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Hi, everyone. Thank you so much for joining. Um We'll get started in just a couple of minutes. Um Hi, 21 has just joined. Um We'll get started in a couple of minutes. Um Hi, everyone. Thanks so much for joining. Um We have quite a lot of stuff to get through, so we'll start now. Um Yeah, so thank you so much for joining. Um So if you haven't been to any for tutorials before, um we do weekly tutorials based on UCL. Um year five topics and year four topics, but it's applicable to all anyone who's doing the UK MLA. Um all our slides reviewed by doctors and they're taught by medical students and yeah, we do it every week. So um hope to see you guys at further sessions as well. Um So today we're gonna be focusing on the breast and um so these are all the UK MLA Testable breast topics broadly um including the niche ones. Um something that people often forget about as a technically breast topic is galla because I think um most UK Malay platforms, things like plasma and sma normally talk about it under um endocrinology more so So just keep in mind that it is something to do with the breast. So it's worth going over even if it's not something um that you do. But if your year five exams, for example, are on breast, just keep in mind that's something to look through um today, however, rather than doing everything, um I've just picked these ones to do just so we're getting good overview of um what are the more high yield ones with breast? Ok. Um So what we're going to start off with is benign lumps and pains to do with the breast and we've got three cases. So 19 year old with a single painless lump, 38 year old with multiple painless painful lumps on both breasts and 2323 year old, bilateral breast pain without any lump. So, um what would we want to ask her? And I'm going to start off by saying giving the first thing that we can ask her. So, um let's start asking if any changes during menstruation. So anyone have a guess for case one? So just drop it in the chart. What are you expecting in terms of changes during when she has a period? Are we expecting a change or not a change for case one to the 19 year old with a single painless lump? What do we think? Any ideas enlargement and worsening? Ok. So we're saying case one, we're thinking enlargement and worsening. Ok. What about case two. So that's the 38 year old with multiple painless lumps on both breasts. What do we think? Here it is or even case three. So for case two or case three, any or case one, any further ideas of what we'd expect just to do with um periods, so that it doesn't necessarily have to be during the period of time, just any fluctuations you might expect um throughout the menstrual cycle. What do we think? So case 12 or three, any further ideas? OK. So, well, we thinking, so I'll start us off by saying the case one, no change during period. And definitely when they say case three could be linked to periods more painful during period 100%. Um So case one, we're saying no change during periods and then case two and case three, we think it's going to be worse during a period. So let's keep that in mind whilst we're thinking about what final diagnosis is the case one was saying no change during period. OK. How do they feel? What do you think? So in terms of if you were to palpate the lump, what would you be expecting? So that's the same thing. Such a case 12 or three, would we think feab 100%? So very mobile robbery, non tender. Definitely case two. Any other ideas? Oh case three, what do we think? So case three, I guess isn't applicable because we don't have a lump. But for case two, any ideas. So if one we said probably firm and rubbery anything we could guess for case two. So I'll tell you the case too we're thinking. Yeah, definitely. So fluctuant mobile and fluid filled. Perfect. Ok. So case three, no focal point of tenderness, nothing in specific to palpate. Ok. So case one any idea. So putting everything together. So case one is single, painless, no change during periods and it's mobile robbery and non tender. What are we thinking? Any guesses? Fibroadenoma? Perfect. Lovely. So a fibroadenoma we commonly refer to it as a breast mouse. So that basically means it's mobile, the most commonly unilateral. It's literally just adenoma just means benign clumps of breast tissue. And that's very common during development and it's the most common cause of breast lump. So if you ever got a question and you're not sure where to go with the breast lump, that's your best bet because it is the most common and between 18 to 25 year old as well. Ok. So done fibro adenoma. Case two, what were we thinking? Any ideas? So case one was fibroadenoma, fibroadenosis. Lovely. So, fibroadenosis is basically fibrocystic disease. So it's most commonly gonna be bilateral painful and fluctuant. It's it's commonly known as lumpy breasts. So you present bilaterally just with lumps on your breasts, but these are painful. They are fluctuant. It's the most common cause of breast pains. That's something to keep in mind, if you've got a painful breast, if you're just really not sure your breast g middle aged woman and it's caused by more ovulations and obesity. So that's things like late menopause, late first child, no prior. So overall width, breast, a lot of things are related to more ovulations or fewer ovulations. So remember, more ovulations means, OK, you started your period sooner and you've had menopause later. So that means you're ovulating more. You've had your first child late and you've not had any Children because while you're having, whilst you're pregnant, you're obviously not ovulating. So just remember that, but a lot of things, it's about ovulation and those are the things that are going to change how much you ovulate. Um If you're having trouble remembering out of these two, which one? Um is the bilateral one? Something that like a small thing I think about is like fibro aoc. So it's like cys, so you've got two of them. So think of it as bilateral if that helps. Perfect. And then number thr three, what are we thinking? So bilateral, no lump, worst drawing period, any ideas they called massage? Perfect, lovely. So that's gonna be young, females, intensity varies by phase of cycle, no focal point of tenderness. So these are your most common benign lumps and pain. And if you can remember these, then these are the most common as well. So you're going to be pretty good. OK. So in terms of investigations. Um We'll get on to kind of two week waits and non urgent and all of that later. But in general, if you were to have investigations for these, it's gonna be an ultrasound mammogram and you're just gonna have an oval, lobulated and circumcised kind of lesion. These ones a common thing you'll see in like passed or ques questions as a halo appearance. So that makes sense, doesn't it? Cause you've literally just got a ball of fluid. So it kind of just lands up looking a bit round and it's fluid filled and then three, there's just no focal lesions because there is no lump. So that's, that's the results of your investigations in terms of what we can do. So case one, what are we thinking? Keeping in mind it's single, it's painless and it doesn't change during periods. What do we think? Or if anyone wants to give case two or case three as well, any ideas of what we can do? Yeah, monitor or basically, yeah, we can monitor it but nothing unless it's really big. Absolutely. Perfect. Brilliant. And you guys have got the exact centimeters as well. So we can excise that if it's more than three centimeters, but if it's less than three centimeters, there's really no need to do anything. But definitely you, you might want to monitor it. Case two. So it's just gonna be simple, analgesia supportive measures. You can self massage and, and that can help and you generally want a safety to everyone. It's really symptomatic, then you can aspirate recurrences and keep following them up and then case three. So you can just do things like supportive measures. Again, oral, topical analgesia. And then if you've got no response to conservative measurements, then you can start thinking about things like hormonal agents. Lovely. Ok. Um So now we're getting on to the more delivery related things. So 28 year old, 17 days post delivery with bilateral breast pain. So in terms of what we would want to ask or start us off. So we're gonna say she's other what she tells us she's otherwise. Well, baby's doing fine, slight fever, breasts, feel hot, red, swollen and tender with improvement on feeding. So what are we thinking? What could be going on? So if you want to give me two differentials to start with? So keeping in mind that she's breastfeeding and it is painful, but it improves on feeding mastitis 100%. Definitely. Ok. So everyone's thinking mastitis lovely. Ok. So I'm gonna introduce two differentials. So we've got mastitis like all of you guys said and breast engorgement. So let's talk about both of them. So what it is in mastitis is inflammation of breast during breastfeeding. Very, very common and breast engorgement is congestion of blood and fluid in breasts due to milk production, take care in lactational mastitis. Remember it's just inflammation. So there's no change or no real change after feeding and you're just gonna be gonna generally not be very well and you're gonna be pyrexal breast engorgement because you've got that congestion of blood and fluid in breast because of the milk production, you do tend to see some like significant improvement on feeding and there may be slight fever. So for this lady, if she told us that there was significant improvement on feeding. Um what do we think for her? Which one? Engorgement? Perfect. And hopefully that does that difference. Hopefully, that difference makes sense that if they're specifically telling you that it gets considerably better with feeding, it makes sense with the pathophysiology, doesn't it? That because you're removing the milk production, there's less congestion. Lovely. So for this one, we're probably thinking engorgement because it's improving on feeding and in terms of what we can do, there's not too much just conservative. So hand expression of milk. That's the best thing we can do for these ones. Ok. Another scenario. So we've got a 32 year old female, 34 post delivery. She's got a mass this time. So stop feeding as returning to office. Mass is painless. Fluctuant, mobile, slightly tender. Otherwise. Well, what are we thinking? So mass, but it's painless. It's fluctuant, it's mobile. What could it be? And your dips. So we've been through perfect. Lovely. So galactocele. So we've been through two of the differentials. We were talking about mastitis and engorgement. This isn't giving a picture of either of those. We're definitely thinking galactocele. Lovely. So all that is, is just a build up of milk in dos when stopping breastfeeding. And she's telling us she stopped feeding because she's returning to work a very common scenario. Lovely. Um in terms of what we can do again, not too much. So, non symptomatic, we can just self massage and safety net. If it's symptomatic, you can aspirate and then just follow up and imaging if required. Lovely. What do we do if a lady wishes to stop breastfeeding? So any pharmacological interventions, anyone can think of any headaches, dopamine agonist. Lovely. Perfect. So um stopping lactation reflex. So that basically means just not having the reflex will be triggered by an infant um at the breast. So stopping that well supported bra and dopamine agonist. An example is cabergoline. That's the most commonly when used. The reason I've got a picture of the cabbage there is that if it helps the way I can, I sometimes remember it is a cabergoline kind of sounds like cabbage. And if you think about cabbage, it's quite dry. So it's kind of like all the milk has gone from it like you stop the reflux. Um Something in general to remember is the association between dopamine and prolactin. Um If you're struggling to remember that one like a very random way, I think about it is like, oh you're breastfeeding, that sounds quite painful. You're probably not too happy about it. Um So it's just that's a random way to remember it, but in general remember that um association because that means if you wanna stop prolaxin, you need to increase dopamine similarly, if you're taking dopamine um antagonists for something. So what's an example where you might be taking dopamine antagonist, any headaches? So it can be a variety of reasons but um won't go into them too much. Yeah. So things like schizophrenia and things like that. Um But anything where you've got, yeah, and emesis basically all of those kind of scenarios. Um So a common side effect in those cases is gonna be galacturia, isn't it? And I'm not gonna go into galactia too much. But that's just a association to keep in mind that that main association between prolactin and dopamine. Lovely. Ok. Um Different scenario, 28 year olds still post delivery breast pain. She's got fever, she's got a painful tender right breast and not any significant improvement on feeding. So this time, what are we thinking? We've mentioned this one quite a few times and I think you guys have given it as a differential quite a few times as well. What we think mastitis? Lovely. Perfect. It's giving a very typical mastitis picture, isn't it? So, 10% of breastfeeding women um have had mastitis. Um So it's very, very common. Um And our first line is just gonna be continue breastfeeding, warm compresses, milk expression, analgesia but something very important to remember is continue breastfeeding. Because if you stop breastfeeding, it makes sense that if you stop breastfeeding, you've already got that information. You've got milk building up, it's just gonna get worse. So you, you want to tell them to continue breastfeeding question is when to give antibiotics. So what do we think? Are we gonna give antibiotics to everyone or some people only? So, I think by the phrasing of that question is probably always, I'm trying to suggest we don't give it to everyone. Um So we only give it in certain scenarios and um yeah, perfect. So, systemic symptoms and the way I remember is like when you're thinking about mastectomies and reconstruction for breast, you, you think of breast flaps. So just forget about the L and that's your pneumonic for this one. So you'd give it if there's a fissure, you'd give it if they've attempted conservative management already and it's not got better. There's been a positive culture. So for some reason, you have cultured the breast milk and if they're systemically unwell. So that's when you're gonna give antibiotics. Perfect. And we're also gonna go for 10 to 14 days of um oral flu clocks. Lovely in general. Just remember if there are skin issues, try flu clock. If you're in doubt, it's a good one to go with. Ok. And Erythromycin, if allergic. Lovely. Ok, same lady comes back after two days. So she's got ongoing mastitis. Symptoms. But now there's a mass. Remember previously, we said there was no specific mass. It was just, the entire breast was basically hot and tender and painful. Now we've got a mass um ongoing. She's getting really unwell. What are we thinking? Abscess? Perfect. Lovely. Yeah. So we're thinking abscess most commonly caused by staph aureus due to mastitis and you're gonna have systemic and local infection. Lovely thing to remember is, and this works for most abscesses that a Swinging fever, spiking fever. So what that basically means is they're gonna complain about your, their fever changing a lot, kind of hour by hour. Like if you were to IMA imagine a chart of their fever, it would very much go up and down and up and down and that's really common absence of any location. Um A way I tend to remember that is that if you think of yourself like swinging on like um like in a playground, you're probably gonna need a lot of core strength, you're probably gonna need abs. That's a funny way. I remember it if that helps. Um But that's kind of a useful one to know. So abs is of any location. Swinging fever is very, very common. What do we do? So just remember your most common SBA question about this is gonna tell you it's in a GP setting and just remember anyone in a GP setting with something that's clearly an abscess, send them urgently to the hospital team, the hospital team is then gonna do an ultra ultrasound side guided aspiration, antibiotics in incision and drainage and all of that stuff. Ok. What is happening here? What does that look like? So be thinking, think kind of back to rheumatology if that helps. So, peripheries turning white bluish, what we like any headaches? Um Raynaud's lovely. So Raynauds of the lipo is pretty common. Um It's just basically vasospasm, spasm of breast tissue during breastfeeding and you're gonna have intermittent pain during and after and it's very similar to your vasospasm and Raynaud's um peripherally as well. Um So conservatively avoid cold heat packs, no smoking, et cetera in terms of pharmacological management. And remember it's only started by specialists. It is very similar. It's the same as what you would do for peripheral retina and all your rheumatological conditions. So, what, what are we going to give them? What drug class C channel blockers? Brilliant. Perfect. So PO NP and just remember not to be started in the GP because it's quite a special thing to. Great. Ok. Next one. So this time we've got a 31 year old with painful red breast. Um It's painful, tender, they've got a fever. Um They've got some skin changes for anyone who's not done obs and Gyn yet. So nulliparous means not had any Children yet. Um So what's something that from that? So it's giving quite a mystes picture but she's not breastfeeding. She hasn't had any Children. So what's something we think is likely in her social history? What do we think? So, thinking about when you take a social history, the two questions you're always taught that you should ask and then think about from those two, which ones are most likely to probably be causing something like this? What we like? Smoking? Perfect. Lovely. So smoking. So it makes sense, doesn't it? Cause it's basically causing damage of your ducks that, that can then become infected and it can also be due to implant, piercings, injuries, et cetera. So the things I was getting on with social history is gonna, the thing they already always talk to us about is alcohol and smoking is in it. Um And in this one is gonna be smoking. So it's very, very common if you're smoking. Ok. So what's going on? It's just periductal mastitis. So it's still mastitis but it's not lactational mastitis. In this case, it's just inflammation and dilation of the ducts with an infection. Ok. So inflammation and dilation of docs with infection. How do we treat it? So, same as lactational mastitis, we're gonna start with the warm compresses and analgesia, but it's not smoking obviously. But should we give everyone antibiotics or should we only give it if flap? So if you guys remember that was my mnemonic for fissure already tried um conservative measurement, positive culture or systemic symptoms. So what do we think everyone or only if those apply any ideas so you can just put one or two in the chat, right? One perfect. Absolutely. Right. So, unlike the other one, we're giving it to everyone. So that's something important to remember. So we wanna give everyone antibiotics because we don't wanna wait as there's a high chance of complication. So that is straight from nice guidance. So keep that one in mind. OK, in terms of things that can go wrong, it the same as lactational mens as an abscess. And like we said, treatment refer to breast in hospital, they're going to do the aspiration, antibiotics, et cetera. But remember any kind of abscess picture if you're in a GP and the the most common UK Malay question is gonna be you in a GP with when it comes to this one, you're going to want to send them into hospital? Great. OK. Getting on to discharging stuff. So the two main conditions where discharging is happening that we need to know about apart from galacturia is gonna be Duc Sassia or intraductal papilloma. So let's just talk about the difference between the two of them. So if we talk about this one first, so benign proliferation inside a milk duct. So what do we think intraductal papilloma or duct ectasia? So which one is that one? Explaining the pathophysiology of why does this one have a high chance of complications um compared to lactational? Because so if we think about it in lactational it doesn't necessarily have to be um infectious. So even though you've got the fever, remember, fever is can happen, even if you don't have an infection, it's just an inflammatory response. So, in lactational medit because you've got all that build up happening of your fluid and your blood and all the milk. Um in theory, if you just keep breastfeeding, if you just warm compresses, you might be able to get rid of it without it. The problem with non lactational mastitis is that it's probably happening because of an infection. There's no reason in someone who's not breastfeeding for there to be all this build up and inflammation and fever happening. So with them, that means you've probably definitely got an infection. Does that mean I hope that makes sense? Um Yes, so I hope, I hope that makes sense. Definitely to let me know if not, but going back to this one. So no proliferation. Um Which one do we think ectasia or papilloma? So let's say that ectasia is one. Papilloma, is two. So you can just put one or two in the chart. What do we think? Et OK. Um So, and then we've got some twos as well. OK. So for this one, it's two and the reason is remember you heard the word papilloma. So things like adenoma, PPI papilloma carcinoma, they're all, they're all different kind of intricacies. But in, in general, the er is referring to some kind of proliferation it could be malignant and it could be benign. It could depend on what kind of tissue it is. So, is it epithelial tissue or not? But, er, is probably referring to some kind of proliferation. So, I hope that makes sense. Um Ectasia that's happening there is just widening and thickening of milk ducts in breast due to cell death. So that's all that's happening there. Ok. Next one, which one do we think this applies to? So that it can be a normal part of aging in 25% of postmenopausal women. Which one do we think that applies to? So the papilloma or the widening and thickening of milk ducts in breast due to cell death, ectasia lovely. And again, that makes sense, isn't it? Because this kind of widening and thickening picture, that's just a really common thing that seems to happen with our physiology as we get older, isn't it in terms of hypertension? So that's where we're getting um all these BP problems in general vessels and ducts are um getting wider, getting thicker, not functioning very well because of cell death as we get older. Lovely. OK. In Papillomas, it's most common in premenopausal woman. So 30 to 55. OK. Next one. So smoking is a risk factor. What do we think? So it kind of proliferative picture or this kind of widening and thickening picture. So you got some ideas for two, definitely any other ideas. So for this one is actually one. And, um, the reason is, and, or the reason II think of it is that this widening and thickening picture sounds quite similar again to what happens when you're smoking, isn't it? So, I think that kind of, I picture it a bit like what happens in CO PD when you're smoking. Obviously that's not, you know, a duct, obviously, that's your entire bronchi and, um, stuff like that. But it's a similar idea, isn't it that when you're smoking, things get wider things get thicker and basically cell death. So anything whenever you're smoking, you're basically encouraging cell death, that's essentially what's happening. So that's why that one is more associated with doctor. I hope that makes sense. Last one. So which one do you think this is more likely what? It's a bilateral clear blood stained discharge? Which one does that feel more common with? Two? Lovely. So Papilloma is more likely to be this blood stain discharges. Remember that bilateral or unilateral dx tasia is more likely to be unilateral thick green discharge the way I remember that one, um is in Papilloma, you've got the O, so that's the O in the blood and then ectasia, you've got the E and then that's the, that's in green. So if, if you're struggling to remember that, hopefully, that helps a bit. Ok. So we'll talk about investigations when it comes to discharge later. But in terms of what we can do, we can't really do much more than kind of just excise. Um There's not too much more, we can really do that. Ok. So going on to malignancies. So in terms of our malignancies, um we've got lobular or ductal and that can be invasive or in situ. So talking about those ones, which one do we think is the most common? Which one do we think is most likely to present without a lump? And which one do we think is most likely to metastasize? So let's start with the most common. Which one do you think is the most common D CS is the most common? Um Most likely to present without lump. What do we think for that one? What we think? So, what, which one is most likely to not have a lump? Almost likely to mess metastasize any ideas. Yeah. L cis. OK. Um So firstly, just in case anyone's getting a bit confused, um D CRS. So that basically means we're talking about duct in situ or lobular in situ. Um Most common I um invasive ductal or like you guys said, um ductal in situ, that's gonna be the main ones, but that's gonna present with a lump um without a lump, it's gonna be lobular and that's most likely to present with skin changes. Um I think it's quite unfortunate that the one, the lobular which is an L is the one that doesn't have the lump. So maybe if it helps think of it as like, oh the one with the L doesn't have the lump. Um And then did they say ectasia was unilateral? And papilloma is bilateral. So both of them can be either um in terms of what's gonna be most common. Ectasia is more likely to be unilateral and papilloma is more likely to be bilateral, but it can happen either way if that makes sense. So it's not hard and fast. It's just in terms of which one is more common. But um in terms of the more salient things to remember, as long as you can tell the difference that the green discharge is more likely to be the ectasia and the bloody discharge is more likely to be the papilloma. Um You'll be able to tell the difference. They're not gonna be super mean about just telling you, oh, unilateral or bilateral discharge. Which one is it gonna be? Also, the more important thing is gonna be the investigation and we'll get on to that in terms of how do you know when to refer and how do you know when to refer urgently and all of those things? I hope that makes sense. OK. Um So BRCA one or two, so, oh sorry. And first, let's do the third one actually. So poorest prognosis. Uh So these are all the different um markers that you can have in your cancer that can be positive or negative. Which one do we think carries the poorest prognosis? Could we think? So. It's slightly a trick question actually. So the poor prognosis is triple negative. So basically, all of them are negative. So you don't have any of them. And that makes sense, doesn't it? Because you don't have anything for your chemo or your hormonal therapy to target. And then after that, it's um her two positive. That's the poorest prognosis. Um in terms of BRCA one and two. So, what is the lifetime risk of either breast or ovarian cancer? If either is present? What do we think have a gas? 50%? It is 50%. So it's pretty high. Um So for BRCA one, it's associated with triple negative ovarian pancreatic prostate. And BRCA two is associated with positives that could be er positive or pr positive breast ovarian pancreatic and skin. So my pneumonic for that one is top pops. So it's like the top of a popsicle if that kind of helps. Um And then you can remember the top is the BRCA one and the pops is the BRCA two. Um but do remember that and we'll get on to history taking later, but it is important to remember that it's very common when you're taking a breast history, you just ask people um any history of breast cancer, most people will end up remembering ovarian cancer because we're thinking around the Gyne lines. But it's very common to miss out pancreatic um prostate BRCA one and BRCA two is most associated with breast and ovarian. So, pancreatic prostate and skin is rarer, but it's just worth asking anyway, especially for example, Pepsis. OK. So in terms of risk factors, so for BRCA or non Bracker, H RT, your C OCP is very common. So that's definitely one that you always, it's always part of the counseling. When you're starting someone on the combined oral contraceptive, you end up telling all of them about the slight increase in risk of breast cancer, smoking, obesity, all of those common things. What does this mean? So we talked about it before. So if you are so non rer only risk factors are, is nly party. So again, for anyone who's not done g that means don't have any kids, early men, you started period, early, late menopause, finished period, late or not breastfeeding. So what does that essentially mean you have done more of in your lifetime? I think we talked about it right at the start. More ovulation. Perfect. Exactly. So more ovulation. So that's just something to keep in mind. It applies for breast is something that's quite useful to remember in Gyne as well that all of these kind of things are just associated with it. More ovulations overall. Perfect. Lovely. Other things are first pregnancy more than 30 that's also because of your breast grow during pregnancy. Great. Ok. So criteria for genetic testing, um these are very complicated, it's very specialist. I don't think you're gonna get a very complicated question on this um in the UK MLA. But um a question that so something just to keep in mind is the first degree versus additive factors. So what that means is the first degree, if you've got a first degree relative who had breast cancer, less than 40 male breast cancer, very strongly associated to um genetic factors, bilateral breast cancer, but less than 50 or two first degree breast um cancer relatives, you're gonna qualify for testing what we mean by additive is that it's not just dependent on one person. Two or more people need to basically have had some kind of problem. So you could have had two first degree relatives, one first degree and one second degree relative, one first degree and second degree breast and then one first degree and second degree ovarian or three first degree and second degree um breast. So the question is that if you've got someone who's their mum had ovarian cancer, so that's one first degree ovarian and dad's sister had breast cancer, that's one second degree ovarian. Is she going to qualify? Well? So not secondary ovarian? Sorry, I shouldn't say second degree breast. So will she qualify? So, what do we think? So that should be a pole. So is she gonna qualify or not? What do we think? So, keeping in mind on what we said about additive factors. So one of the additive ones, is that one first or second degree breast and one first or second degree ovarian. So give it like a few seconds more for everyone to put in their guesses. Ok? So we're pretty split um in terms of whether we think she will or she won't qualify. So, different sides of the family are not additive. So what that means is this is her mom. So that means on her maternal side of the family and then it's dad's sister, not mom's sister. So that means it's on her paternal side. So you can't add up different sides of the family. Because what that basically means we're saying is that we saying that, oh, on one side, there was a case, on another side, there was a case. Therefore, that somehow means overall there's a greater chance that you're going to have a BRCA mutation, which doesn't make sense, does it. But on the same side of the family, a lot of people have it. That means that, oh, there's probably something genetic going on here. But if it's on two completely different sides of the family, and obviously we're assuming here that mum and dad don't have any genes in common, um that means that it's probably just random. It doesn't mean that it has to be, it could be genetic, but it's not increasing the likelihood that it's genetic. And I don't think the NHS can afford to be um genetically testing everyone. So I hope that makes sense. And that's something I've seen in a lot of ba s. So just remember different sides of the family are not additive. OK. So triple assessment um seems pretty obvious that the three things to it and I'm sure you guys all know the first one. So we wanna physically examine them. Um So something to keep in mind is that this is the way it's done in clinic. So the person who's examining the patient and obviously physical examination history is part of it that they're gonna give them a score. So one is just normal. That basically means there is nothing to really examine two you're examining, but it feels benign. Three, it's uncertain, but probably benign. It's suspicious of a malignancy and then five, it seems very highly malignant. That's one, two. Um So this is something really important to remember for SBA S and I've seen it a lot that if you're over 40 you're gonna go for a mammogram. If you're under 40 the first line is going to be an ultrasound. And that's because your breast tissue is too dense if you're under 40. So if you're under 40 your tissue is that dense, you, if there is something going on, you're not going to actually see it in an X ray. So that's something to keep in mind. Um It's a compression x-ray and you're gonna do it in two dimensions, you're gonna one get one front on and one from the side and then ultrasound you're gonna be ultrasounding everyone. Any. Every anyway, for axilla screening because we know that breast cancers are gonna metastasize first to the axillary lymph nodes. Good. Again, are we gonna biopsy everyone? So we're only gonna biopsy people if their exam and their imaging, if they examine their imaging is less than three, we're only gonna do it if either they're more than 25 or their discordant results. So that means let's say the mammography suggested an M three. But the examination score suggested a one or a two that's making us a bit suspicious and maybe bi biopsy needs to be done. But if you're, let's say you were 21 and you, you were less than three for examination and imaging, there's no point in doing it for both. OK. Um And in terms of FNAC and core needle biopsy. So I don't think this is very SBA but it was something I was asked on placement. I actually had no clue. So an FNA basically just means fine needle aspiration of cells. And that's for cytology under uh and you're doing aspiration under ultrasound and that's for cytology. So what that means is you're looking at individual cells with the core needle biopsy, that means that it's core tissue done under ultrasound for histology. So it's only the histology that can determine invasive tumors and margins and all of that kind of stuff. The final fine needle aspiration is just cytology and that's just going to tell you about the cells. So I hope that makes sense. That's the difference between them. No, that's that one, some place. Absolutely no clue. So, other kind of staging and grading. So obviously grading 1 to 3. So that's gonna be dependent on histological and pathological stage of cells that's from your histology and your cytology. And then like most cancers, you're gonna have that radiological staging on you. So that's gonna be your CT pet and metastasis allowing TNM staging. And like all other cancers TNM staging is very important in breast cancer. Great. Ok. So what cancers are most likely to um metastasize to the bones? I got another pole for that as well. So what do we think of the following ones? Which ones rarely metastasize to the bone? So we'll give it a few seconds for that. Ok. So I'll wait for two more responses and we'll have a look. Ok. So we're fairly split. Um So my pneumonic for this one is um oh, and we've just crossed over into the majority of the right answer, which is great. So my um pneumonic for this one is all kids learn to persevere and that means breast, kidney, lung, thyroid prostate. Um So liver is not, is it most, it's a metastasis site, isn't it? So it's, it's not most likely to metastasize the bone. So these ones are the ones where you really want to look out for any kind of um bone metastases and what's a really common way bone metastases is gonna present. So you can give me the most common way it's gonna present and then you can give me the most kind of deadly way. It's gonna present something you're gonna be really worried about. So, back pain, definitely. Or just bone pain, 100% fractures. Definitely. All of that. One of our oncology emergencies of a way it might present unlikely. but it could cordia quina. Yeah. So that's gonna, that's probably one of the biggest oncology emergencies that you can have and you wanna keep that one in mind just in case. Um So back pain, corna hypercalcemia. So you're gonna get all your secondary and tertiary parathyroid disorders, all of that stuff can come into this and just remember you do it load, it's kind of drawed in from the staff, clean years, whatever. Um uni you're at the qui I just remember it's going to be your full spine MRI you don't just want to do a lumbar spine. Just remember that. Keep that as like a thing. You always always remember because that is a very f one thing to be doing. So they, they're very um right to be testing us on that. Lovely. Ok. So going on to management for this stuff. So in terms of surgical. So if for number one, so if we've got a large tumor in a small breast or we've got a multifocal D CS that's greater than four centimeters. What are we thinking? So, what do we think we'd want to do for that person? And our options are either for mastectomy. So that's removing the whole breast or lumpectomy. We're only removing a bit of tissue. What do we think? Yeah. Perfect. So, for num for the first person, we're gonna be doing a mastectomy and for the second person, just an excision or lumpectomy. Lovely. Perfect. Ok. Um I've not seen that many questions on that kind of decision. Is it gonna be a mastectomy or lumpectomy? But something I have seen a lot of questions on is radiotherapy. So what we need to just remember is that if you've just had an excision and I feel like this makes sense that if you've just had an excision, you'd probably wanna give them um radiotherapy anyway afterwards. But if they've had a mastectomy, we only wanna do it if they're t three or t four or they've got more than four positive axillary nodes. So I hope that makes sense. So only t three or T four or more than four positive axillary nodes otherwi otherwise, after mastectomy, you're good. You don't need it. OK. So what is a Sentinel node? Because I don't think I knew this till I went on placement of my first breast surgery. I had no clue what that meant any ideas. So all the Sentinel node means is that's the first lymph node. And remember it's an axillary lymph node that cancer cells are most likely to spread to from the primary tumor. That's all that. And a sentinel node means a sentinel just means first essentially. So let's say that on examinations that could be during your triple assessment at the start or at any point. And you've got palpable lymphadenopathy, then it's quite simple. We're just going to take out all axillary nodes and surgery and then they're probably gonna get biopsied and tested et cetera. But if you didn't have any palpable ones on a combination, you're gonna have a preoperative ultrasound again. So that means at the start, obviously, during the triple assessment, we said everyone's gonna have the ultrasound preoperatively because there's obviously going to be a bit of a gap. You're gonna have another axillary ultrasound. And at that point, if it's still negative, so that means you still can't see any um any evidence of lymphopathy of your axillary node, you're gonna only do a sentinel node biopsy. So that means only the first lymph node and they've got ways of determining that um at surgery if it's still negative. So I hope that makes sense. Ok. Some complications. I don't think this is that high yield are things like arm lymphedema and function impairment. So that can happen from axillary node clearance. And that makes sense, doesn't it? Because your auxiliary nodes are clearing, clearing the lymphatic fluid from your upper limb. So you're gonna get lymphedema there axillary Web syndrome or coating. So that basically means that you've got these fibrous cords from your axilla to your hand and you get the sensation of tightness and pulling in chest area and that's probably going to need surgical intervention. Um Something else, a choma that's a localized accumulation of fluid beneath the skin surface. Ok. So for pharmaceutical management, OK. So if your E II feel like most people once you've done breast, obviously, most people do tend to remember this. So if your er positive, if you're premenopausal, what are you gonna give them? And if you're post menopausal, what are you gonna give them? So that's how it, so you can give me either a premenopausal or postmenopausal for the er positive. What are we gonna do? Tamoxifen? So, Tamoxifen for premenopausal. Yep. And then any ideas for postmenopausal? What do you think? So, postmenopausal, we're probably gonna stick with anastrozole or letrozole. Um the rest of them um are less high yield. This is the one I see the mo I tend to see the most questions on. So remember, Tamoxifen is a anastrozole is an aromatase inhibitor. Um So her two Herceptin, that's an easy one, but that's the fancy name which I'm not going to attempt to pronounce and that's a biologic um triple negative. So, chemotherapy or immunotherapy and then axillary node disease specifically, this is one of our adjuvant um chemotherapy. The um most people are going to know this but just quickly, just in case you weren't sure. Um, do you remember the difference between neoadjuvant and adjuvant chemotherapy? So, neoadjuvant means it's happening before surgery and adjuvant means it's happening after surgery. Uh, most people do know this, but just in case anyone wasn't too sure about it. Well, out of all of these, the most useful one to remember is this. Tamoxifen is a anastrozole business. Um And even if you're in primary care because breast cancer is so common, you're gonna see so many people on tamoxifen or an astrazolo because they're gonna be kept on that for life after breast cancer. Um in terms of, oh, and what's something quickly? So let's say you've got a pre, you've got uh someone who had breast cancer in their forties. Um Now they're going, they're on tamoxifen, they're going through menopause. Um What's something that a lot of people take for menopause that you absolutely don't want to give to this person um who has um had breast cancer in the past? What do we think? They're a really common thing given to a lot of people do menopause. H RC. Perfect. Absolutely. Do not want to give someone who's had breast cancer and especially er positive breast cancer. We do not wanna give them HRT and most of you guys seem to know that lovely. Um So some side effects of tamoxifen and astra zole or Herceptin. If anyone has any ideas, I want to put them in the chat. So just for the sake of time, I'm gonna go a bit fast to the point. So, endometrial cancer, VT E VT is very, very, very common with Tamoxifen something to keep in mind um in terms of anastrozole. So he not uh the one I can't pronounce, but it's the one where you get the purpura and you get the thrombus happening. So that's something to keep in mind. So HSP um hypercholesteremia and you also wanna, you're gonna wanna do a Dexa scan before starting. Um because osteoporosis is very, very, very common with that Herceptin. Just remember heart disorders and cardiomyopathy, cardiomyopathy. I've seen a lot of questions on that. So just remember that association between Herceptin cardiomyopathy. It's quite a common one. Ok. Cool. So quick pictures. What do we think is happening there staying on the malignancy thread. What do we think aod pagets actually bear that lovely. Um So pagets um that it's eczematoid changes of the nipple. But whilst it might look like eczema, it's mostly caused by DCIS and it starts at the nipple and spreads outwards. Just remember the difference with eczema. Someone's mostly gonna say that oh, it started outside of the nipple and spread towards the nipple in pagets, they're gonna complain of the opposite. So that's something to keep in mind and very common. Ok. Cool. What's going on here? Any ideas, orange skin appearance? Absolutely. And you want to know what the specific type of cancer happening here is, but you're completely right. That's how it's referred to the orange skin appearance. So for this one, it's called inflammatory breast cancer and exactly like you said. So it's um called, it's referred to as orange skin or PDO rash skin because it does kind of look like that, doesn't it? Um it's most likely going to be caused by invasive ductal carcinoma. It's most common in young people. It is very rare. So I think I was speaking for a breast surgeon, they said in their entire career, they only really seen and three or four cases of it is very rare but something you do not want to miss. So it's rapidly progressing swollen red breasts. They're triple negative. It's very poor prognosis, almost always needs the adjuvant chemo, but it's associated with that page or, or skin appearance. Great. Ok. So one last thing. So one thing, so 45 year old unilateral firm irregular lump that has grown no other symptoms. BMI is 29.5. So overweight. So what's one thing that would be? So it's not here yet, but one thing in her history that would make cancer quite unlikely. So it's an obese lady um with this unilateral firm irregular lump, but she doesn't have any other constitutional symptoms. So what's something that when we ask her, she might tell us in her history that's gonna make cancer pretty unlikely for her. Any ideas. Something she might tell us happened. So trauma. So what we're getting at here is a fat necrosis. So it was very common car accidents cause if you imagine a seatbelt. Um Perfect, lovely. You guys have got it. So if she had a seatbelt and she had a car accident, there's obviously going to be a lot of trauma and pressure on her breast. So it's very common in obese women with large breasts. The only thing to keep in mind, however, is that it does present up to around 1.5 years after trauma. So we're gonna get onto it later regardless, we're gonna be referring her. But in terms of your head and how worried you should be or your first differential if she comes up with this, you know, just around a week after the trauma, it, it's probably not got to do with that. It's, it does take quite long to present quick. Ok. So now let's get on to what I think is the most important part about this because most of us are gonna land up having to do a GP placement as an F one or F two. And this is something where it gets quite important. These two week waits and urgent versus non urgent referral. Ok. So I apologize. The text is a bit small, but if we say let's take the first scenario. So she's got mastitis without any improvement, the skin changes that are suggested with breast cancer or there's unilateral bloody or clear discharge. What do we want to do? What do we think? So? Two week wait, non urgent or nothing. And here it is two week. Wait, brilliant. Ok. So mastitis without any improvement just going a two week, wait, skin change is suggestive of breast cancer in a two week. Wait, you need actual bloody clear discharge. We're going a two week wait, they're all gonna get two week waited. What about unexplained breast or axillar lump? What, what gets important at this stage? Something that not, not something we're gonna have to even ask the patient. We're just gonna know about the patient that's gonna change our approach. Kind of clue in that. It's not something you're gonna have to ask the patient for. You're gonna know about, know this about the patient when they, when they present basically age. Absolutely. Perfect. Lovely. If they're more than 30 you're gonna two week with them. If they're less than 30 you are still gonna refer them. That's something that gets quite confusing. It's gonna be a non urgent referral, but they will get referred. So something to keep in mind. And then the last ones if you've got, if you're over 50 you've got unilateral nipple retraction, not inversion. And I suggest going and looking at some pictures of that because they do look a bit different. You're gonna two week with them. Yeah. So this is the most important thing that the only one or really, it's not an urgent referral is going to be some under 30 but they're still going to get referred. And in terms of mastitis, that doesn't mean everyone with mastitis, you're going to be two week waiting them. But if it doesn't get better, you are going to refer them. So that means after maybe one course of antibiotics, it just doesn't get better. You're going to refer them skin changes. So all of those kind of pagets inflammatory breast cancer, you are going to refer them. It's still quite important. OK. So then let's talk about our cases. So um in person, number one, so 38 unexplained unilateral breast lump, what are we thinking? Two week away or non urgent? And here it is. So following the algorithm, we've got unexplained unilateral lump that over 30 probably gonna be two weeks later on there. OK. Yeah, perfect. You guys got it. OK. Um Number two. So 57 discharge from right nipple only. So that's over 50 unilateral discharge. What are we thinking? Two week? Wait f OK. Number three. So mastitis not resolving in three days. So we're gonna assume we've probably given her um antibiotics there. What do we think nonurgent f brilliant. Oh sorry, not non urgent. Um That's the next one. Sorry. 28 we're gonna be um referring, isn't it? Because mastitis without improvement? Next one. Um And then that because what were we thinking with that one? So what, what are we worried about in terms of mastitis? That's not resolving. What could that be indicative of one of the things that we spoke about? Yeah, exactly. So we're worried about inflammatory breast cancer. Great. Ok, so 27 that's the one we said non urgent. It, bilateral breast lumps. It's giving such an adenosis picture, isn't it? But they're still gonna get referred. That's the main thing to take away. 61 discharge from both nipples probably gonna be non urgent referred. Just gonna go faster. Now, 45 skin changes in around left nipple only. So skin changes, we are worried gonna be two week waited um because we're worried about pagets, 26 unexplained single axillary lump, non urgent. Still gonna get referred though and then 41 unexplained axillary lump two week later. So the main thing to take away from this is everyone gets assessed. It could be really clearly fat necrosis, adenoma cyst, you might be convinced it. Um Just a papilloma ectasia, everyone gets assessed. That's the way they're going to try and throw you off in those questions. Just remember everyone gets assessed or you really need to do is decide it's a non urgent or two week. Wait. And again, we can see most people are getting two week waited. Anyway, it's only if they're under 30 that the chance seems really low. And even then again, if they give you some really strong bracer sounding family history you're probably going to two week, wait them as well. But for example, if there's just non urgent, if they're under 30. Ok. So lastly with screening, so who gets screened? What do you think? So, wait for three months? Perfect. Great. Ok, so we've all, we've mostly gone for the majority. That's 50 to 70 every three years with a mammogram. So for anyone who's a bit confused about the the so some people got the 50 to 75 that's close. But remember ultrasound. So remember what we said, if you're under 40 you're gonna go for ultrasound because your breast tissue is really dense. Anyone over 40 you can go for a mammogram. So that's the main thing to keep in mind. Um I think some people went for the 25 to 49 every five and then 50 to 64 every three years, that one's giving a bit more for cervical cancer picture, isn't it? With the pap smear? So do you remember that, that those in terms of breast and our Gyne screenings, these are the two most important ones to remember. Great. Something else to remember is if let's say someone's had cancer surgery under 50 they're still going to also get a five yearly mammogram maybe a bit more frequently at the start until the screening age. So if someone let's say had breast cancer really early on at 41 we're not just going to let them be um until they're 50 then start screening them. We're gonna be screening them earlier anyway. Ok. So now we have, um, some S pa and we'll do them quite nice and quickly. Um, just for the sake of this one, just assu um, assume they're not penicillin allergic. So I know I've said that on the side. Just ignore that penicillin allergic part. What do we think? Ignoring the penicillin, penicillin, penicillin, allergy. Let's just get a few answers. Ok. So for this one, I got again going with the thing that we're assuming they're not penicillin allergic. Um, we're gonna be giving them um Oh no, I did change that actually. Sorry. So if they were penicillin allergic, we're going with Erythromycin. If they're not penicillin allergic, we'd probably go for flu block. But the main thing to remember for this one is why are we giving them um, antibiotics? So if we go back to the fap thing or the flap thing, I said at the start fissure is one of the reasons we'd give someone um, um antibiotics and they're talking about the small tender slit on. They, so that's suggesting a fissure. So the main thing to remember this one is if we're saying penicillin allergic urethra, not um not penicillin allergic flu clock, but either way because of that fissure, they're going to qualify for antibiotics. And then also to remember that if this wasn't a breastfeeding related one. So if this was just simple periductal mastitis. Everyone's getting the antibiotic straight away because we said that's probably giving a more infectious picture. Great. Ok. Next one. What do we think? So, you've got a 28 year old female recently gave birth breastfeeding one week history, tender, red hot left breast, also feverish. Um examination shows tenderness, erythema in a wedge shaped area, affected area feels firm and hot. What do we think? Two options are adenoma abscess, um purple or mastitis, um or lactational mastitis, cysts or inflammatory breast disease. What do we think? Ok. So we've got a bit of a split picture in this one. So adenoma, no one's gone for that. And I agree it's just not giving another adenoma picture. Is it um inflammatory of breast disease? Again, it's a breastfeeding picture. Feels unlikely. The breast cyst is not a bad idea. But remember there's gonna be that history of lumpy bilateral breast not likely to really be feverish. Also, they're gonna give you that picture of, oh, it's changing with their periods. So it feels unlikely. Then we're getting down between the abscess and the mastitis. I agree. This one's a hard one. Just remember they're giving that the thing with the wedge shaped area thing. But what they're basically trying to get at is there is a lump or there is a localization of area and that's suggesting an abscess. If there was no specific area. They just said overall, the breast was quite red and hot that would be suggesting more of a mastitis picture. I hope that makes sense. And again, if we're talking about a GP picture, main thing to remember is GP abscess reverse hospital. There's, there's no real gray area there. Ok. Um, speeding up a bit. Um, what do we think for this one? So 27 year old lumpiness in breasts, breasts are painful, heavy mother who was diagnosed with breast cancer at 67 no Children normally has regular menstrual periods. What is your first step after completing examination? So options are pregnancy tests, genetic testing, ultrasound aspiration, two week, wait after the way or non urgent referral for triple assessment. What do we think? So, any other guesses? What are you thinking? Ok. So um a bit of a hard one. So non urgent referral for triple assessment, definitely not a bad idea at all. Two week wait, probably not aspiration again, probably not first line genetic testing. Remember we're not really hitting the criteria, are we? So it's not telling us anything about a broader family history. We're just getting a picture of one first degree relative with breast cancer over 67. Not really genetic testing. Something that funnily no one has gone for is the pregnancy test. So I know that's a hard one. Not something we've spoken about, but just remember you've got somewhat of a reproductive age. Um She's not saying anything like, oh, I had my period yesterday. I'm on my period, right. Now, um these are symptoms that you can get when you're pregnant. So, just remember for most things, if you've got any kind of anything vaguely breast sounding or gyne sounding history in anyone of a reproductive age, this will really be JD in when you do your ops and Gyne placement. If you haven't done it yet, just do a pregnancy test really, really important. Everyone's just gonna, it's just such an easy one to do and it can actually tell you a lot if it is positive, it really explains a lot then. Ok, so this one exact same scenario, but this time we're saying, ok, the pregnancy test is negative. So in that case, what do you guys think? So, I just realize, I think I'm gonna skip this one because I just think the slide, the options were wrong but I feel like most of you probably guess that, but it should be fibrocystic disease, isn't it? Because we've got that bilateral painful heaviness, um complaining of lumpiness in the breasts, we can ignore the kind of family history, but it's that lumpy breasts that are painful and heavy. Um And we, if we probably don't further, they're probably gonna give us that history of um the changes around pregnancy. Ok. So next or what? We, they only got a couple more guys. Um So what are we thinking for this one? So 22 year old concerned about new breast lump. She recently had a triple assessment with a needle biopsy, um which was confirmed to be benign. Since that, she's got a second lump near the biopsy site. Lump is irregular firm detach, immobile, no pain, no overlying skin changes. And let's assume no weight loss fever, anything else either. What do we want to do? Ok. So we've got both a mixed picture but most people are completely on the right lines that we're still gonna send her for that non urgent referral. So I completely agree that it's giving a picture of basically a fat necrosis and it, it's not like the typical kind of seatbelt trauma I was talking about but um it was a needle biopsy, it's still some kind of trauma to the area. Um, since then she has found um a lump near, they're not telling us how long, but she has got a lump, it's probably giving fat necrosis, but it doesn't matter how sure we are, she's gonna, obviously she's under 30 but she's still going to go to that non urgent referral for triple assessment. Great. Ok. What we think? So, most important things are, we've got 70 year old surgical treatment, um, postoperative admen radiotherapy done all good. Um, she's not got any allergies. She's clearly, if 70 is giving post menopause and she's her two positive, er, positive and pr positive. What do we want to give her? Ok. So everyone's going for anastrozole and perfect. So we've got postmenopausal, we've got, er, positive, wanna go for that. Um, the thing that can get a bit confusing in this, obviously Herceptin isn't an option here, but let's say it was. So she is her two positive. Firstly, I think that would be quite a mean question, but if that was a question I would still go for, um, I don't think they would give that because that's quite specialist but I would still go for the anastrozole or if they were premenopausal, the Tamoxifen just because, er, positive is a very good prognosis because when you target the er, positive, you are really reducing your um chances of recurrence. So it's the best thing to target. OK. What do you think? So for this one, follow the one on the pole um Instead of what's on the um main thing, if that makes sense. So not what's on the side and just in the interest of time, I'm going to go a bit faster. So I'll do both of them, the one that's on the pole and what's on the side. So, for this one, it's just gonna be wide, local excision, isn't it? Because um it's, they're telling us that it's um a 3.5 so that's under four centimeters. Um There's no metastasis. She probably can have wide local excision. Um in terms of the further details that we've got that if it's at 41. So even though it was a wide local excision because it's t four, that's one of the criteria we said that then you qualify for, even though you've just had the um wide local excision, you're still gonna have the radiotherapy as well on you because we said everyone's gonna have radiotherapy. Ok. And last one, what do we think? I was just gonna wait for one or two more responses, but I feel like you guys made this one. Cool. Ok, perfect. Lovely. So everyone's gone for the right one. So 53 year old we, well, she's meeting all that criteria. She's got the unilateral um discharge. Um So we're definitely gonna be two week waiting. Her main thing in this one to remember. So I remember what we said over 40 mammogram, under 40 ultrasound and she's over 40. So she's gonna get the mammogram. Perfect. So main things just keep in mind and I'm not going to go through this in too much detail. So feel free to come back and look at the slides or take a screenshot, whatever is easier that um things that people often forget with these kind of things with lumps. Remember the changes with menstruation, remember how it feels, remember, skin and nipple changes, double check about any trauma discharge. Pretty important. So asking particularly about things like color in terms of family history, just remember age of onset, really important if they say that. O2 of my aunties had it. Make sure you ask them are these aunties on the same side or is it one of mom's sister and one of dad's sister? Because it does make a big difference. Ovarian bilateral, these pancreatic prostate and skin ones, if they're male, all very important that Gyne history really, really important for breast. So make sure you don't forget it. Um These things about age of menarche, age of menopause, all of those are going to tell you that idea about how many ovulations have they had very important breastfeeding. Obviously, if there is a mass that's very concerning if your own GP abscess straight to hospital. So, co CPH RT and smoking all very important. So just keep those in mind because if you get a breast history and endoscopy of actually quite a nice one, but it's just quite important if we to know we ask all the right questions. Perfect. So, thank you guys so much for coming. Sorry, you ran over a bit, but I hope it was helpful. Um Please feel free to put any more messages on the chart, but if not, please do fill out the feedback form and hope to see you guys another week. Thanks so much. Thanks so much guys.