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Good afternoon, everyone. Good afternoon, everyone. Uh uh uh The topic is uh breast surgery. Uh We, uh this is normally, I do it in the university as a, um, as I say, as a, a small group discussion and uh do a clinic uh and with act test. So even with a patient, if you have the chance, uh it's the important thing is, uh here is, is uh getting the history and then uh um how to give a diagnosis on the same day. Uh and uh breaking bad news uh scenario that should be acted out uh among yourselves. And uh uh that is an important thing to do, uh because this cannot really be done as a lecture. But I, uh but because it is so important to know the, uh, know the protocol, uh we will discuss that. So, number one is that, uh if you have a patient with a suspicious lump uh in the clinic, um uh So, uh, or say that uh in the local GP surgery, uh what are we going to do? Uh uh uh because the patient is really uh uh in distress, uh uh it may not show it and the whole family is in uh uh alarmed and therefore you should handle the situation uh very nicely. Uh So what are the uh uh symptoms and signs that you need to think about? Um, that is a lump, the presence of a lump which the patient possibly felt uh uh in the bath or maybe felt by the partner, um, or seen by somebody during a shower or, or, or something like that. And quite unexpectedly, patient has this sort of lump and the uh uh second one, the patient may complain uh or you may elicit uh is abnormal uh uh discharge uh from the, from the nipple and especially a bloody discharge is important in cancer situation. And then uh uh uh so, uh so the patient may have pain, patient may not have pain but uh any pain in the breast for a female. Uh I is uh important and uh we'll be worried about it. Uh Then of course, deformity, various deformity. We can, we can mention, you know, occurring in the uh skin on top of the breast uh uh lump, obviously a protruding lump or ulceration or uh or uh something like po de ra with the local lymphedema uh due to ligaments of Ashley Cooper uh is uh pulling it in inside inwards uh with the local edema in the skin, uh where maybe cancer spreading onto the skin known as cancer plate, uh uh and Curis and the um uh those dis deformities may be seen, there may be benign deformities as well. You know, there may be uh thrombophlebitis, which we call Mondo disease. Um, uh, and uh various even sebaceous cysts could appear and patient may be very alarmed. Uh, but, um, we are really trying to deal with the suspicious lump. Um, so LAPD, I, uh, you can make a mnemonic if you want, uh, uh, Los Los Angeles Police Department. Uh so lump abnormal discharge, uh pain and obvious deformity. Uh uh Right. Ok. So though if you see that, uh uh you, if you are sus if you suspect this is a cancerous lump, what are we going to do is that the most important thing? And uh just as I said in the colorectal tumors, rectal bleeding? Yeah, you should be seen. That is the protocol in United Kingdom that uh you should be seen within two weeks. If you think it's suspicious bleeding due to a, the rectum in the, in the same manner, if you have a suspicious lump in the breast, that patient should be seen within 10 days. And that is written now into the books, it's known as the 10 day rule and you may be asked the question, what is the 10 day rule? So, uh so, so how you write to the, the uh the consultant and also uh uh you make sure that the letter has been received by the consultant secretary. Um I usually every day, ask every morning, ask the secretary, have you got any, any uh uh any uh 10 day rule patients or have you got any, any two weeks R BC clinic patients? So you have to be proactively uh track these letters is so important because as I said, the whole family is alarmed and uh yeah, and that must be sorted out uh fairly urgently, fairly quickly. So that is what is known as the 10 day rule. And uh then of course, you re you, you, you should see this patient um uh I uh in the uh in, in the clinic and it should be what we call the MDT approach. So, multidisciplinary team should see the patient because it's going to be a one stop clinic uh to give the diagnosis on the same day. Um The most of the uh Asian, I don't know about the African countries that it may not be possible. But uh it, it is so important to do that uh for uh uh humanity reasons, you know, uh and not to worry the whole family for a long, long time. So uh MDT approach who should be in this clinic. So I in this clinic there should be the surgeon and also there should be a, there should be a a radiologist, uh cytopathology should be there, breast care nurse should be there and sometimes the patient gets so distressed. Uh uh We have a psychologist as well to uh, uh especially when you're going to do break the bad news, the, the, the probably psychologist and the risk should be there. And, uh, uh, it is important because you patient don't know what's exactly going to happen because patient never thought about any surgery or even breast uh, up to this uh, terrible moment. So, because, um, I, um, as a consultant didn't know for a long time, the patient think that when you take the breast out, do a mastectomy, there will be a circular ulcer in the chest which I never thought never, nobody told us in the in the um in the uh medical uh college as well. So a patient thinks like that, you know, my breast will be taken out and I have a circular hole. That's my breast care nurse, uh who is the psychologist herself uh uh told me. And so that has to be properly explained that everything will be sutured out and you have a normal skin once the wounds healed up. So uh that kind of uh that kind of uh reassurance has to be given. So uh all those has to be in the clinic MDT approach because you have to give the diagnosis on the same day. And that's why this clinic is called One Stop Clinic. So that is within inverted kma the 10 day rule one stop clinic MDT approach. You will be asked about that separately. Uh Yeah, so you should be able to why, why it is one stop, why it is MDT uh why it is 10 day rule um and how to do that in one stop clinic. So uh so that is known as the triple assessment. You must have already uh seen that in the books triple assessment and you have to say the triple assessment in the clear order. So a history and clinical examination is one assessment. And then the second assessment, you have to be careful that uh not to say uh imaging. Uh no, sorry, not to say fine needle aspiration. So, uh because if you aspirate with the fine needle as a second assessment, then of course, there could be artifacts, there could be bleeding, there will be some uh swelling uh which, which uh then of course, give us a false uh uh um artifacts. So, so it is uh important that you do the imaging next. So what kind of imaging? Uh uh I I didn't go through the risk factors, the nli par, the obesity, the HRT you should know that it is in every book. Um uh uh uh and the uh uh Menno and the uh first uh born child, the periods and the ho ho how many number of periods before you uh have the first child is that is very important. And so um uh so you should do the um do the imaging second uh without disturbing the breast. And what kind of imaging you will be doing. So under 35 you should, that is the s so far accepted rule. Under 35 you do ultrasound because of the gland, the mammograms, you may not see anything through the gland. And also you don't want to uh want to uh radiate the developing breast unnecessarily uh because of the obvious cancer risk. So under 35 you do ultrasound and over 35 you do mammography. Sometimes even over 35 mammography may be because still the pa the patient may be uh sexually active and also the uh breast is too glandular. You may not see much. So you may end up doing mammography as well as ultrasound uh in the over 35 group. So uh the remember that uh who is getting ultrasound and who is having uh mammography. So after that, you do fine needle aspiration cytology. Uh for some reason, uh uh most of the medical students when you ask about this, they say fine needle aspiration and stop. So we'll, we will stop and I look at his face. Uh So you must say fine needle aspiration cytology, the last word should be sounded. Well, otherwise the examiner necessarily get annoyed. So fine needle aspiration. So how do you assess the fine needle aspiration? Sorry, this is not a powerpoint presentation. This is, as I said, it was a discussion. So fine needle aspiration, there will be uh C one to C five when the re when the report come back, normally the report comes back. Uh Well, after the morning clinic is over, we ask the patients to go and have a uh have a meal in the canteen downstairs. And uh then we will be uh looking at the cytology in the meantime. Um uh and the uh uh so uh cytology C C, we will be divided into C 1 to 5, C one means uh either aspirate is not a, not adequate, just blood and some cells came. So, C one is inadequate. Uh aspirate. CC two is oo obviously benign, benign cells, you know, the, so uh uh uh there are no change in the cells. It uh they are, they are uh properly uh uh uh co with a normal cohesion. So that's the one if you, if you put a needle in uh and uh if the cells doesn't separate and they break and the nuclei come out to the cells, we call that we use that word bare nuclei. That means cells didn't separate, only the nuclei came out because you broke into the cells. So that is a good sign. So uh bare nuclei is a good sign. So, uh so because the cells didn't separate, so that is C two, C three, maybe uh uh difficult to say uh there, there may be benignity but uh there could be some atypical cells. C three. So not too sure. So, C four will be obvious malignant cells with hyperchromasia, uh various things that you know about malignancy, different kind of cells. Uh and the uh uh the uh there are no bear nuclei in it and uh the uh there are different separate cells in the, in the, in the aspirate. And uh and then of course, too many um malignant cells which will be C five totally uh anaplastic cells in the C five. So that is how you divide that cytology and uh uh uh into C one to C five. to give the report of C four and C five are malignant uh CC three. you have to repeat the test and if not, maybe do a core biopsy uh because without uh definite uh uh uh malignant uh cells uh or uh uh uh w when you do a core biopsy, obviously, that is histology. So uh that is how you do the c then, of course, uh uh uh the uh the uh the uh uh uh so we uh so that is the last uh last of the file assessment. Then you correlate with that with the uh whatever the uh imaging you have done and sometimes imaging is used. Uh And then you do the biopsy. If it, if the uh uh if the tumor uh is not palpable, there may be just uh microcalcification, which is a sign of malignancy, uh necro maybe not. So, um then you have to break the bad news and so you have to have the appropriate stage. Uh uh So I think you can go to the internet and look for spikes protocol, spikef spikes protocol. So that is probably so far the best. Uh we use that to uh set the stage and make sure that uh the uh the uh uh that you are not looking at computers, uh You are not looking at uh your uh to go to the next hospital for your private practice and you have a total concentration on the patient. So that stage should be set. We have a special room for this uh uh besides the clinic uh with flower vases and all that, you know, and, and we uh we sometimes ask, ask the patient, do they want to have a relative in the room? So find out the perception but the patient know until now, you know, remember that uh we did this test uh uh this morning. Uh you know why we did this et cetera and the patient may say yes. Uh uh I think you probably suspect something uh serious uh in my breast. And that's probably why you saw me so early as well. So the patient may be already prepared. So the uh the patient's current understanding is important before you start uh bombarding with your, with the, with the knowledge that you have medical facts. The uh the uh uh the, the language should be uh fairly clear. Um You cannot just go on saying, uh, uh, well, you know, it doesn't look nice. Uh, you know, it, it is a lump, it is a tumor. If it is cancer, I think you'll have to say that is a cancer and the empathy is important. Uh, the patient may start crying and, uh, that is one of the scenarios we act out, uh, sometimes in, in our exams and how you deal with this thing. Um, the patient may start screaming. Uh, I don't want to live anymore. Uh, you know, the, the, the, uh, what is the point of surgery? They will come back? I know that my next door neighbor died, et cetera. Uh, the, the, the, what you have to do is that the empathy is I, uh, important. You, there is something you must never say, you must never say I can f uh, II, I know how you feel. You don't know how you feel, you know, how you don't absolutely know how you, how the patient feel. Er, you, what you must say is to say, I think most of the politician if you take. Oh, yes, we know how you feel. It's so bad, er, et cetera but you don't know how you feel because you are not in the same situation. You know, I'm not in Sudan, I'm not in Ukraine. I don't know how you feel. I don't know how you are, how worried you are et cetera. So I must not say that I know how you feel. So it is it annoys the patient sometimes. So, but the relationship with the patient has to be maintained quite well. So what you can say, it must be terrible for you. Coming at this time, your daughter just got into the university and your husband got a new job, you know, and you built a new house and must be really bad. Uh You know, you must be feeling bad but we we you will receive the best available treatment. So you have to have the uh you have to be ready uh the uh to tell the patient if you think the patient needs a say that after colorectal cancer, if the patient need uh uh need uh to see the oncologist for chemotherapy radiotherapy, I normally go and ss uh book this appointment before I break the bad news maybe here. Of course, you can't uh because you just got the information. But if you had the information already, I go and talk to the oncologist and I will tell the patient he uh uh mister so and so uh doctor so and so will see you in next Tuesday at two o'clock. So I have booked the clinic for you but uh not in this scenario, but that is the thing about breaking bad news. You have to have the the strategy al always uh boo to know. Another thing is that I if the patient has had a uh chest x-ray, uh sometimes uh your registrar order, the chest x-ray and you must make sure, you know, you know, that the patient had another x-ray and the patient may, may not be interested in the breast lump, but she is more interested in that x-ray done this morning. And you can say what, what x-ray that's is really bad. So if the patient, so you have to click everything in the, in the notes uh in the clinic notes, x-ray is done, you know, s uh the uh cytology done, et cetera. So, and then you must tell exactly what happened. You know, you, you can, may, maybe patient was coughing and uh bringing up something uh uh bad phlegm and you may have done x-ray uh just to check everything is OK. So, uh but you must see that because the other patient may be more interested in, in, in that. So, uh uh OK. Anyway, uh uh as I said, I'm the triple assessment. I'm not going to go through that again. Uh So, but make sure when you talk about it, uh get the right order clinical examination uh and then imaging and FN AC and make sure you say fine needle aspiration, cytologic, please don't stop at FN A. That really annoys me because I'm waiting for the next word because it is cytology you are interested in. Um the uh uh OK. So uh as I said that this is, this is not a really a lecture. This is a, a scenario. What? So what uh so if you found a lump in the, in, in the breast, you have to decide on surgery. That's what I am. I want to, I want to uh give the message. So what uh surgery will you do for this patient's particular lump? So it is this individual patient's particular lump. Uh What are you going to do? Because uh every surgery does not fit the patient or even the lump. So, uh so you have to decide what actually you are going to do. So what are the kind of surgery, what are the kind of surgery you do to a breast? So, there are two areas in, in breast lump. Uh you do surgery. Uh So one is breast itself and the other one is axilla. So uh the, and sometimes the axilla, axilla surgery will be uh will uh will be decided uh aside from LEC, make sure that they are mutant, please. Ok. Right. Uh So, uh uh so uh uh uh sorry. Uh the, so what are the type of surgery you are going to do to this particular patient and this particular lump? So I said there are surgeries for the breast and surgeries for the axilla. So, uh uh there are three types of surgery you do to the axilla and about three types you do to the to, to the breast. So, what are the three types of surgery you do to the breast. So the uh ma mastectomy, let's uh one is mastectomy. The other one is wide, local excision, wle mastectomy, wide local excision is. So the other one is, is depends on whether you feel the lump or not. So, what are we going to do? I, I'll, I'll, I'll, I'll get rid of that first because that is not the most important one that we don't have to do it often. But I will talk about that first. Uh So if you cannot feel the lump, what can you do? And you may see just microcalcification. So you have to localize this. So, and uh how do you localize to get rid of that lump? So I think the way to do is to needle localization, there is one fine needle uh uh uh in a sheath, you put that into the lump and then uh the end bends once you've taken the sheath out, out of the, out of the breast. So it bends around the microcalcification and you leave that uh and, and, and, and do your surgery and take the lump out uh uh in that manner. So they are going to be small, they don't need mastectomy. So you localize that. So needle localization and leaving the needle behind, excise the whole thing and take the whole thing out with the needle and send it for the word is contact x-ray. So anything you do uh any, any, any organ, any any lump, you leave it on the plate, not the patient. And that is known as the contact x-ray. Sometimes you may be asked, write short notes about contact x-ray, I think contact x-ray. That is one and the other one is the uh the is the kidney uh to look at the stones inside it and you can put a plate just around it and take a picture locally. Uh People do that kind of thing as well. So contact x-ray is right? The um uh uh so that is one we that is a rare thing we do. But you should know if you can uh for microcalcification. What what can you do? So, the mastectomy. So what patients will have uh mastectomy? Uh OK. Um uh I don't think I can find that slide. Uh But anyway, we'll talk about that. So one thing is that if the lump is larger, we say usually a small breast lump is large. Usually this come to 3 to 4 centimeter lump in a smaller breast. Obviously, you will have to do a mastectomy because uh you can't just leave a sleeve of breast that is ugly and in human to leave anything like that. And uh you do a mastectomy um for that patient, what is the other group of patients? So other one is if the lump is placed in the uh uh nipple areola just under the nipple areola complex, then of course, you cannot really take out the middle. Although some Scandinavian countries do that, then I don't know how they stitch that up. But uh uh in the UK, we, we do a mastectomy for those patients. So uh uh so that is the second group, anything under the nipple areola complex. Before the deformity, you will be leaving uh uh uh in such an operation. So you do a mastectomy. What is the third group? Multicentric tumors? So, not one tumor. I think the last one I did, I think we had three tumors in the same patient confirmed. And of course, we'll have to do a mastectomy for these patients. So, uh so widespread uh multiple uh Multicentric tumor within the breast, you will end up doing a mastectomy. What's the other one? If you do the other operation, which is the wide local excision? And although we mark the uh the superior aspect, inferior aspect, the axilla aspect and, and medial aspect, we still uh leave sometimes a tumor behind and it's very difficult to go back and locate it. Unless the breast is very large, then you may be able to take uh a sleeve out. Uh but uh it's a bit messy and it's best to do a mastectomy. So that is the fourth group uh uh residual tumor following a wide local excision. So, what is the other one? The uh the uh sometimes the patient will say that uh I like to get rid of the whole thing because I am uh patient may be psychologically upset and uh maybe a, a family member has had a small operation and had recurrence. So she will say so, patient's choice is the fifth group. Um So we have to some pe people come and say uh uh they have heard that if you do a if you do a mastectomy, you may not need radiotherapy, the chances are less. So some people say, I don't want radiotherapy, I want the whole breast out and without radiotherapy because in, in certain countries, there's a special hospital and uh and the they don't want to go there because they will think somebody else will see and sometimes it is horrendous. They may not have told their Children and they may not have told their husband or relatives and suddenly they found themselves in, in the cancer hospital and they will be worried about it because these operations can be done uh in normal, normal general hospitals. So, uh patient may not want to um the relatives, the next door neighbors uh to see her going to the cancer hospital to have radiotherapy because radiotherapy is only in the cancer hospital in certain countries. So, uh so patient's choice is, is the last group, maybe there are other groups in like, you know, inflammatory carcinoma with uh which in the books they describe it is spreads like uh uh wildfire uh and possibly better to have a mastectomy done. But that, that is very, very rare. So, uh so those are the five groups that who should have uh uh who should have a, a mastectomy uh uh during the mastectomy. Uh before I forget you have to do a, a uh receptor receptors. So what are the receptors? We do? Uh we do uh the uh uh er receptor estrogen receptor. And also we do uh uh pr receptor progesterone receptor. Uh we do itchy uh uh her two receptor and you should know what is her two means because sometimes you may know about it but you don't know how to describe it. It is, it is a bit embarrassing. So uh human epidermal growth factor receptor. So make sure that you actually uh actually know uh the name of the receptor K I uh 67 is another one that we do in certain countries, not every country has it. Uh Also uh uh it is important to get all the four receptors done. And a lot of people, a lot of students ask me why, why you do a er receptor? Because you are really not uh treating according to that receptor. That is not true because if er and pr uh both uh uh pr receptor I'm talking about. So that's why you do PR receptor. So, so er receptor obviously you give tamoxifen. So uh uh be because if both are positive uh the, the, the uh uh tamoxifen Nolvadex treatment is, is, is 70% effective. So that, that the uh you can almost prognosticate using that uh pr receptor, um her two receptor, her two new, they call it as well. I don't know why they call it new uh because it can be treated with Herceptin some Zuma. So something like that. Uh it's very expensive. Again. Uh for us, I think we need to get the uh permission because expensive, but it's a very effective treatment if the the receptor is positive. Uh hm. Right. So, OK. So uh uh so that's the receptor uh be before I forget you, I normally forget to tell about the receptors. So uh uh it's very expensive treatment uh expensive to do receptors. But if you get it done in the National Health Service, then of course, you can get it done free. Uh So, so what are, what is the other type of surgery? We said wide local excision? So all the things not applied to uh mastectomy. You do, you do a wide local excision? Uh So uh uh so you know, small, small tumor, et cetera, et cetera, not under the nipple lala complex. Another one who come to the nipple areola complex is obviously the uh the page's disease. So, because it erodes into the nipple lala complex. So uh you normally end up doing a mastectomy for those patients. So, Paget's disease where there is nipple area like eczema type situation with an underlying carcinoma of the breast. So, Uh So, so we just talk, finished talking about that uh about the breast. So, three types of surgery, wide local excision, um mastectomy and uh for un palpable tumors where there is microcalcification, especially Choo carcinoma is the, is the one which gives more prominent microcalcification uh that uh you do need localization. Uh occasionally uh uh there is a thing called uh uh mammotome uh which uh you uh with I in the department, there is some department has it with the breast hanging through a circular uh opening. And then you do get, get the whole breast on the screen and you see the microcalcification, you put the mammotome on the local anesthetic and co out just uh uh co out uh the uh the the area and send for histologic uh uh uh and uh uh so for mammotome. So, uh but again, that kind of thing uh very rare. Uh uh OK. Right. So axilla, axilla. So what are we going to the axilla? So, uh uh there are two type of surgery we initially do to find out whether I need axillary clearance. Why do you do clearance? It gives a, gives a prognostication uh as well as you can decide on the treatment if the nodes are positive. And um uh there's a question about where, whether you need any axillary surgery for uh in situ carcinoma. But uh again, uh still people debating on it. Um Some of some, some countries don't do uh ax clearance uh or axillary, any, any axillary surgery if they are not clinically palpable. And also it is in situ carcinoma, maybe they are, they have a point. So, um uh uh so what are the type of surgery you do to the axilla? One is the um sentinel node biopsy. I'm sure it, it came into practice uh for Melanoma mainly. Uh then eventually they applied to the breast. So you inject a dye as well as this isotope uh beforehand around the tumor. And then of course, uh you open the axilla, put the G counter and uh see or you can uh uh gamma camera, you can see that it is going uh uh making the sound proper sound. Uh And uh so what is the sentinel node? That is another question you would be asked, that is the first ever draining node from the tumor. So it could be one, it could be two sometimes at the same time, it may go into two lymph nodes. So, but we still call it a sentinel node. So uh you take that out if it is negative, no need for any clearance. And the um uh the other one is the uh you do axillary node sampling. Why we are, why are we going so reluctant to go to the axilla because of lymphedema? And then I have a uh lecture on lymphedema, but I'm not doing it because we haven't got time to do that. Uh uh So uh in order to avoid the serious discharge for months and seroma uh formation, we try not to do the axilla unnecessarily. So that's why we are doing sentinel node biopsy. So the uh uh the axilla uh the uh uh so the other, other operation is uh before that I must talk about a bit of anatomy which is L1, L2 L3. Remember that, those, I'm sure you all know that because you can see in the nodes, L2 dissection uh uh uh oh nobody just L1 dissection. L1 is the area. We take 44 nodes and the uh uh four nodes. And if that is negative. Uh So it is simple, uh simple node biopsy uh from L1 area. And if that is negative uh axillary node sampling is known as axillary node sampling, you take four nodes, make sure you have the four nodes. And if that comes uh negative, you don't need to go and disturb the axilla. Uh we never go to L3. So L1 is outside, one is outside L2 is behind the pectoral is minor and trees inside. So uh proximal to the pectoral is minus. So, remember that uh you may uh you may be asked what is L1? What is L2? What is L3? Because you need to uh uh sign the consent. So, uh uh so L2 dissection. L2 clearance. Uh nobody goes to L3. I normally put my finger into the axilla. And if I feel a lot, no, I try and remove it because I know it is uh it is, although it is dangerous uh because there are a vein, et cetera, et cetera there. Um You may cause some nerve damage but uh gingerly you can take it out but uh you must uh uh possibly warn the patient that you may get swelling of the arm or seroma developing postsurgery. So, uh uh so L2 clearance is the one that everybody does provided. Sentinel node biopsy is positive and the uh uh uh and the axillary node sampling is positive the, the four nodes. So uh so that is your axilla and the uh the, the uh you may have seen this type of surgery, wide local excision and mastectomy. Um and sometimes you may have seen the Sentinel node biopsy as well. So, remember uh so that is the uh uh so one stop clinic. So go through the book today. So go through what is one stop clinic. What is, what is the uh what is the uh 10 day rule? Uh And what is MDT Clinic? How to tell the uh C one to C five cytology and then of course type of surgery, three types of surgery to uh uh breast, three types of surgery to axilla. So, so uh that is a summary. So, what uh uh needle, a needle localization biopsy or mastectomy or right local exci for the breast and for the axilla sentinel node biopsy and the uh uh axillary node sampling if one of those pass you go and do A L2 clearance. So, so I hope that is clear. That's the message I want to do. Uh please make sure whether you can go and conduct AAA form of a clinic and the uh uh and, and uh, how to tell the bad news. Uh I made a, made a, uh for my, uh, my students, I made a little, uh DVD but I can, I'm not allowed to give it to anybody else, uh, or even put in the uh youtube, uh therefore that remains in the university uh bank. So you, that's all I wanted to say today. Um, and we uh will meet again with colorectal cancer just to talk about with the surgery. So any questions now you got to 15 minutes. You can ask any questions you like. Thank you very much doctor. I'll just end the recording and then anyone can ask any questions.