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Good evening everyone. My name is an I am one of the F one doctors working on the team at mind the bleep. Uh Today I'm gonna be giving you a lecture on breast surgery. Um Just before we start though, um just got a small note from the, from the BMA. We've got Dan here who's joined us. I want to tell you a little bit about the BMA, which I'm sure a lot of you will be getting involved with once you qualify and, and start working next year. Perfect. Yeah, thanks. So, yeah, I, I'll literally talk for a couple of minutes before you, you guys get going. Um It's obviously a very important time uh for the BMA and for you guys as, as a whole. Um Juniors, I mean consultants, staff doctors as well. Um So yeah, with the pay campaign, we're, we're into a new year now. So this is technically the third calendar year. This has been rumbling on for uh for juniors. Um So yeah, just an important time to, to be members, especially with you guys um becoming F ones. Yeah, you know, it'll, it'll come very soon. Um So yeah, it just something to think about um, for those watching it live and also anyone watching this, um, er, recorded. Um, yeah, if you, if you wanted to join, you get a bit of a benefit of joining, using this link that's on the screen, um, you get a 10 lb Amazon voucher. So it basically equals out um free your first three months of membership. Um So yeah, take advantage of it. Um, just use that QR code and then I know it's a bit fidgety but drop me an email after you've joined. Um and and I'll get an Amazon voucher sent out to you. Um Yeah, simple as that really. If you go online, there's nothing, there's no really incentive to join. We don't really do incentives that often. But yeah, so this is like a little secret thing for you guys. So yeah, join, get a time on Amazon voucher. Um Yeah, cover cover membership for about three months. So it's like three months free. So it's 3 lbs 75 a month um for for final years and that rolls through like a little bit into, into a fun. Um So yeah, just a little bit about it. I mean, I mean, I ii guess everyone knows what we do. Uh these days it's so sort of sort of everywhere and, and, and, and very much in the news so you can't really um confuse us anymore. We used to get a lot of confusion with, um, more indemnity to do. So. People come up to me and say, oh, I'm part of the MDU. Is that the same thing? Um, so no, BMA is, is your union? So it's your trade union professional association. So you can be a member, um, right now and, and sort of reap the benefits right now. Er, I'll, uh, I'll, I'll get onto it but, but it's very important for, for what's going on at the moment. Um, in terms of the fact that if, if there is a, a pay offer that's, that's put up by the government. I mean, it's, it's the negotiations have been, um, not been great so far but, but, but pretty adamant this, this year, um, things will sort of get sorted. I mean, it's been going on for so long. Um, anyway, if there's a, if there's a pay offer that comes out anyone who's a member in their final year, uh, and upwards will get to vote on that. So, yeah, it's, it's very important that, that you guys join. Um, and have your say, cos it affects your pay for the next, you know, 1520 years or so. Um, not to mention the con, the consultant stuff, but, but the consultant's vote is going on right now. Um So, yeah, so we're the trade union for, for doctors and med students in the UK, so not just doctors but med students. Um, and it's important knowing that we are only for doctors and, and med students. So, um obviously there's RCM for nurses. BMA is purely purely for, for doctors and med students. Um And yeah, you can see there's 100 and 91,000 members um that we've got at the moment. So most of the, most of the N A, uh most of the, most of the doctors and, and most of you are members. Um, so yeah, we're, we're very strong and that's why we're able to, to, to be doing what we're doing right now and fighting for, um, pay. So, yeah, uh touched on us already. I mean, I haven't go into massive detail on this cos I'm sure everyone knows what's going on and everyone's aware of, of the strikes going on at the moment. Um, juniors have just had, um, bit of a break over Christmas, let's say we've, we've, we've had the biggest, uh, strike in, in NHS history just come to an end the other day. Um And yeah, like I said, uh, it's important for you guys to be involved as of now. You can be members now and you can get the benefits other than obviously the union, the union side of things, which I'll go on to. But yeah, it's just important that you guys show, show sort of strong force coming in as the new F ones. Um, and yeah, you'll have a say on it and any of us that put out. So yeah, a few of the other things that might, that might help um, in terms of being a BMA member, I'm sure you guys all know about the BMA library. Um, it's all sort of moved completely virtual now but every single book textbook you could possibly need um, is, is, is on, is online on our bma.org dot UK four slash library four slash library. Um, er, you can access any book you could possibly need um instantly. Um So yeah, check it out if you're already a member or, or thinking of joining B MJ learning as well. You've got full access to that. You may get access to B MJ learning through your med school. But um this, this, this version of B MJ learning is the complete version. So no paywalls or anything like that. Um You've got lots of revision tools on that, lots of online modules. So yeah, I mean there's that clinical key, don't know if you guys have ever used clinical key um essentially a point of care tool so you can download the app log in through your with your BMA login. Um And it will, it will give you all sorts of um sort of point of care videos and, and um guidance and uh you know, you type in any condition, it will bring up every single thing uh related to that, textbooks, journals. Um You could, you could ever think of so ano another great tool um as fun students. Er, not a lot of people know this but you're entitled to the, the B MJ. So the full doctor's version. So the subscription of that is included in as being a final year um member. So you get one B MJ through the post a week. So, I mean, even if you just divided the 3 lbs, 75 between the four, um, BM Js, you get through the post every, that's less than a pound uh delivered to your door. Even if that's the only thing you, you, you use or, or read. Um, so yeah, if you are already a member, just give us a call on that on our general number and say yeah, I'm in found a year. I just want to opt in to get the B MJ. It is an opt in thing. So if you know, you know, um we don't just start sending it out just in case sort of addresses aren't necessarily up to date. So yeah, do do opt in if you're already a member and you want that. So just give us, give us a call any time. Um, we've got a great um wellbeing support service um completely um unique of anything of anything else that I know of, to be honest, um because it has a, a peer support doctor service. So if you phone up, you can either speak to a counselor or a peer support doctors. So someone who's been through um similar situations to, to, to what you may have experienced. Um And obviously, if you've grown us more than once, um we'll try and make sure that you speak to the same person again. This is completely um free to everyone. So regardless of whether you're a member or not, um, it's there for everyone to use special explorer may be a bit early to think about your uh specialty, but this is a really good tool to sort of use now and maybe, maybe um sort of f one and just every, every six months or so take, take this um psychometric test, takes about 20 minutes to complete um and ask lots of work life balance questions and then at the end, it will break down um all top suited specialties according to the answers you've given. Um and always throws up sort of a lot of things that you, you might not expect. Um Yeah, breaks, breaks down, why, why certain specialties would be great for you. Um a series of graphs and charts if, if you're into that kind of thing. Um It's really detailed in, in its reasoning. Cool. That's it. Thank you for listening to, to my, to my talk. Like I said, if you're not already a member this, this year is a pi gonna be a pivotal year. Um in terms of, I mean, your, your pay for the, for the for a big chunk of your career. So yeah, do get involved. Um Do have your say when, when, when things um start to materialize. Um And yeah, get, get an Amazon voucher for joining a day, 3 lbs 75 a month is, is all it costs. Um So it's sort of like balancing out the first three months and obviously you're free to, to leave any time as well. That's it. Um Try to be as quick as possible. Thank you for having me. Um And I'll let you get on with the session. Thank you so much. Just we show my slides. OK, good. So, yeah, good evening, everyone. You see Daniels posted, uh posted the link into the chat if you wanted to access uh the Amazon voucher that he shared for signing up. So yeah, as I mentioned, we're covering breast surgery today. Breast, it's quite a nice succinct topic, I think for your uh for your finals. Um taking a look at the UK A UK MLA content map. You've only got a handful of conditions and presentations you need to be aware of. And I think really this boils down into, to breast cancer uh and then benign breast disease that, that presents. Um It's, it's quite nice. I think there's not a huge amount of detail that's, that's really expected at your level as an undergraduate. Um But I think it's being aware of common concerning features as well as managing, um and appropriately managing breast cancer. I'd say. So we'll start with an SBA, I'm just gonna share the pole. OK. So a 47 year old female is referred to the one-stop Breast Clinic by her GP following the discovery of a lump which of the following will be the most will be most likely undertaken. Just give you a little longer to get your responses in. Got a bit of a split at the moment. Oh OK. Yeah, we're chopping and changing a little bit. OK. So the answer was actually breast examination, mammogram and then fine needle biopsy. So just about most of you put this one, but there was a little bit of a split. So we'll talk through it. Um So in the one stop breast clinic, I guess the best way you could uh think about it is you want three forms of evidence to reassure you that you're not not dealing with breast cancer, clinical examination, imaging. So radiographic evidence and then pathological evidence. So a biopsy that an example um examination was feature in all the answers. So we don't need to worry about that. Why mammogram as opposed to ultrasound in this case, um ultrasound's not a wrong answer, so to speak necessarily. Um the reason why mammogram is more important is because as we get older, our breast tissue becomes less dense. So on a on a mammogram, um the lumps or or inappropriate lesions are better visualized in less dense breasts. Ultrasounds are more useful in younger women. Um But unfortunately, if you were to do a mammogram in a very young woman with very dense breasts, you almost get a white out picture. I've got a slide, uh a couple of slides along that, I'll show you, show you that. Um So typically this age range can sometimes be denoted as over the age of 40. I've known other centers might use um different age cut offs. Um But generally speaking around the age of 40 or so, you probably opt for a mammogram as opposed to, to ultrasounding. The final component was uh the specimen taken. Um So different types of um biopsies are undertaken at the one stop clinic. Um The final bi bi biopsy is just using a needle and aspirating really the the lump. This is something that can be done on the day in the clinic. Um If it if deemed appropriate core biopsies are also done. Uh although the correct answer didn't feature a core biopsy in this case, um core biopsies require the use of an ultrasound. They're a little bit more invasive. Um It probably wouldn't be as accessible um As doing the final little biopsy, it takes a little bit more time. Um Excisional biopsies are was the red herring. Here, there's no real role for excisional biopsy um in obtaining specimens for breast cancer cancer, uh excisional biopsies more. So in the case that you could think of when you were say removing a suspicious skin lesion. Um So here I'm gonna collection of images and mammograms and you can see as the breast cancer gets more dense as you see in younger women, you get a white out and it's not very easy to make out much. Um so often this can mask the appearance of lumps or other suspicious lesions. Ok. Yeah. So the first topic we wanna talk about is breast cancer, which really is the bulk of, of, of what we're working with in our, in our breast discipline. The triple assessment is the, is the mainstay of assessing the breast lump that we talked about is the two week weight cancer pathway. Um I've included a resource at the end which I suggest taking a look at for your two week eight pathways. I think it's um really helpful. It's the guide that Macmillan produces. It's what I use to learn my pathways for my exams. It's very succinct, all the information is in one place and I think it's quite easy to digest and they update it regularly as well. So I definitely recommend taking a look at that. I'll, I'll pop a link for that on the chat later. Um And yeah, I think it's, it's important to remember that most lumps won't be cancer. Um But still it's important to thoroughly assess them and reassure them because it's, it's quite a frightening experience. Um, for those of you that attended breast clinic or, or the, the one stop clinic is often called people come in very, very nervous, very anxious. Um but most lumps aren't, aren't cancer defib assessment. Like we talked about examination, radiographic imaging and then follow specimen as you're progressing throughout this assessment, we're creating essentially a risk score for each stage. So the examination, the imaging and the histology um from the from the sample that we collect and we're grading the the likelihood that this this lump is, is malignant. Um and as people progress, either then we can reassure them. Actually, you know, there's, you know, examination findings are normal how to look at the imaging that isn't a suspicious lump. Uh people can be reassured us at home or if cases are suspicious and we take a sample, then all this information is collated. Uh and an M BT discussions is, is later had about every case that is uh is, is concerning. Um and from there, then you can generate management options which could be operative and also involve non operative adjunct therapy as well. The other main um way by uh which women may interact with the breast service um regarding breast cancer would be through screening. So if they haven't come presenting with a lump, it could be that they've come for their regular check. Uh and perhaps something suspicious is found then. So at present, women aged 50 to 70 are invited to screening the asterisk is because for the past several years, actually, there's been um a clinical trial run by Oxford University called the Age X trial. And basically what this is looking at is whether they're offering an additional screening opportunity uh once between the age of 47 to, to, to 50 then another one from 70 to 73. So essentially an extra one, either side of the current window um reduces um uh risk of harm caused by, by breast cancer if um breast cancer is picked up easier and sooner and if outcomes are better. Um So at present, as per the nice guidelines, it's fifties to 70. But I imagine that uh this could, could change in the future. So that's why I put the asterisk. So you're aware, um women over over 70 can still self refer themselves for screening. It's just that they're not given the invite letters in the post as they would have been previously. Um And I think this could very reasonably be something you'd have to counsel somebody on um, in a simulated or even in a real life scenario. So I think it's important to have some degree of awareness. What, what happens. Um Women have mammograms when they come in for these, for these checks. That's the, the way the, the um the appointment works. I don't know if any of you ever seen a mammogram, but if you had to explain it to someone, I think it's worth noting that the process can be a bit undignified uh or feel undignified to patients and can be a little bit uncomfortable. Um, normally they take two views of the breast and I think the picture on the right is from cancer research. I think it, it demonstrates it quite well actually what, what they do. Um, a woman essentially has to have her breast compre compressed between uh two plates. Um, and they try and get the breasts as flat as possible to get the best image of the best breast as possible. They take two views, one from the top and then one sort of from the side. Um and a caveat to that might be, you may need more views if breast implants um are present. Um just to make sure that they're not uh obscuring your view of, of a suspicious looking lesion from this women may be reassured. There's nothing of concern and they return to their normal three hourly, uh three hourly, sorry, three yearly um follow up. Um or there may be some concern and then further imaging or further tests are required, um which would be taking a, a pathological uh sample. Of course, if the results are inconclusive, then you repeat the investigation. Ok. So we've got another question. Um I'm just gonna put the pole up. This is probably just one you either know you don't sure got a split so far. Ok. That's good to the answer. So the answer is induct invasive ductal carcinoma. Um So the reason I included this is I felt that it's often important to know which things are common, co common things are common. And I think if you're uncertain, having some gauge of um incidence of disease can help make you allow you to make a more educated. Yes. Um When you're faced with these type of questions, so, invasive ductal carcinoma is the most common type of breast ca cancer. Um Invasive lobular carcinoma is the second most common type and then ductal carcinoma in situ is the most common type of noninvasive breast cancer. The other two are actually very rare types of ca cancer. Um So I think if faced with a presentation in a, in an SBA or a question, um it would be uh unlikely to be one of those, those two N SBA. So a patient is being counseled ahead of a mastectomy with axillary clearance, which of these is not a recognized complication of the procedure. Got you. Yeah, you've done, you've done very well on this one. Nearly everyone got this one right. So, yeah, so the answer is hypermobility in the ipsilateral shoulder. So just to run through them, winging of the scapula that's due to long thoracic nerve injury. So the long thoracic nerve um can be damaged uh in a mastectomy and it's one of the responsibilities of the long thoracic nerve uh is innervating the cerastus anterior which is responsible for keeping the scapula tucked in against the thoracic wall. Um So winging of the scapula is definitely a complication. That's possible numbness in the armpit. So the inter costal brachial nerve can be separated in the procedure. Um And unfortunately, that results in paresthesia in, in the armpit. Um So it's a known complication, lymphedema in the arm on the ipsilateral side. Um Again, it is very much possible axillary, no clearance. I think it's almost self-explanatory, the removal of the axillary nodes, um impairs lymphatic clear lymphatic fluid, clear clearance. Uh and as a result, um you can develop lymphedema. Um choma are are common but actually, uh often do resolve postoperatively. Um And what you're more so likely to get is uh stiffness and uh immobility in the arm um following um following surgery uh due to the long period of immobilization. Um So, this may re may require some degree of physiotherapy uh to get people back mobilizing as, as per normal. So, yeah, I think it was just worth men mentioning and um flushing over some of the gross anatomy. Um Just so the c the cancer terminology makes sense to you. Um We talked a little bit about um the ducts uh and ductal carcinoma in situ and invasive ductal carcinoma. Um And I think it's just worth noting um the lobules and um the ducts within the breast uh and having an understanding of, of disease progression from, from DCIS to invasive disease. Ok. So next SBA so a 55 year old female has diffuse lesions in her upper inner quadrant and upper outer quadrant of her left breast. What would be the most appropriate intervention? I'll just put the phone up. Mm OK. So we got a a mixed split so far. But yeah, a good chunk if you did really well on that one. So the right answer uh I've got down here is left mastectomy, placentin node, biopsy and then post operative radiotherapy. So we'll go through it. So I think we can rule out um bilateral mas mastectomy because there's no indication for for bilateral um mastectomy, bilateral mastectomy uh is performed actually prophylactically in some, some ladies and I think it was popular popularized um by Angela Jolie um perhaps about a decade ago now because she had prophylactic uh bilateral mastectomy. Um but it's really um indicated in actually people that have um known and diagnosed um mutations associated with the disease. I won't talk too much into this cos it's gonna come up a little bit later. Um But there are very specific indications. I think that would warrant a bi bilateral mastectomy. Um And the disease here is confined to the left breast. So we have no concerns about the b right breast from the, from the vignette attached, left wide local excision would not be appropriate in this case because she has diffuse lesions. So I think um a concept worth getting to grips with is the fact that breast conserving surgery. So wide local excision. Um really is mo mo more appropriate when we have AAA small localized tumor, which is small relative to the to the breast itself. I think that puts a new position where um you can perform a wide local excision uh and conserve the breast um and have enough tissue uh to conserve the breast, you know, left behind. Um In this case, this lady has diffuse lesions. So it's unlikely that wide local exci excision would be possible or feasible. Um She's got essentially different small pockets of, of, of cancer in the breast. Um probably her breast would only be amenable to, to an entire mastectomy. So, removal of all that breast tissue, there are um really quite um a lot of, you know, weird and wonderful things they can do actually. Um of course, there's breast reconstruction using implants, but actually even using your own your own tissue. Um If you're so interested you, you can have a read up about tram uh and Diep flaps, um flap, sorry, but there's um there's lots of that can be done in the way of reconstruction. Um And there's nipple sparing reconstruction and, and lots of actually options from an oncoplastic point of view. But um they definitely aren't really in the scope of, of what you need to know for, for your finals. The last option was um why did we not include axillary? No clearance? Um So essentially auxiliary, no clearance as we talked about earlier is not only is it um significantly increasing the operative burden physiologically on the patient. Um but also there's the real complications or side effects. So you've got lymphedema, which is quite pronounced and that could become quite disabling for the patient. So in order to try and prevent that, uh and minimize, I guess the the um impact on the patient, it's worth assessing the spread um of the cancer in the lymphatic system and trying to be as conservative as possible. So what they do in a, in a sentinel node biopsy, which I think is really clever actually, um they use this um gamma missing radioisotope. Uh And what they do is they inject it. It's this dye that they inject into the lymphatic system, the axillary lymphatic system uh and the axillary lymphatic system is uh sequential. So the nodes all follow from one to another. Um And this, this dye essentially um is used uh and a gamma probe is used to look for for radioactive nodes. Um So they work their way down the lymph nodes. Um And all of the ones that flag up uh as being radioactive and showing, you know, signs of, of malignancy are then can be removed appropriately. Um And those that are not uh are left behind. And what this does is I think this minimizes uh unnecessary surgery and I think preserves the, the patient's uh lymphatic system as best possible. Um So that's why it would be inappropriate to, to jump straight ahead to axillary. No clearance. Um, ok. Sure. So we have, uh, an OS case scenario. Um, a 45 year old female presents your surgery with complaints of a new breast lump. What questions will you ask as part of the focus history? If you could pop into the chat, any questions that you would like to ask, uh, this patient if she came to the GP surgery? Uh, yeah, I absolutely agree. Yeah, we were talking about M malignancy, of course. Yeah. Mastectomy would be very, very radical, um, for a benign breast condition. You're absolutely right. So, has it gone over time? Very good. Is it painful? Excellent. What about some skin changes? Skin changes? Very good. Very good. Very good. It will discharge with loss. Yeah. Really good. Really good. All excellent suge suggestions, all the red flag sort of symptoms we're all picking up on as well as assessing the, the history of the lump as well. Ok. So, yeah, these are, oh, there we go. Yeah. So these are just some of the things that I mentioned, but of course, it's not an exhaustive list. So for the lump, just to take a thorough history of the lump. Socrates will be used for pain. I'm sure you've been taught, um, you can also remodel this and just apply it to the lump as well. So, the site of the lump when she first noticed it, what's the character of the lump, what's the texture like? Um you know, associated symptoms with the lump? Has it been progressing? Has it been getting larger? All of these things are very important when profiling if, if this is a malignant process or if this is more of a benign pathology. Uh and then yeah, lots of these symptoms you mentioned. So, red flag symptoms and then as well, things specific to, to the breast or redness, ulcera dimpling. Um Is the patient febrile, is this an infected position? Um Will they be able to, to slide up? I'll try and send them out to you guys. Um And yeah, I really impressed as well. You guys mentioned taking a fo focus ops and Gyne history. We'll come on to talk about that a little bit later. So we'll expo that and a family history which a lot of you guys mentioned as well. And then also, I think at the end if you have time, um you know, drugs, alcohol, smoking, we know that smoking is a, is a risk factor for breast cancer. Um But of course, I think this the focus of your history should be on, on the lump and then screening for, for concerning symptoms. Ok. So what we look for examination. So we've um we've done the history now. Um What features are you gonna do when you take a look at the breast, if you could pop them into the chat again? Yeah. Really good. How firm is the lump? Is it mobile? Is it tethered? Yeah. The size, the shape the symmetry. Yeah. Definitely palpate. Exide's. Yup. As well as palpating all four of the quadrans. Always, always remember to, to continue to palpate into the axilla. Yeah. Bucking the skin discharge. Is it bloody check for the limbs? Yeah. Absolutely. Sure. Yeah. So I'll share some of the, some of the ideas I had. So, yeah, another thing is perhaps that she had some, some previous uh breast surgery before um abnormality is very, very valid. I think important to remember the brush probably, you know, are unlikely to be I, you know, symmetrical. So some degree of asymmetry is normal where, you know, normal human beings. But I think if one breast say looks particularly in gorge or erythematous uh inflamed or, or perhaps there's um uh a, a visible lump uh often, you know, lumps aren't visible, but perhaps perhaps the, the, the lump is visible, then I think that would be more cause for concern masses. Um If there's a significant masses visible inver inversion discharge we talked about. Um and then we've got scaling erythema, puckering, uh p orange, I'll I'll show you the next next slide attempt to express some nipple nipple. Very, very good. Sure. So some of these are, these are some of the, the signs that we talked about. So if we look on the top left, that's just basically like the skin on the breast is look, looks akin to an orange sort of skin if that makes sense like of the, of the fruit. Um It's not a common sign. It's uh I understand to be associated with um inflammatory breast cancer, which itself is a rare form of breast cancer. Um But I thought worth noting it, it's uh interesting enough. Um on the r the middle, we can see in erythematous breasts, you can sort of make out the breast um on the contralateral side. Um And you can see it looks quite different. Um We can see some nipple inversion on the, on the top, right, on the bottom left, you can see a lump just outside the areola and then on the bottom, right. Um uh hopefully you can see some uh eczema ec eczema changes uh on the nipple. Does anyone know what that could be? Yeah, it's pads. Yeah. Um The point I'm just trying to make is that the eczema is starting right in the center of the nipple. Um So I think to put, to simplify cruelly, what I've I've learned is that, you know, er on the, on the center of the nipple expanding outwards is more likely to be pagets as opposed to some eczema changes of the breast. Ok. Yeah. So um I've got my uh feedback slide here. So you can complete, complete this. Now we can complete it at the end. Um But yeah, you'll get a certificate of attendance um which you can keep through your portfolio. So your Bits and Bobs um once you complete the feedback, I won't go for it too much. We can uh give you a chance to do it at the end. OK? We're back into another SBA. We'll just start the PVI. So a 57 year old female has been diagnosed with estrogen receptor positive breast cancer. She used to be started adjuvant therapy, which of the following would be most appropriate leah. That's a, a good question. Um We'll discuss it after. OK. So yeah, you guys, you guys did um very well, a little bit of split. But um for the most part, we, we got there so I can, I'll just scratch off number one for you. It's a red herring, it's an anti fungal agent. Um Nothing to do with breast cancer. Um The crux of the question really came down to the fact that this woman um needed uh either number two or tamoxifen, which is a SERM. So letrozole is an aromatase inhibitor. Uh As one of you guys carefully pointed out um is this woman menopausal or not? Uh therapy changes significantly post menopause as opposed to peri or pre menopausal women. So, pre or perimenopausal women are still producing endogenous estrogen from their ovaries. Menopausal women stop being able to do this. Um So their mechanism of, of, of providing estrogen for their body is through aromas, androgens. Androgens are either produced by the ovary stool, um, or by the adrenal glands. Unfortunately, I didn't tell you if this lady was strictly men menopausal, which was just to try and make it a little bit more complicated. Um, what I was hoping you'd go for is that this lady is 57 mean age of menopause is, is, is around 50 years old. Um, more than likely this lady is menopausal. It's probably she'd be an outlier if she was uh still premenopausal. Um And from that, I was hoping you'd go for letrozole um just to add some more challenge to it. But yeah, Tamoxifen is a SERM. So in pre or perimenopausal women, we just use Tamoxifen. I think this diagram is really nice because it just shows how um uh the drug uh acts on um estrogen receptors and modulate them. Um trastuzumab uh which we'll talk about a little, little bit later is a biologic drug. Uh And then um we've also got a chemotherapy agent at the bottom in DOXOrubicin. OK. So this slide is really important. I think if there's one to take a sort of screen grab off or even just have a look at uh on the website itself or in the, in the guide, it's this when you're, I think setting an SBA question or AMC Q being able to, to work around your knowledge of uh a guideline is probably one of the easiest ones you could set. Um So having an in and out knowledge of this is, is and particularly the top part. Um when we talk about consideration of referrals, it makes it a little bit more challenging to set an appropriate question. But being able to set a question on a patient over the age of 30 having an unexplained breast lump. It is very easy. Uh And and probably very likely the other things to know are over 50 year olds um only require discharge refraction or other changes of concern in one nipple. So there's quite a low threshold to referral. Um I would say but yeah, I definitely know this in and out this top portion here. Ok. So which of the following is not associated with increased risk of breast cancer? Ok. Yeah. So we got a split between, between two and the correct answer is BMI less than 18.5. So just to run through it, we've got a couple common themes. One is is of um increased hormon hormonal exposure. So both um progesterone only pill and pre precocious puberty um are both in there because of the increased hormonal burden that are associated with them progesterone only pill you're giving yourself exo exogenous progesterone. Um And then with precocious puberty, you've got more cycles, uh more menstrual cycles uh in your lifetime. So you're increasing that total lifetime dosage um of your endogenous hormones, Nolly, parity. Um similarly is in there increased hormonally hormonal exposure because of the fact that you've got fewer menstrual cycles. So, you've got a break from that um regime of, of, of serious endogenous hormones. Um And interestingly, there's quite a lot of research that shows that um early pregnancy. So having, specifically having a uh a child young actually causes a permanent um decreased risk of breast cancer, uh that's lifelong. Um And there's a lot of different postulated sort of cell to cell mechanisms for this. And I think there's descriptions of, of potential gene modification and uh decreased proliferation of progenitor cells um in the mammary epithelium. Um So it seems like there's probably more to it than just um uh hormonal dosage. Um But I think it's an area that's uh that's still quite um developing in, in research. And I don't think there's, there's a thorough understanding as of yet, but there's a strong association in the literature. Um The other is BRCA one mutation which I'm sure you're familiar with is, is the most significantly associated mutation with, with breast cancer. Others, of course, being BRCA two and uh some others that micro a little bit later. And yeah, so BMI less than 18.5 which makes someone um clinically speaking, underweight. Um obesity is an associated risk factor for breast cancer. So, we've got a 63 year old woman. She started on Herceptin following diagnosis of Hersey breast cancer, which of the following side effects are the most important for her to be counseled on. I'll just pop the poll up for you. Ok. So we got a little bit of a split. So the correct answer is cardiom, Withy. So the two known side effects that are included here, teratogenicity and cardiom. Um BT risk I put in as a red herring. There's, there's no associated risk that I'm aware of in the, in the literature. Uh It's actually used Herceptin or, or uh trastuzumab, uh which is, it's also called, uh it is used to treat gastric cancer and esophageal cancer as well. Um So I II didn't remember them actually, but when I was writing these slides, I actually, it came to, came back to me once I was um writing them up. The two that are known, obviously, it's rationality and cardiom and of the two, the woman is most likely past childbearing age. I don't want to say it definitively because I think I saw a case of a 62 year old lady giving birth recently, but by and large she's, she's um past childbearing age. Uh So probably most significant to her would be cardiomyopathy. But yeah, both of those two answers are um significant risks. OK. I'll just put this one up. So this one, yeah, the, the answer to, to this one is quite a messy flow chart um that they have and I think it's one where you kind of just have to sit down and get familiar with it because it can get quite confusing it's more of a rote learning type of thing as opposed to um understanding. But I think you can simplify it down by just uh having an awareness of some key principles. OK. We've got a nice split across the board on this one. Nobody's going for the one that's very wrong though, which is, which is the important thing. OK. Sure. Let's discuss it. So for which of the following would genetic testing be least indicated? And again, I think it's quite a mean question for me because I've said um least indicated. So I'm asking you to, to, to flip the answers on the head. Um The caveat here is, is actually having a mother. So your, you know, your first degree relative um diagnosed with breast cancer less than 40 warrants genetic testing. Um So it's, it's really just being panicky and, and, and uh writing the question around the rule, um the TP 53 gene is one of um the significantly associated mutations uh alongside BRCA one BRCA two we've discussed and um a host of others, male breast cancer is um alarming. It's very uncommon. 99% of cases of breast cancer are women. Um So it's one of the criteria that actually um uh does want referral to secondary care. Um Four, we've got her aunt being diagnosed with breast cancer. So a secondary second degree relative and then her sister being diag diagnosed with ovarian cancer. So a first degree relative and due to um common uh genetic risk factors, um that would qualify uh as well as mother and grand mother, both being diagnosed with breast cancer. So 1st and 2nd degree relative with breast cancer. So here are some snippets from um nice, essentially. What did he say? Not sure. It, between three and five, the difference between three and five is that in three, it's just his mother that has breast cancer. So one first degree relative and that's over the age of 40 in five, he's got both a first degree and a second degree relative. Um If I show you the summary of the guidance here, it will kind of um it hopefully will make it a bit clearer. These are not uh again, it's not really about understanding, it's purely rote learning uh the different criteria and what warrants genetic testing. But um for a first degree female relative to be diagnosed with breast cancer, uh the age cut off is 40 years um that we have, again, I imagine in real life, in real practice, how much this is adhered to. It probably would vary. Um But in terms of writing an SBA and writing a question, um I think it'd probably be fair game to, to be that specific. Yes. Yeah. Option five is any age, I'll include the link for this again at the end. So you guys can take a look. It's probably one you just need to go over and digest but things like male breast cancer, bilateral breast cancer, concurrent ovarian cancer and of course, things like a per personal history of, of breast cancer. All sh all should raise alarm if you're in doubt and, and can't quite remember these. Ok. So pop this one up, nearly getting there now. Yeah, everyone who's on this has, has got this uh got this all wrapped up. I let her come and we answer and we'll go through it. But yeah, since you've all got this right, does anyone wanna just pop in? What you think the vignette was alluding to um is a diagnosis or we can just, we can just get through it. So, what I was trying to get at here was fat necrosis um of the breast. So, fat necrosis is uh a condition, it's a benign condition. Um that presents really what could be quite similar to, to, you know, a malignant lesion. You could have a firm irregular lump, um painless. Um And it could be quite concerning for a, for a patient to discover it. I think the key thing to, to know is fat necrosis is associated with obesity. So I'm trying to paint a picture of this, this patient has got a metabolic syndrome. Um And then the other, the factor is that it's can be atraumatic, but it's often associated with minor trauma. Um So those are the two things I was getting at. She's a, a lady with a previous history of metabolic syndrome. Um And then you notice her ankle is, is booted up really? So she's had a, she's had a tumble, although this is a benign condition. Um it's transient, there's often, you know, not um any management that's, that's undertaken, it's often just managed conservatively. Um Although if, if it is problematic, um I think uh intervention can be, can be pursued. Um, it still does require a referral to a breast breast clinic because you can't clinically rule out um something like an, you know, inflammatory breast cancer or whatever it might be. Um So because of the concern um for any irregular lump, uh you need to still consider and rule out malignancy appropriately. Ok. Yeah. So just to touch through on to benign breast disease, we've got your final question for today. Hopefully this is a nice easy one. Mm Awesome. You haven't got it. So, yeah, this is, this is staph aureus. Um So lactation mastitis is an important one to know about probably the important and effective condition to know about. I think just understanding the mechanism probably perhaps it makes sense. So um the lactational ducts get blocked and then these get engorged with the backflow of blood, blood, sorry milk. Um you get inflammation of these ducks and then this, you know, engorged block duck gets infected. Uh And then this can lead to an abscess if you're, if you're, if you're unlucky. Um the mainstay really is initially just simple analgesia. And if the lady is breastfeeding, um it's important to know, you know, mastitis isn't just lactational but often can be lactational. It's encouraging, encouraging, uh you know, milk expression, um trying to unblock those ducks. Uh and um hopefully that will alleviate the symptoms. Um of course, if symptoms persist. So, you know, 12 to 24 hours after continued effective milk removal, um then you can provide antibiotics equally, say, if you've had a milk culture and you know, 24 hours, 48 hours for that culture di process has elapsed and it, the culture comes back, positive antibiotics are also warranted. And then finally, a fissure which is just, you know, like a slit that you might see in the, in the nipple complex. If a fissure is present again, antibiotics are also warranted. Um empirical treatments with flucloxacillin. But if the patient's panallergic, then um Erythromycin or Clarithromycin or it can be used and that's for a 10 to 14 day course. Um Of course, if you have cultures, then you can also have sensitivities. And if the sensitivities are, are you suggested differently, then of course, follow those. But the presentation I think is, is relatively straightforward. It's a a fluctuant lump, uh It's tender breasts will be erythematous, you know, as you can see on the right side of the screen and the patient often can be. Um And as you rightly said, Staph A is the most likely causative organism. But worth noting that all of these organisms listed uh are known and documented to cause um uh lactational mastitis. Oh yeah. And of of course worth mentioning the patient is septic. So you know, their, their scoring on their Q score you're concerned about and they're unstable. Uh then they need to be sent at urgently to the hospital and then a quick summary of of benign breast disease, almost like a sort of cheat sheet just for key phrases and things. Um Some of the key things to know about are fibroadenomas, fibrocystic disease type ectasia and intraductal papilloma. Um So fibro adenoma is uh the, the highly mobile, you know, discrete breast lump that uh a young woman might present with um very common in, in women sort of age 18 to 25. And really, you, you're gonna see them in women under 30 they develop from the lobule itself in the breast, from the, from the picture we talked about earlier. Um And actually these, these can be managed conservatively if they're small. There is a small concern um if they're, if they're larger or say that they're growing that this could be something called tumor. This is a very rare um breast uh breast tumor. Um And I think it's, it's, it's probably not worth diving too deeply into. Um but it's worth knowing about fibrocystic disease of the breast. And this is really applicable to all women of, of, of menstruating age. So, premenopausal women uh and this has changes to the breast that happen uh concurrently to the to the hormonal cycle. Um it's crudely probably described as as bilaterally lumpy breasts and women have breast pain and this really reaches a, a peak one week prior to menstruation treatment for this is largely supportive again. So, you know, use of a supportive bra um offering analgesia. Uh Most of this actually resolves with menopause. Um And I think there's an emerging and potential role for for use of uh hormonal therapy in the form of a contraceptive pill duct, ectasia. Conversely, then now we're talking about menopausal women um with menopause, these ladies get uh shortening and dilatation of the, the uh lactic lactiferous ducts. Uh and these can then become clogged. Uh smoking, predisposes these ladies to this condition. Um And what you can character characteristically see is discharge um which can even turn sort of a greenish color. Again, there's no really specific treatment but like we mentioned before uh discharge in a lady um over the age of 50 can be concerning uh from a, from a red flag perspective. So the two week wait rules do apply again here. Um And it still be worth getting checked out on the One Stop clinic. Um And then la lastly is uh the intraductal papilloma. So this is a, a benign tumor of the of the ducts. Again, usually 40 to 50 year old ladies uh and you get singular duct discharge. So rather than discharge, you know, coming from the, the nipple at various points, it, if you uh if you ever see a picture of it or see it in real life, it will literally just be coming from, from one, from one duct. Um And this can be clear up, could even be blood stained as well. Um And if problematic, this is uh just treated of that duct itself called a a micro ductectomy. So yes, to summarize, we talked about, you know, the sort of the two week great criteria for breast cancer. Uh What happened to the triple assessment? We talked about features to look for in an examination, history of a breast when pre presented with a lump and then operative, non operative treatment for breast cancer, uh as well as some features of benign breast disease. These are some of the resources, what I'm just gonna do is pop them into the chat. Um If you guys aren't familiar with them, I would highly recommend mcmillan's rapid referral guide. This is the segment on genetic management for, for, for breast cancer, family history of breast cancer. Um And ki me, I'm sure you're familiar with as well, but I definitely recommend uh those two resources and yeah, just a little bit for me on my, on my references. Perfect. Thank you so much guys. That is my talk. We're just past eight. So yeah, hopefully right on time for you guys. Um Next up, we've got ent in a couple of days if you'd like to, to scan the feedback form. Um And yeah, once again, when you complete that, you'll get a certificate for your portfolios and I'll, I'll pop it into the chat as well. You're very welcome. Thank you for, yeah. Thank you all for joining. I hope you have a nice rest of the evening. Thank you guys. Yeah, I'll, I'll end the call here. Goodnight everyone.