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At Roland actually Barts Trust. So today I'm gonna be presenting a lecture on breast pathology. So, with any condition, we need to start with a history presentation, investigations and management in terms of the history taking the most common complaints um are pain um in the breast, uh breast lump, abnormal nipple discharge, and there are significant risk factors that we always ask um about which are specifically um previous breast cancer, family history or brachy carrier, um history of ovarian cancer as well and bowel cancer. Um if we're thinking those genetic syndromes, alcohol and take get peripheral aromatisation and increase estrogen with patients that are obese and the fat cells. So they are more likely to have more estrogen exposure. And of course, with increasing age, you are more likely to develop cancer. Also, particularly with estrogen exposure, we want to know the age of men are key if they've had Children and if they've breast fed, if they are on any hormonal contraception specifically and at what age they hit the menopause. Mm. And how are they in general, do they have any medical conditions? And are they on any medication for anything moving on in terms of the examination that you'll have in the pacs exam, it's usually five minutes um allocated to the breast part of things. And it's combined with the vascular station, usually at least it was for me. And you usually have a, a healthy young female. And I would say definitely for this one, you need to watch a lot of geeky medics. It would be very useful if you attended the breast one stop clinic. Um but essentially will be going through palpation technique. But I go through the quadrant method, make sure you don't squeeze the patient's nipples. If you want, you can ask them to express um any discharge if they have. And um I always recommend using GK medics and things like that because they really help in terms of the any examination, as we said, like introduce yourself, get consent, explain why you're doing the exam. And then in terms of the positioning of the patient, you need to have them sitting up, but also ask them to do different movements like putting the arms behind the head and also on the waist. And usually we ask people to lie flat, like sorry, lie at 45 degrees for the palpation technique. In terms of the auxillary lymph nodes. What I do is I basically get the patient to put their arm on my hand on my shoulder, sorry. And then I feel the lumps in their axilla and it's quite helpful basically because you get them to kind of relax the skin there and you can feel if they've got any axillary lymphadenopathy. And then always at the end of the examination, you want to offer other things. Like if you actually think that there's a lump you'd offer imaging, which will be according to the patient's age. If they're a young female, usually we go for ultrasound. If they're old, older, we recommend mammography or mammogram. And then if we're thinking malignancy, we want to also check for metastases. So they would be going ct chest, abdomen, pelvis. Um You'd want for imaging, but also from an examination point of view, you want to feel the liver for any hepatomegaly. You want to listen with your stethoscope for any pleural effusions, which can be malignant. And then you want to assess for point tenderness along the spine, which could be again malignant metastases. And of course, particularly with the breast station, make sure the patient gets um dressed, offered to help them and respect their privacy at all times. Here is the examination video that I like from ki medics. But also this is a infographic on the right showing breast self examination and it sort of shows you the palpation technique. Um A lot of people use the clock pattern and they and I use like three fingers to basically palpate the breast and make sure you're gentle with this. A lot of the time women may have fibrocystic disease, which may make their breasts feel lumpy all over and that's ok. However, sometimes it's harder to distinguish what is an actual separate lump in those cases. So you definitely would need imaging if you are suspecting a lump as well. With the breast clinic. It particularly the one stop clinic, what they focus is on a triple assessment. There's a physical assessment which involves the history and examination. You've got a radiological assessment which is the ultrasound mammogram or both. And then you've got the histological assessment, which is either a fine needle aspirate or a core biopsy. One of them, basically the fine needle aspirate is what it says. It basically is on the chin. You know, you put a needle into the lump and you aspirate a bit of the c a few of the cells and then look at it under the microscope. Whereas a core biopsy, you're actually cutting out tissue when then you are doing a histological analysis of that tissue. And then what happens is according to whether it's physical radiological or histological assessment, they give a score and usually that score is normal, benign, intermediate suspicious or malignant. And according to what all three of those parameters show in terms of the score, then you decide how you're going to manage the patient. Sorry. Our first S VA then a 24 year old presents with a 18 millimeter mobile lump in the left breast at five o'clock one centimeter away from the areola what imaging would be ordered if you guys wanna pop your answers into the chat. I don't know. Is anyone saying anything? Yeah, we have a few people saying ultrasound. Yeah, these are today. So in young patients, particularly under the age of 40 we suggest the use of an ultrasound as the first method. Um Next SBA 25 year old with intermittent pain and heaviness in both breasts but worse on the right, worse before her periods but has a normal e examination. Sorry, what imaging would be ordered. So we have a few people saying a yeah, so no imaging. Ok, because this sounds like psychical breast pain. And we don't think that there's a lump or any sinister pathology. However, we would do an examination as the question stem suggests and if, if the examination is normal and the patient is not complaining of any specific lumps, then we wouldn't give any imaging. So, benign breast disease is quite a big umbrella term and it covers quite a few things. Um We're only going to go through some of them. So the fibroadenoma breast cyst or fibrocystic disease, mastitis and abscess, bit necrosis DTA and then you can have chronic inflammatory condition. Um This doesn't really come up but just to briefly just tell you before I go into the common ones, particularly in patients with granulomatous disease. They may have um inflammation in the breast tissue and granulomas in the breast tissue and it may have a similar appearance to breast cancer and is excluded with biopsy. However, unlike cancer, this is usually self limiting, but you can consider steroids now onto the common things. So, fibroadenoma. So what a fibroadenoma is, it's a very, very common lump, particularly in young females, which is benign, often referred to as a breast mouse. And essentially, it's a solid lump that is not tethered to the skin, not associated with any skin changes. It's more common in Asians and Afro Caribbeans and there is no increased risk of developing breast cancer if you have this. However, sometimes if the the lesion is, is um categorized as indeterminant, they may need follow up scans and may need a biopsy if there's any size increase on those scans and if the size is over four centimeter, you'd need a diagnostic exci excision. Ok. And here's a very nice infographic. I don't know if you can see the moving parts to it. I quite liked it. I thought it was cute showing the difference between fibrocystic changes and fibroadenoma. And here you can see on the right, you've got a fibro aoma with a natural lump and women usually come in saying I can feel a lump in my breast. It's painless. I can move it around and it's different to fibrocystic disease, which is, you basically have lots of different cysts where let let's move on to that slide. So, basically, fibrocystic disease when you've got benign fluid filled lumps and often as I said, you have like a lot of them. And if there's a very large cyst, you may choose to aspirate it and the fluid is usually straw colored or green. And once again, there's no increased risk of developing breast cancer moving on. Can anybody tell me what the image on the top? Right shows and what the one on the bottom shows? I can't see the charts. So if someone minds just if you can unmute and tell me what it is, that's also good. So the top one looks like mastitis and the bottom one looks like an abscess in the second picture showing it being drained. Exactly fantastic. So it's quite hard just from the, from the images because you actually have to uh palpate the breast. Well, the difference with the two is whether there's underlying collection. So with mass, you have an infection of the soft tissue without an underlying collection. But with abscess, there is an underlying connect collection, sorry, with soft tissue infection as well. Um And general with mastitis, you can get lactational and non lactational mastitis. It's therefore more common in smokers. Uh those that are postpartum and breastfeeding also because they're more likely to introduce bugs. If you're diabetic, you're also more likely to get skin infection on the breast, autoimmune disease, granulomatous disease and skin disease. Like if you have eczema psoriasis, et cetera and lactational mastitis specifically is caused by skin commensal um and the advice we usually give is to still continue feeding the baby express or expressing the milk if they are on antibiotics that you don't want the baby to get. And you usually give flucloxacillin unless they are predniSONE allergic because you want to cover those skin commensal like staph and strep. If there is underlying collection and it's an abscess, they need referral to breast clinic and if they are septic, they need to go to A&E and usually, and the ones that are systemically unwell, have a big abscess of those that will undergo the incision and drainage like any other abscess with antibiotics for approximately a week, moving on to fat necrosis. It's what it says on the tin. Really, you've got a nonsupperative inflammation of adipose tissue caused by the destruction of oxygen supply to fat cells, which ultimately leads to cell death. You usually get a collection of clumping of cells as you can see on the mammogram in the bottom, right and on the left, you can see what it looks like under the microscope. And here you can see all the fat cells and usually this happens to women that have undergone breast trauma but also or injury to the breast, but it can be associated with malignancy. Excuse me. And you may get some associated redness or bruising and a thickened tissue around the area that you have the fat necrosis with or without a lump duct ectasia. Here you can see very nicely in the mammogram. Um a visual description of this really where you basically get blocked stuff in the milk ducts, right? And usually you get the milk ducts widening with the walls thickening up and it's usually caused with the because the duct is blocked and that leads to fluid build up. However, the exact cause is unknown, you may get green or brown discharge and it's more common in breastfeeding mothers than smokers. And as we said before, you always encourage breastfeeding to help with the stagnancy of the milk in the ducts which will improve. Um Basically, the difference here though, between uh sorry with mastitis and duct ta is the fact that one of them is an basically infection of the skin and underlying tissue where duct tase is just blocking up in the ducts and the breast may become engorged because of that. That's why you want them to continue expressing the milk as much as they can because it will help promote the um reduction of that uh of that fluid becoming stuck in the milk ducts. Moving on to our third question. So we've got a 28 year old woman, four weeks postpartum with a painful swollen right breast that is hot to touch and red with a temperature of 38.5 and a pulse of 120. Do you want to a admit for septic screen and IV antibiotics b discharge with oral antibiotics in breast clinic. Follow up c urgent referral to breast clinic. D discharge with lactational advice, e discharge with GP follow up. Mm and if ta over shot you, if you could read out the answers when people put them in. Yeah. So we have D and A how many people for each and just one person for D and 2 O2 for each basically. OK. Um Anyone else II think that's it. OK. So the correct answer is a and the reason for this is this woman is septic. She is high risk because she's also postpartum. So you know, there may be a safety issue, sending her home. She's got a young baby to look after, but she's really unwell. She's got a potentially an abscess here. She's got mass or breast sepsis, but she's per and it's quite a significant temperature, an tachycardic, we don't have the BP, but based on that she is septic and that proven otherwise. So she definitely needs a septic screen and she definitely needs antibiotics most likely IV at this point. But you may con consider discharge if she normalizes thereafter. But you also want to do the sets of six. So IV fluids, antibiotics and you want to take a lactate, take blood cultures, monitor urine output. OK. So that's very important SBA form imaging is performed in a 38 year old which shows an irregular 43 millimeter mass that is solid with some prominent nodes in the axilla biopsies are taken which show lymph lymphocytes, granulomas and fibrosis. How would this be managed? A wide local excision and axillary clearance? B chemotherapy C referral to appropriate medical team for consideration of steroids d surgery and chemotherapy. E no further action. So we have a mix of answers. We have two CS and an A and ad sorry. I think the A and the D were for the previous question. I think it's just two CS so far. Ok. Yeah. So correct. The answer is C and the reason why it's C is here, you've got potentially something that could be a breast cancer, right? And with metastases to the axilla, however, you've had a biopsy which shows that she's got granulomas, right? And no real cancer cells, right? There is no irregularity. They are not talking about increased mitotic index, all those kinds of things. So this woman most likely has granulomatous disease, which is why she needs work up from the medical team and consideration of steroids to suppress the inflammatory response. Are there any questions at this point for benign breast disease before we move on to malignant breast disease? Hi, I just had a question. I think um I think it was for mastitis. You mentioned um the mother could be on antibiotics. Would you still encourage breastfeeding whilst they're on antibiotic? So it depends on if the antibiotics that they're receiving are safe. Right. Yeah. Um I would definitely encourage them to express the milk that they're producing. It depends what you're giving them because certain antibiotics are, uh, all right to pass to the child and some of them are not. So, it depends and sometimes when it's, when they're pen allergic, that's when you have the problems, um, when you have to give them macrolides or other, other class of antibiotic, that's really a discussion for micro. But definitely you'd be encouraging, um, them to express the milk. But I don't think the last you something specific to that um It's just going to be a manage and they're basically just gonna ask you how to manage the patient. I don't think they're going to go into the nitty gritty about the breastfeeding as well because even we would have to look at the BNF and consult a micro um biologist, biologist if necessary. Does that answer your question? Yeah. Thank you so much. No worries. Let's move on. Then if you have any questions, just please tell me at any point guys, this is a small group. So I'm very happy to do so. So can anybody tell me what the image on the top? Right shows and just shout out. OK. Does everyone wanna have a go at one of the images on the screen? Just just tell me if there's one that you know what the answer is just unmute and tell me what you think it is anybody. So is the bottom right? One PP or yeah. So you have skin tethering and it almost looks like basically like the skin of an orange. So yeah, that's po orange. Great. Well, I'm going to just go through them and go through the breast cancer findings. So here in the middle image, you can see skin changes associated with breast cancer. Um you can see on the left a fungating breast tumor, it looks very deformed. This is what you usually get with ulceration. It's horrible. This poor woman bless her. And then on the top right, you can see Paget's disease of the breast to be not, not to be confused with Paget's disease of the bone. And this is actually a rare finding where you have eczematous like changes around the nipple. However, this is not eczema, this is, this is cancer. Ok. So if you see this, you do not just show it with steroids. You investigate for breast cancer that's very specific to breast cancer if they have it, look for breast cancer. So usually you get a fixed irregular shaped mass with new asymmetry. When you're comparing the shape the size of the breast, you may have the Poonch changes, which are the tethering of the skin tethering of the lump to the skin by the cobra ligaments. And you may also get associated nipple changes such as nipple inversion, nipple crusting or abnormal nipple discharge, particularly blood stained. Sometimes if the breast cancer is found in late stage, you may get profound axillary lymphadenopathy. And then according to whether it's metastasized to distant places in the body, you might get symptoms and signs related to that such as breathlessness fractures. Um Hepatomegaly, as mentioned before, with breast cancer, we have local treatments which usually involve if it's not very, at a very severe stage, you'd either give a lumpectomy or wide local excision or mastectomy. Now, the difference with these things are lumpectomy, removal of the lump, wide local excision, removal of the lump, plus a bit of tissue mastectomy, removal of the whole breast. And this really depends on the breast itself that you have there. So if you've got a lady with a big lump with a small breast, they're going to need probably a mastectomy. Whereas if somebody has a big breast and they've got an isolated lump, you might do a wide local excision. It just depends on, it depends on the location and it also depends on the type of cancer that we're dealing with. If it's a carcinoma in situ, we are more likely to just do a wide local excision rather than a mastectomy. But if we're worried that this is invasive cancer and need a mastectomy, and then you may also do auxillary clearance. If there are any lymph nodes in the axilla where the cancer has spread to. And if it's spread to multiple ones, it may not just be a sentinel lymph node biopsy, it may just be the whole axillary, lymph nodes like all of them together. And that's when you get lymphedema because the reason why we have lymph nodes is they promote the flow of lymph around the body. And a lot of breast cancer patients, if they've had a mastectomy, and they've had a full axillary clearance on that affected arm, they are going to have a lot of fluid called lymphedema. And, and it's very challenging to manage for these patients. They sometimes will go on reconstruction and that's either immediate or delayed. And you can do autologous autologous implants which are sorry, autologous reconstruction, which are usually flaps. So you can either do a free flap, which means you take the tissue with its blood supply and you put it onto the uh blood vessels of the breast and connect it. And by magic, it works fantastic stuff. Um you can do deep. So the place that they usually get it from is the deep inferior pro gastric um which is an abdomen, um abdominal pedicle. So you take the deep inferior epigastric vessel with, with the tissue um of the abdomen and you almost give them like a tummy tuck and, and reconstruct the breast from that. And you can also make a nipple or you might do a transverse upper gracilis flap which is from the thigh. And then you can sometimes do a latissimus dorsal pedicle flap and more pedicle flap is basically you're moving the flap um with its blood supply, but you don't um disconnect it, ok? And you can also just do regular implants. But the reason why we prefer to use people's own tissue because you get a better um reconstructive um outcome. And yeah, so that's usually done by plastic surgeons. Whereas the um whereas the implant is usually done by the breast surgeons, ok? But it can be, both of them can be done by plastic surgeons. And um the, the thing to mention is yeah, pedicle flap, you basically just it's still attached their blood, it still attached the blood supply and then and then you take it there. Whereas free flap, you disconnect the blood supply. So you cut the very gastric for instance and you take it to the breast. Then according to the type of cancer which I'll go into, you do systemic treatment, you may do systemic treatment, you usually do some kind of systemic treatment most of the time. And that's chemotherapy, endocrine therapy such as anti estrogens, like tamoxifen and immunotherapy such as anti her two like Herceptin. Um and the drug name is Tra trastuzumab and it's as we said, targeted to the biology of the cancer. So we've got nice infographics here and graphs on the bottom, right, you can see the distribution of breast cancer cases. Um most of them, as you can see are hormone receptor positive as an estrogen receptor or progesterone receptor positive and her two receptor negative. And those are the most common, 73% of cases. Um the ones that are the hardest to treat are the triple negative cancers. So, estrogen receptor negative progesterone receptor negative her, her two receptor negative. And as with most cancers, we do the TNM staging. So T is tumor size and here you can see grade one is 0 to 2 centimeters. Grade two is 2 to 53 is greater than 54. It's broken the skin gone through, et cetera. Lymph nodes. You can see it here. But basically how many lymph nodes it's gone to how many vessels affected. And then sorry, how many lymph nodes affected and then metastases if you've got distant metastases, local metastases, etc. And here you can also see a summary of the different types of breast cancer. You can have um as we mentioned, a lobular and ductal carcinoma in situ and they are considered non invasive, but they are still cancer. So here is what we would consider a wide local excision. And then you've got the invasive lobular carcinoma, invasive ductal carcinoma. And then you've got, as I said, like some weird ones like Thos Paget's disease, et cetera, inflammatory fungating tumors. And most of them are invasive ductal carcinoma. Ok. Let's go on to an SBA we've got a 59 year old with a 26 centimeter, sorry, 26 millimeter uh grade three in invasive ductal carcinoma which is estrogen receptor positive. Her two positive with involved nodes, what is her likely treatment going to be? And I'll let you guys read the option because it's quite wordy and just shout it out or write it in the chart. We have C in the chat. How many people have responded had before? Great. So she is the sorry c is the correct answer. And the reason for this is here, you've got a cancer that has, is grade three. So it's 26 millimeters. It is hormone receptor positive and it's um her two positive. Ok. And here most likely we'd be going for a wide local excision with axillary dissection because of the involved nodes. And here we can go for radiotherapy. We can go for endocrine therapy and we can go for immunotherapy because of the her two as well. So basically we can go for the whole shebang if necessary. Good. Here we've got a 41 year old woman with a small breast that has a 45 mill grade two invasive ductal carcinoma estrogen receptor positive. Her two negative with normal nodes. What is her likely treatment? Is it? B Yeah, we have two more bees. Yeah, exactly. So here, the thing that's relevant is the fact that she's got a small breast. So here you'd be going for a mastectomy in all cases. Even if the nodes appear normal, you will be doing a sentinel node biopsy. And what the sentinel node biopsy basically is is that it's the mother node that all the blood, that all the blood goes through essentially. Sorry, all all the lymph, basically, if the cancer is going to spread, it's going to spread to that one rather than the ones lower down. That's the mother node basically. So that's why you're going to do that to just make sure that there's no involvement. And here she can't have immunotherapy because she's her two negative. So her only other option is eastern receptor like tamoxifen. Basically. So endocrine treatment, that's it. This was quite a short and sweet lecture. I hope that was helpful. Please please fill in the feedback and let me know if you have any questions for me. I'm very happy to answer. I didn't want to make this long winded. It's actually quite simple and those are the main conditions that come up. The only other thing I would say is make sure you revise your pathology stuff. So a lot of the time they might ask you about the cell types or they may tell you what cell types are there. So just remember that um in terms of like being able to name the type of cancer that the patient has. Does anyone have any questions?