problems. Yeah. Put a ranch. I always pronounced it as peut orange until someone who's someone who who actually reads, corrected me on it is pronounced food orange. Okay. And that's what you do ranch looks like. It looks like an orange. You know, there's dimpling on the skin and the skin changes color as well. It becomes more tan which is why it's called food orange. Now, other questions constitutionally should ask is fever, weight loss, malaise lymphadenopathy. And these are standard questions you ask in, in almost any history. Okay. So that's just a quick summary of what you were asking someone with with breast symptoms. Okay. So we'll move on to question one. Any questions can just ask in the chat. Let's give 60 seconds for this one. All right. 20 seconds. Okay. I think quite a few of you have answered. So I'm happy to continue on. Okay. So if we look at the question, 28 year old woman who gave birth two weeks ago, and she presented to the G P with two days of right breast pain and a tender area that feels firm, warm and swollen and it looks erythema tous. She had reduced milk output, which means she is breastfeeding, but the output isn't great. So if you see a woman breastfeeding, tender breasts warm um and swollen, this more likely is pointing towards a diagnosis of messed itis. Okay. So when someone with MS Tight, someone presents with mastitis and it's the first presentation, you always try to continue breastfeeding normally first. And when I say breast feeding, normally you have to make sure that they're expressing milk effectively. Okay. Um That's what they mean by breastfeeding. In this case, they have to express milk. Um So yeah, so that's the first line for, for mastitis. Um Now really quickly, um how do you differentiate mastitis from breast abscess? Because they can, they can present similarly okay. Um For for mastitis and breast abscess. So they both present with tenderness, erythema, warmth and swelling of a part of the breast and both can be due to breastfeeding. However, mastitis is inflammation of breast tissue alone, but there's no collection of pus due to infection in a, in a, in a in mastitis. Okay. Whereas in breast abscess, there's an abscess there. So there's puss within um within the breast tissue itself. So how you can tell the difference is in a in mastitis, there may not be a fluctuate lump, but in a breast abscess, there tends to be a fluctuate lump, which means the lump can be moved around and you can feel the liquid within the lump. So patient's with breast abscess also tend to present with more systemic upset. Okay. So they tend to be sicker there, there, there tends to be more pain. They tend to have a fever, raised white cell counts, raise crp basically signs of systemic upset, maybe even sepsis in some worst case is okay. Um So if someone presents and you're not really sure which is which just perform an ultrasound scan, you should be able to see the the abscess on an ultrasound scan. Okay. So, mastitis and breast abscess can present similarly slight changes and to confirm one or the other, you do an ultrasound scan. Okay. Now, quickly on mastitis is inflammation of the breast tissue typically associate with breastfeeding. Yeah, we've talked about this. So it's when you're not expressing milk. So when milk stasis happens, that's when inflammation, that's when it can cause inflammation to the breast tissue. So, we've talked about this pain and tenderness, red and hot symptoms, difficulty expressing milk. So the first line is to continue breastfeeding. Okay. That's the first line for mastitis. Continue breastfeeding. When would you, when would you put them on flu cloxacillin in which is antibiotics? When would you think? Like? Oh, okay. All right. I'm gonna put this, I'm gonna put her on foot clocks. Um, well, you could, well, you would, yeah. Well, yes, you can do aspiration and culture, but I was more thinking like you would do it after they've tried breastfeeding for about 12 to 24 hours, essentially. Okay. Um, so when symptoms don't improve after 12 to 24 hours of effective milk removal, that's when you would consider the use of antibiotics. And yes, you would do an aspiration and culture as well. But if they are systemically unwell, you wouldn't delay it. You just give flu clock Sicilian, why if they're allergic to penicillin, well, you just give them a rhythm Eisen and it's flu cloxacillin for 10 days or a rhythm izing for 10 days as well if they're penicillin allergic. But yeah, I think you do do an aspiration in culture as well, but it shouldn't delay actually giving antibiotics in this case because usually mastitis almost always caused by penicillin. I think it's like staff, mostly, mostly staff that causes it. So any, any penicillin flu called Sicilian definitely is the is the right choice in this case. Okay. So hopefully that makes sense. Ok, really quickly on breast abscess as well. So we talked about this collection of pus causing bacterial infection or the area of the breasts, same thing as mastitis, but systemic upset is more common and there's a fluctuance swelling as well. So the management for a breast abscess is you give antibiotics and then you need to actually drain the abscess itself. So you can use a fine needle aspiration or you can use um an incisional drainage as well. Okay. So you need to refer to the on call surgical team to do those. Yeah, you could you do an ultrasound to confirm the breast abscess drainage of the aspiration and then sensitivities and cultures of the aspirated fluid, right? So that was a bit on mastitis and breast abscess and how you can differentiate between the two. Now, question too. Okay. Let's do 45 seconds from here. Alright. 10 seconds. All right. Okay. Let's talk about it. So we've got a 30 year old lady with three week history of worsening erythema over the left breast. Okay. That's the key there worsening erythema over the past three weeks. So that's subacute, it's not chronic, it's not like slow and it's not immediate as well. So it's subcut. So she's not breastfeeding and feels otherwise. Well. So the question is sort of pushing us away from something like messed itis because mastitis is heavily associated with breast feeding and she says it's not painful as well. M est itis is usually painful but it has not resolved. Now, the breath is, the breast is swollen and has marked erythema. No discharge, no nipple changes no mass. Her vital signs are normal and she's apyrexia also immediately you can sort of rule out cellulitis and mastitis because those are infective mechanisms or infective conditions. Okay, fibroadenoma as and Paget's disease of the breast will talk about it later on. But basically, the patient also has erased C A 153 level, which is basically the tumor marker for breast cancers. And what this patient has is basically describing a very severe form of breast cancer called inflammatory breast cancer. Okay. It progresses really quickly is uh it can be um it's a oncological emergency. Okay. This this lady needs to be seen ASAP for management. So what is inflammatory breast cancer is a progressive form of breast cancer caused by obstruction of lymph drainage by the cancer cells itself. Okay. So the cancer cells in the breast actually block the lymph drainage and that's what's causing all the symptoms and the rapid development of symptoms as well. So you get progressive erythema or redness and a Dema of the breast. It can be painful but sometimes can be painless as well and there's absence signs of infection. So no fevers, no discharge, no elevated white cell counts and no CRP. So that pushes away from all the infect. It causes like breast abscesses and mastitis. Okay. So the management urgent referral and then um the mainstay is chemotherapy and you need to remove the breast with a total mastectomy. But plus radiotherapy and this is what inflammatory breast cancer can look like. Okay. It's just redness spreading throughout the breast. So we've talked a bit about some of the some of the conditions that can cause breast erythema. Okay. So on the right, you see red and tender lump, pour milk expression and breastfeeding. So that's have a think about it. It's mastitis, okay, red, tender and fluctuate lump with systemic upset. That's an abscess, okay and rapidly progressive red and tender breast plus edema. That's systemic uh sorry uh inflammatory breast cancer. Okay. Now, question three. So just just to be clear, these are the ones that present with erythema but they can present with other stuff as well like pain and stuff. It's not just erythema. Okay, but these are some of the conditions that have that have erythema. Right. Question three. Okay. 40 seconds from here simply because we've got a lot to cover. So sorry lads have to shorten the time. Mhm. Okay. 10 seconds. Okay. Let's talk about it. So we've got a 52 year old lady presenting to the G P. She notices a lump on the left breast and associated with green nipple discharge. Now, I can tell you right now that there's only one thing associated with green nipple discharge in uh in in breast related conditions. Okay. Um It's not discolored or hot to touch which one of the following conditions will be most likely to cause it's okay. So they're also pushing you away from something like, um, an abscess or a mastitis from this case because it's not discolored and it's not hard to touch. Um, but it is tender. Okay. So when someone presents with a green nipple discharge and you don't think it's mastitis or breast abscess, it's almost always duct act asia. So, what is duct ectasia? We'll talk about that in a bit. Okay. So, let's answer this first 30 seconds from here. Okay. A few more seconds. All right. So now this question is just a lead on from the last question. Okay. So 55 year old woman presents with creamy nipple discharge. So green nipple discharge is always associated with Doctor Act Asia. But doctor ectasia can also present with brown nipple discharge and creamy nipple discharge as well. Okay. So it's green, brown and creamy nipple discharge can be associated with Duct Act Asia. Um So her mom mammography, screening mammography, mammography, I don't know how, but the screening is normal. Okay. Clinical examination is reassuring repeat mammogram. Um Also no abnormalities and the prolactin is normal. Okay. So it sounds like this. This person has a duck tacked Asia as well. And for most duct act Asia's, most of the initial treatment is simply reassurance. That's all you have to do. Okay. So the reason they measured the prolactin is because high prolactin can cause galatasary A as well and, and creamy nipple discharge as well. So, but in this case, they ruled out a prolactinoma essentially, okay, which is why it's duct Act Asia. And the first initial treatment is just reassurance for decked ectasia. It usually goes away by itself, right? So what is duct ectasia is basically dilatations of the ducks in the breasts? Okay. It's a benign condition. Um So when the ducks are dilated, they can also get inflamed as well. Uh and that can lead to discharge. Um So this is inflammation of the ducks, not the breast tissue like it was in mastitis or a breast abscess. Okay. So act Asia means dilation. Um and it's most frequently in you can be most frequently seen in perimenopausal women. Okay. So symptoms of that checked Asia includes, well, most commonly it's nipple discharge and nipple discharge is either green, characteristically green, brown or creamy. I I don't, I really hear creamy. It's usually green or brown for, for Doctor Ectasia and it's the nipple discharge. Okay. You can get tenderness or pain as well and you can feel a lump in the Act Asia as well. And but there's usually no redness unlike mastitis and breast abscesses. Okay. So just remember duct act Asia green or brown nipple discharge management usually resulted that any treatment, no increased risk factors of breast cancer. All right. Ok. Question five, 45 seconds. Alright. 10 seconds. Okay. Right. Let's talk about this. So we've got a 42 year old woman. Now, the first thing you see is that she's got discharge and his blood stained. Now, not a lot of things cause blood stained discharge in a breast condition. So it's either breast cancer. So breast cancer can cause blood stained discharge. But more characteristically as soon as you see blood stained discharge from the nipple, you're immediately thinking an intraductal papilloma. Okay. The prompt also says the appearance of the breast is normal, there's no overlying skin changes. Um and they see a fixed and tender lump as well. The fact that the lump is tender sort of pushes it away from cancer as well. Okay, because breast cancer tends to be painless. That's why breast cancer is dangerous because a lot of people don't notice it. So it's a tender lump and it's got um right underneath the nipple and it's bloodstain, you're immediately thinking intraductal papilloma. So what is an intraductal papilloma? It's basically a growth within one of the ducks due to proliferation of the epithelial cells. Okay. It's a benign tumor and can be associated with breast cancer, but it's not cancerous in itself. It causes unilateral bloody nipple discharge. Okay. The same with Doctor Ectasia as well. Doctor Ectasia and intraductal papilloma, both are usually unilateral. It would not be bilateral, um can have tenderness can have a lump. Um But the the key thing is the bloody nipple discharge, unilateral bloody nipple discharge. Okay. Management is usually um patient's will still need referral as well just to rule out breast cancer. Um and surgical excision of the intraductal papilloma as well. And then the tissue that is excised from the papilloma will be um will be seen under a microscope for for any cancerous changes. So, from this, we know that any patient presenting with bloody nipple discharge always needs, always need a referral okay to the breast clinic. So just remember that bloody nipple discharge almost always intraductal papilloma, but they still need to rule out breast cancer. So any bloody nipple discharge still needs a referral for breast clinic. Okay. Question six. I'll talk a bit more about what happens in a breast clinic after this 45 seconds. Yeah. Alright. 10 seconds. Okay. So let's have a quick look at the question. Okay. So in G P, there's a 15 year old female. So she's quite young and she's complaining she's complaining of nipple discharge bilaterally, which means that it's not something that's um it's not something that's just within the breast is something more systemic because it's bilateral okay. And the volume is small and there's no masses palpable. So it sounds like she's just going through some hormonal changes and having some physiological discharge. Okay. And this can be um this can present quite commonly in young female, young female patient's okay. So the answer is hormonal changes. So physiological discharge um associated with hormonal changes especially during puberty and breast development uh involves multiple ducts and systems is bilateral. Usually it's bilateral, clear nipple discharge. Okay. Um there's no treatment necessary. It is just a normal process of uh it's just a normal physiological process. Okay. So, we've talked about nipple discharge now. So there's unilateral bloody discharge, which is intraductal papilloma, unilateral green brown or creamy discharge. That's duct checked Asia and bilateral clear discharge, which is physiological discharge. Okay. No question. Seven. All right. Okay. 30 seconds. Okay. Yeah, I think most of you would have gotten this one. Um Right. So let's go through the question. The thing that really stands out here is that it's a well defined two centimeter mobile mass as soon as you see the word mobile mass, more or less it's pointing towards one thing and that's a fibroadenoma in this case. Okay. She's pretty young as well. Um She's pretty young. There's mild tenderness and there's no skin discoloration or discharge. Okay. A mobile lump always, almost always a fibroadenoma right now. Quick one, this one is another follow up question on a fibroadenoma as well and this one has to do with the treatment. So, really quick question, I won't spend too long and this one probably another 20 seconds. Okay. Okay. All right. Okay. So let's, let's move on from this. So she's got a fibroadenoma in this patient and it's measuring 3.5 centimeters in diameter with clearly defined edges. Okay. So usually for a fibroadenoma, if it's less than three centimeters, you can just leave it alone and it'll usually regress by itself, but because this one is more than three centimeters, um you can refer her for an excision biopsy to remove the mass. So that's the answer in this case. Okay. So, fibroadenoma is basically just a benign growth of the epithelial duct tissue. And it's sometimes it's sometimes called breast mice because they are mobile. Okay. It's common in slightly younger women between 20 and 40 years because they respond to estrogen and progesterone which had the female sex hormones. So, symptoms of a fibroadenoma, their painless, they're smooth and they, they're mobile. Okay. That's the key there. Mobile there. Uh the masses firm and smooth as well. And in terms of management, if it's less than three centimeters, you can just leave it alone and if it's more than three centimeters, you can exercise. Okay. So that's a fibroadenoma and there's no increased risk of malignancy as well. Okay. So this is a quick one question nine. Uh this is gonna be sort of like a spot diagnosis essentially for the next few questions. So 30 seconds for this one. Okay. Okay. Five seconds. Zheng Jinjing, well done. It is fibrocystic disease. Okay. Fibrocystic disease. Um it's not necessarily a condition, it's more of a variation of normal physiology. Okay. So the connective tissue, the ducks and the lobules in the in the breasts are very receptive to female hormones. So they can become fibrous and cystic and they fluctuate with menstruation cycles because men menstruation cycles change the hormonal changes in uh in the body. Okay. So you wouldn't get a particular mass but you get more lumpiness of the breasts because of the fibrosis of the connective tissue. You can get tenderness and in pain as well. And you can even get changes in breast size in fibrocystic disease. Okay. Um, aside from supportive stuff, there's not much you can do for fibrocystic disease. Um you can use a warm compress for the pain and say it's for the pain and wearing a supportive bra uh to help with the with the pain as well. Okay. That's all you can do for fibrocystic disease. Another spot diagnosis, 15 seconds. I'm sorry if I'm going really quick, but I do want to finish on time today just so that I don't hold you guys back. Okay. Well done. The key here is hitting the coffee table table as the same spot as the lump. So this lady has a history of trauma or localized trauma to the area where the lump is. She's also obese as well, which is a risk factor for fat necrosis. Okay. So what is fat necrosis is basically what it says on the tin. It's necrosis of the fatty tissue that causes scarring of the fatty tissue in the breast. Okay. And it's commonly triggered by trauma, radiotherapy or surgery. Uh and it causes an inflammatory reaction that leads to fibrosis and necrosis of fat tissue. Um And in obese women, there's just more fat tissue, which is why they're more susceptible to inflammation in necrosis as well. So, the symptoms of fat necrosis can present very similarly to breast cancer. So, regardless of the symptoms, even if you think it's fat necrosis, people will usually be sent for a referral anyway, if they have fat necrosis because it presents with a painless lump that's irregular and firm uh and it's fixed to local structures. So that sounds very much like breast cancer, doesn't it? The only difference is that it's got a history of trauma uh in this patient. But otherwise you would still refer them for um for a referral for a breast clinic. Okay. Um Yeah. So you still need to rule out breast cancer with fine needle aspiration or biopsy. Uh you still need to do an ultrasound and a mammogram. Okay. All right, fine. Another spot diagnosis. I think this is the last one that's like this. Hopefully or maybe there's one more. All right. 30 seconds. Alright. 10 seconds, last few answers. Okay. So a few of you answer like poma as well. So like poma if is basically a it's a benign tumor of fatty tissue that's not necessarily within the breast. Okay. It can, it can, it can arise anywhere on the back. It can arise in the neck, it can arise um on the sides of your torso as well. But lipoma's are not usually fluctuation and they don't usually present in the breast, which is why lipoma is not the answer. It's smooth and fluctuate and it's a painless lump which means that there, it sounds like there's some fluid within this lump. So it's a breast cyst is the answer. Wait. Did I show you guys the answer just now? Oh, no, I forgot to add. Okay. Well, the answer is breast cyst but yeah, sorry about that. I didn't realize the answer was, was literally showing. Okay. So it's a benign fluid filled lump and it's the most common cause of breast lumps, especially between 30 to 50 years. Okay. Now, the thing is the thing about breast cyst is the most common lump. You can feel that it's fluctuating. Uh You can feel that it feels like a breast lump like a breast cyst. But you still need to send them for a referral. Okay. You still need to send them because they still need to rule out even the slightest possibility of breast cancer. So it's usually smooth, well circumscribed which means it's not irregular. Um it's fluctuate which means you can feel fluid within the lump and it can be mobile but isn't always the case and you can have pain there as well. You still require a referral for, to rule out breast cancer and if it's painful, you can use aspiration to, to, to get rid of the cyst essentially, okay, may slightly increase the risk of breast cancer as well. Okay. Last last spot diagnosis for this one. I didn't show you guys the answer in this one. Thank goodness. But I do think the answer is pretty obvious. Oh, no, wait, I didn't give options. Okay. Never mind. Type it out. Type out what the type of what you think it is. Uh Sorry guys. I, I don't know how I forgot this but yeah, just type out what you think the answer is. Yeah, it's breast cancer. It's classic. Um The lump is hard. It's irregular and it's fixed and there's also retraction of the left nipple as well. So yeah, it can only be one thing. The big see the big see breast cancer. Okay. So here are some symptoms of possible breast cancer. Okay. So you get heart immobile lumps. They tend to be painless. You can get nipple inversion, bloody discharge, skin tethering, put a ranch adenopathy. Um you can get weight loss, malaise and bone pain. So if they get bone pain, that's when you know that it's, it's quite late. Even weight loss is quite late. Ok. Bone pain means that it's metastasized to the bones. Um That means it's usually they're, they're, they're, they're usually in for palliative care at that point. Okay. So it's not, not a nice thing to experience. So we've talked about breast lumps today, okay. A smooth for mobile breast lump. So if it's mobile, it's a fibroadenoma. If it's irregular firm lump and can be fixed history of trauma, that's fat necrosis, lumpy breasts. As you do as soon as you hear lumpy breasts is fibrocystic disease, irregular firm fixed lump, skin changes and tethering. That's cancer lump with green brown discharge. That's duct Act Asia. Now, I know Dr Act Asia was in nipple discharge, but it can present with a lump as well. And then lastly smooth fluctuate, well, circumscribed lump. That's a breast cyst. Okay. So you guys will get the slides at the end after you feel in the feedback form. So don't worry about it. Question 13. Okay. 60 seconds for this one. Mhm Yeah. Sorry if I'm rushing through the first part because I kind of want to focus the parts at the end, which are quite important actually. Okay. Okay. Got 10 more seconds on the clock. All right. Shall we talk about this? Okay. So 32 year old woman presenting with a lump in the right breast, she has no past medical history. The lump is small firm nontender in the upper left quadrant of the patient breast. Okay. The remainder of the best examination is unremarkable so that they don't, they don't give us a lot of information in this uh in this question. But the key thing here is any patient that presents with a breast lump or an an unexplained breast lump will require a referral. So it doesn't matter what age you are anyone, almost everyone who presents with a breast lump, it's unexplained and they need a referral for it. Okay. That's, that's what I that's what I take away from, from, from this question. Okay. So almost everyone above the age of 30 requires an urgent referral to the breast clinic. Now quick, quickly for question 14 before we go on into the referral criteria. Mhm. Yeah. Let's give this 30 seconds or 25 seconds. Okay. 10 seconds or even less than that just so that we can talk about this. Okay. So we've got quite a split. Quite a lot of you went for safety netting and routine referral and I can see why patient has a mobile well delineated lump. Okay. So it sounds like it's just a fiber adenoma and you don't need to do anything for a fiber adenoma, but it is a lump nonetheless. So remember I mentioned before, everyone who presents with a breast lump will require a referral regardless of their age. So the only two things that can happen when a patient presents with the breast lump is they either get a routine referral or or an urgent referral? Okay, because yes, it feels like a fiber adenoma. But can we actually prove it? What if it actually turns out to be cancer? Okay. Yes, it's unlikely because it's mobile, but it can still be early signs of cancer which is why every patient who presents with a lump always gets a referral and unexplained lump. Okay. Even if you think you know what it is it's still unexplained until you properly investigated. So any patient presenting with a lump is either a routine referral or an urgent referral. That's it. Okay. Yeah. So it's a in this case because the patient is less than 30 years old, they qualify for a routine referral to breast clinic. Okay. So for urgent week wait referrals, patient's who are aged over 30 and have an unexplained Breslin with or without pain, get a two week wait referral or patient's who are above the age of 50 um and have unilateral nipple discharge, nipple retraction or nipple skin changes or skin changes anywhere on the breast. Okay. But it has to be unilateral if it's bilateral, it means that there, there's more likely to be, it's more likely to be a systemic cause. So only if it's unilateral nipple changes that you refer for a two week wait referral and even then it's in patient's over the age of 50. So for non urgent referral is basically um any breast lump in patient's less than 30 years old. Okay with or without pain. So what happens when you get a referral? So I I've been saying you refer all these, all these people for, for, for, for a breast clinic. But what what what happens when they get a referral? What happens at the breast clinic? What's it called? What do they get if anyone can tell me on the chat? Yes. Yeah. Boy, they get a triple assessment So what are the three assessments in a triple assessment if anyone knows well done? So it's an examination uh and history, a mammogram and a biopsy. Okay. So it starts off with the clinical assessment by the breast specialist. Um and then they do imaging. So in terms of imaging, you can do a mammogram, you can do an ultrasound scan as well and you can do an MRI scan as well. But the thing most people do is a mammogram and mammograms are usually used for older women because older women don't have very dense or glandular breast tissue, which is why mammograms are good, are good for it because it goes straight through but for with more dense tissues. So younger patient's um a lot of the dense tissue can actually show up on x rays and it can mask what's behind it. So for patient's with who are young or less than 30 they tend to use ultrasound scans, okay. Um And it's, it's a good, it's a good, it's a good uh investigation to rule out sort of like breast abscess is because they can ultrasounds are very good at differentiating between solid and liquid tissue, sorry, solid tissue and, and sort of fluids. So it's good for ruling out things like breast abscesses, for example. And then MRI scans is only if, if required. So if they need to assess the size and the features of the tumor or the location of the tumor then they can do an MRI scan, but usually it's mammograms. And if you don't know what, how a mammogram looks like, it's basically just an X ray for your breast. So they squeeze the breast in between two plates like this and then they do one oblique. So you get the entire view of the breast from the two pictures. Okay. So that's what, that's what a mammogram is. Um So biopsy uh is basically taking a piece of tissue from the suspected cancer and having a look at it under the microscope. And there's two ways to do this. You can do a fine needle aspiration um or core biopsy. So fine needle aspiration is to get a sample of fluid, but it's not great if you want the best results, you would do a core biopsy which is literally taking a piece of the cancer and looking at it under a microscope. So what can you tell with a micro with a, with a car biopsy under a microscope? What does it tell you? What can it tell you if anyone knows? Just type it in the chat? Yeah, that's one of the important things about core biopsy. It can tell um if the cancer itself is receptor positive for, for um for any of the, for any of the hormones essentially. Okay. So you can tell the type of cancer, the grade of cancer, the invasiveness of the cancer and the hormone receptor expression of the cancer. Yeah. And the cell architecture as well. Um And there's also something called a K I 67 proliferation marker. You don't need to know this, but it's basically how quickly uh a cell divides. Uh and they use it as um to measure the prognosis, sort of of the cancer. Okay. So a car biopsy is definitely better, always go for a core biopsy instead of a fine needle aspiration because it just gives you weigh more information. Um Right. So what would show up on a mammogram of breast cancer? So let's say someone has breast cancer and they go through a mammogram. What would that mammogram show? What would you see on the mammogram? Yes. Tunisia calcification. More specifically microcalcifications. Okay. Microcalcifications can be normal in, in, in breasts. Um So, but in breast cancer, the micro calcifications will be clustered up in a specific area of the breast. Now, that's for early breast cancer. If she's got established breast cancer, you would just see a mass, you would just see a whole calcified mass. But for a lot of people who have mammograms, um they, they tend to present early so they have microcalcifications. And what I mean by that is if you see on this picture, do you see the small white dots at the bottom of the picture? So those are microcalcifications and they're clustered together. It's not a few bits here and there that can be normal, but it's when they're all clustered and there's way more of them in one place. That's when you're worried about early breast cancer. Okay. And on the right, you can see just a very clear picture of established breast cancer on the right. Okay. So that's what you see on a mammogram. Now. Question 15. Okay. 30 seconds from here. All right. 10 seconds. Okay. Now, let's talk through this question. Okay. So 52 year old female presents female patient presenting to GP with rash over her left nipple. She's got no past medical history. No family history. The brash is a rhythm Ettus. Um and there's no changes to the areola which means it's just on the nipple itself. Okay. So the nipple is the is the tip and then the aerial is the is the skin around it. Okay? Skin around the nipple. So in this case, what what might be going on in this patient? Can someone tell me what are we worried about in this case? That would that would that might require an urgent referral? Mhm Yeah. So you're worried about Paget's Paget's disease. That's what we're worried about. And so let's talk a bit about Paget's disease. Okay. So it's basically a cancer affecting the nipple um and it can be invasive or institute which mean which means it's just, it's just within their um inflammatory breast cancer wouldn't present with exematous changes, Tanisha. So inflammatory breast cancer just presents with um the progressing redness and erythema that we mentioned before. But for pageants, it's the rhythm. It is the eggs, immitis, nipple changes. That that's what we're worried about. Okay. So you get like eczema on the nipple and it can spread to the areola. But how can we differentiate nipple eczema from Paget disease? So, nipple eczema can have eczema on the nipple as well. But how do we, how do we differentiate? So I realized my internet might be a little slow. Uh Well, pageants. Yes, that's why I was looking for Oscar. So um for pageants, it starts in the nipple and then spreads to the areola. But for um nipple eczema, it starts in the areola and then spreads to the nipple. Okay. So if paget's, it spreads from the nipple to the areola. So that's how you tell the difference. Okay. So nipple eczema starts in the areola and spreads of nipple pidge. It's Paget starts in the nipple and spread to the areola. So the management is with the rest of the breast cancer. You, you send them in for a referral, they will need a biopsy, they'll need a mammogram and then they'll go down the same treatment pathways as the other breast cancers as well, right? So let's talk a bit about the types and the classification of breast cancer. So there's two ways you can classify breast cancer and that's through the tissue, okay, the tissue involved. So that's either doctor tissue or lobular tissue. You can also classify them by their invasiveness or whether they're invasive breast cancer or breast cancer institute, which means it doesn't spread from the local tissue that there initially in. Okay. Um So you get invasive carcinoma carcinoma institute. So the types that we should know for our level is lobular carcinoma institute, invasive lobular carcinoma. Doctor Carcinoma Institute and invasive doctor carcinoma. And one of the most common types of breast cancer is the invasive doctor carcinoma. And because it's so common people call it the no special type. Okay. And the rest of them are called special type. So, Doctor Carcinoma Institute, invasive lobular carcinoma. Popular Carcinoma Institute, they're all special type. Only invasive doctor carcinoma is called no special type. I don't know why they decided to use this naming system, but I just know that it exists. Okay. So other types you need to know that we've talked about already include Paget's disease that we've talked about just now. And initially at the start cysts um inflammatory breast cancer. So these are the other two that we should know about. There's a bunch of other types of cancers that are very niche and very specific, but we don't need to know that for now. Okay. Question 16. We're almost done. I will be able to finish on time today. Let's give this 40 seconds from here. Oh, um I'm going to send in the feedback forms because I realize it's already eight uh in case any of you need to go. Um, please do take the time to fill in and if you have time to stay, uh, it shouldn't be very long after this, hopefully. Okay. Okay. Right. So, let's talk through the question. There's a 45 year old presenting with three cm breast lump. They've gone through the triple assessment and then investigations of the histology show an E R positive cancer confined to the breast. Okay. And they're asking, what is the next step of management? What's the next step? So I know a lot of you would have gotten tricked out by this because er positive immediately you're thinking tamoxifen. But the next step is to actually remove the breast cancer first. So you actually all breast cancers need to be removed first before you do any extra stuff. So it's a wide local excision, white, local excision just means that you remove the cancer within the breast with wide margins around the, around the, around the cancer itself. Okay. So that's what you do in this case. So breast cancer management, you're always most, if most breast cancers that have not metastasized, that have not metastasized, that have not metastasized will require surgical um excision. Okay is the first line for most grades of breast cancer when a surgical excision not indicated, I mentioned it before. Metastatic breast cancer and breast cancer affecting more than 10 notes or stage three C essentially. Okay. And there are two types of surgical excision. So, there's wide local excision and there's the feared mastectomy. Okay. So, when do we have to do a missed a mastectomy instead of a wide local excision? Because a lot of women would like to do a wide local excision. You know, it maintains a lot of breast tissue, it's less invasive. Um, there's less recovery time for a wide local excision, but when would a wide local excision not be appropriate? When would you do a mastectomy? A mastectomy instead? Okay. All right. So you would do a mastectomy when there's multifocal breast cancer? Uh Yes. Yes. Exactly. So, if the tumor is, yeah, big lump on a small breast, correct. So if there's a large cancer or if it's small breasts or if the location of the tumor itself is in a difficult location, um then they might have to do a, a mastectomy. Okay. So when you do a wide local excision, what other form of treatment is required for every wide local excision? What else do you have to do? I'm sorry. I realized my internet is probably a bit slow. So if you guys typed in the answer, it might, it might take me a while to, to actually see the answer. I apologize for that. But yes, what form of treatment is usually required for every wide local excision? So you would do a full breast radiotherapy, okay. Like a whole breast. You need to give them radiotherapy. Yes. Correct. Rightly. Um And this reduces the chance of recurrence by two thirds. Okay. Because previously, when they didn't do radiotherapy, um, the recurrence rates would be surprisingly high for a wide local excision. And the only way to bring it down was to do concurrent radiotherapy. So now, as long every wide local excision has to be accompanied by radiotherapy, a whole breast radiotherapy. Okay. That's just the, just the, that's just the guidelines and that, that's the way it is right now. Um after a mastectomy, radiotherapy is not always needed. Although you can give radiotherapy after a mastectomy, it's not always needed like a wide local excision. Okay. So patient had a wide local excision and there is recurrence in the same breast. So the recurrence is small and not multi focal. So what is the next step? So, patient had cancer in the right breast. They've had a wide local excision to get rid of the cancer and now there's a bit of recurrence. It's just small. What do we do? Okay. If any of you know, if not, it's fine, I'm just gonna move forward just because I don't wanna spend too much time here. So you basically have to do a mastectomy. Yeah, you have to do a total um mastectomy because why, why do we have to do a mastectomy? Why can't we do another wide local excision? The the the the tumor is small and it's on the other side of the breast, not on the other breast, it's on the same breast, but it's on the other side. So we can get rid of it through a wide local excision. But why can't we do it? Okay. It's because remember I told you every uh not, well, not really Riley. Hmm. Well, I guess there's that, but the main thing is, remember I told you every wide local excision required radiotherapy afterwards. So if you give the same breast, the same dose of radiotherapy as you did last time, you actually severely increases the risk of other cancers. So like soft tissue cancers can um can form because of all the radiotherapy you're giving to that area. So that's why you can't do too wide local excision. Aside from the stuff you've you've mentioned before, there's a higher chance of recurrence. Yes. And risk of metastases. Yes. Um So having a mastectomy not only reduces the recurrence, but it means you won't need radiotherapy. And that's, that's important because you don't want to increase the risk of other cancers as well, right? So on examination during triple assessment, there are palpable lymph nodes in the axilla of a patient with suspected breast cancer. So, what's the management plan? What would you do for this patient? Mhm. Yeah. Sentinel. Well, well, no, no, no, you wouldn't do a sentinel node biopsy because because you can feel the lymph nodes. Okay. So if you can feel palpable lymph nodes, you don't actually need to do a Sentinel node biopsy, you can just straight away um go for an auxiliary note clearance. Okay. So, primary surgery, it can be a wide local excision or a mastectomy. But you do an axillary node clearance as well. One of the complications of an axillary node clearance is arm lymphedema and functional arm impairment. So you can imagine axillary node clearance is basically you just tearing away at the lymph nodes and getting rid of all the lymphatic ducks. So all the lymph has nowhere to to flow to okay. Which is why some a lot of patient, well, a proportion of patient's can get arm lymphedema. So if you go to a breast ward, you'll see a lot of patient's with swollen, left arms or swollen right arms. And that's because they've had auxiliary note clearance on that side of the breast essentially. Okay. And they always say things like, oh no, don't use this arm for cannulation because oh because it's the, it's the bad arm according to them. But I think recent studies have shown that it doesn't matter which arm you cannulate is the same either way as long as they get, as long as they get what they need. So yeah, that's a bit on um axillary know clearance. Okay. So what hap what happens if there's no palpable lymph nodes? But on pre op ultrasound, the auxiliary of the auxiliary, they suspect lymph node involvement. So uh this is when you would do a sentinel node sentinel node biopsy. Okay. So previously you felt the nodes okay. And if you can feel the notes in the axilla, you just proceed straight to an axillary node clearance. But if you don't feel the notes, it, if there's no is that if there's no palpable lymph nodes in the axilla, you always do a preop ultrasound, okay. If there's notes axillary clearance, if there's no notes that can be felt, you do an ultrasound and if you find something suspicious on the ultrasound, then you do a sentinel node biopsy. Okay. And basically what a sentinel node biopsy does is they inject um dye into the, into the lymph nodes and then uh the sentinel lymph nodes are basically the closest lymph nodes after the primary lymph nodes. Okay. So if the sentinel lymph nodes have the dye, um you can identify it, take the sentinel lymph nodes out and then look at it under a microscope. And if there's cancerous changes in the sentinel lymph nodes, that means it's more likely that the cancer has spread to other lymph nodes as well. So hopefully, that makes sense. The sentinel nodes aren't the primary notes there, the notes after the primary notes. So inject dye identify the sentinel notes, take the sentinel nodes have a look at it and see if it's cancerous. If it is, then there's a high chance that there's axillary involvement and you would do an auxiliary node clearance in that case. Okay. Hopefully that makes sense. That was a bit of a mouthful. I've got a summary of what you do if you suspect lymph lymph node involvement here. So, don't worry about it. Right. Last question, last question. Let's see, 45 seconds from you. Uh Again, if any of you have to leave, please fill in the feedback forms first if that's okay. All right. 10 seconds. Okay. Now, we've got a lot to digest in this one. Well, not, not that much, but the answer is actually a nest result. Okay. So if we go through the question, it's a 47 year old woman diagnosed with breast cancer. Why? Local excision with whole breast radiotherapy? Okay. And the tumor is estrogen receptor positive. So it sounds like this. This lady needs tamoxifen right estrogen receptor positive and she's only 47 but she has a past medical history of premature ovarian failure, which means she's gone through menopause. Okay. So that has a big impact on which drug you use for hormonal therapy. So, let's talk about that. So, hormonal therapy, when do we use hormonal therapy? When the breast cancer, the one we took a biopsy of comes back as estrogen receptor positive, which means there is estrogen receptors on the cancer cells and they react to uh they react to estrogen. Um estrogen stimulates the growth of the grant of the cancer cells. That's what happens in these cases. Okay. So what is the function of hormonal therapy is to dampen the hormonal production of estrogen in the body and reduce stimulation of the cancer cells. Okay. Now, the to hormonal treatments available are tamoxifen and a no anastrozole. Okay. Now, tamoxifen is a selective estrogen receptor modulator. And basically it's used in premenopausal women. So why is it used in premenopausal women? Is because it blocks estrogen receptors in the breast and stimulates receptors in the uterus and the bones. Um so in premenopausal women, a lot of the estrogen is produced by um the uterus. Uh and the yeah, a lot of it is produced is it produced by uterus way. Well, it is external production of the of the estrogen. So basically just blocks the receptors in the breast but stimulate receptors in the uterus and the bones and other parts of the body. So it's good for patient's who are premenopausal because it only targets the breast. Okay. And because it's a stimulator for estrogen receptors in the bones, they actually are protective against osteoporosis. Okay. The disadvantage is with all the estrogen active on the other parts of the body, it actually increases your risk of venous thromboembolism. Okay. So that's tamoxifen. Tamoxifen is used for premenopausal women. It blocks estrogen receptors in the breast but stimulates estrogen receptors everywhere else in the body. Because of that, it prevents osteoporosis but increases the risk of A B T E. Now the other one, the answer to the previous question for the patient who was postmenopausal is called an aromatase inhibitor. So, what aromatase inhibitors do is they inhibit aromatase, which is an enzyme use for the process of arrow matiz ation, which is the main way, postmenopausal women get their estrogen. Okay. So, postmenopausal woman don't produce estrogen from their ovaries anymore. Um so they, they rely on a process called Ara Matiz ation to produce estrogen. And that's what aromatase inhibitors do. They just inhibit and they just inhibit that. Now, the downside of aromatase inhibitors is because that's since that's the only way um that's the only way postmenopausal women get their estrogen. It actually causes increases the risk of osteoporosis, essentially. Yes. Tamoxifen does increase the risk of endometrial cancer as well because because of the high estrogen content. So yeah, it does increase the risk of endometrial cancer. Um Yeah. Okay. So I know it's been sort of, it's not as direct today. It's a lot of me leading the teaching just because I feel like there's a lot in breast that you just need to cover in a quick amount of time. Other notes that I would have a lot of that I included in this one is Herceptin, which is a biological um biological agent called trust eczema. Um And it's used for tumor's that I heard two positive, which is basically just another receptor expression in breast cancer. Okay. Another topic I didn't get to include in this one was breast screening, but it's definitely something you guys should look into. It's pretty easy. People from the age of 50 to 70 basically get breast screening every uh every three years essentially. And it's the same thing as um and it's basically just getting a mammogram. That's it. They just get a mammogram or an ultrasound. They don't need a biopsy, but that's basically breast screening, 50 to 70 years old every three years. Ok. Um And yeah, so thank you so much for attending the breast session. I was just sort of like a quick run through of all the topics within, within breast. Thank you so much for staying. Um So I've sent another feedback form. Hopefully you found the session today helpful. Uh Again, I'm really sorry, I had to rush through quite a big part of it. Also felt kind of kind of very directed today I feel. But yeah, please feel in the feedback forms and do leave your feedback if there's anything you think I could have done better for this session today. Um Yeah, I'll stay for a few minutes if any of you have any questions. Um But yeah, hopefully that was helpful. I know I kind of skipped through. I kind of went like just just quick run through off a lot of the conditions. So hopefully it all made sense. Um But yeah, join us for our next session next Tuesday on E N T. So Josh will be, will be giving that talk and I'll be around to just to just help out. No problem, no problem. The superior of the surgical specialties. Well, it is pretty nice being in the N T you don't do a lot of nights in the N T. Um, a lot of the cases are elective. Um, occasionally you might need to sort out airways, but honestly, that's about the ENT is a good lifestyle, not going to lie, but it is very competitive to get into. Now. It's very, very, very competitive. So any of you are looking to get into ent, start prepping, start prepping. All right. So I think I'm gonna call it here. If any of you have any questions, please feel free to email me. I've had a few of you already email me regarding slides. Um, happy to send you guys any of the slides if you need it. Um Just, just drop me an email or Joshua an email and then we'll be more than happy to do that. If you don't have our email, you can join us for our next session and you can chat with this there. Okay. Again guys, thank you so much for your time for today and I'll see you guys real soon next Tuesday. Have a nice evening, everyone.