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If at any point you have any questions, pop them in the chat, I'll kind of go between looking at my slides looking at the chat. Um, I've tried to make it as high yield as possible, so I'm not going into detail. Um, about kind of random things. I'm trying to present it as if you get questions in your actual exam. Um, and it shouldn't be too long. I think I only have, like, 40 slides. We're gonna go through it to the three things we're looking at is like key causes of breast disease that you need to know key factors within a history to look out for and within empty Hughes, Um, and a little bit on the management of breast cancer. Um, it can get quite detailed, obviously, because it's a whole specialty, But you don't really, I think pattern recognition is a key thing, and you don't really need to know that much detail for breast because it's more of a niche, um, specialty amongst the surgical ones. Um, so I've tried to just include the key points, but obviously we don't have time for it to be, you know, completely, um comprehensive and The other thing I would say is I've tried to make it case based. So we're going to try and do it through questions. Um, I guess because I'm going between the slides and sharing screen. I'll sort of be I'll just flip between the two to look at the chat. But it would be really great if people can post, um, an answer in the chat, even if you think it might be wrong. Um, all of them, they'll be five possible answers for for each case question. And if you get it wrong, nobody cares. But it will help engage in your learn. More so cool opening questions. So 41 year old women with six months of cyclical cyclical pain in both breasts, um, she recently noticed lump in the right breast. There's diffuse nodularity of the axillary tales of both of them, Um, and she has a discrete 20 millimeter mass in the upper outer quadrant of her right breast. If I need a aspiration is done in five middle of brown fluid is removed and the mass disappears. Cytology shows cellular debris with no malignant cells. What is the diagnosis? I think I flipped, too fast. Anyone have any idea? I'll have a look at the chat. I'm not gonna create a pole. I'll go back on the question. Any idea? Someone said fibrocystic breast disease fab Cool. Nice. And I, uh, cool. So the first, uh, thing we're going to talk about in general is benign breast disease. So, um, that's the one that we just looked at. And it's fibroadenoma sis. Phibro. Adenosis can also be known as fibrocystic disease or benign mammary dysplasia. So if you see those answers, don't be concerned. Um, traditionally, you're looking at middle aged women, and it's very, very common, and it's just lumpy breasts, so they it tends to be bilateral, and they can be painful. They can also be nonpainful, um, for women who are still menstruating. The symptoms can get worse before, and it's associated with no increased breast cancer risk. Generally, you don't really do much for them. You just reassure them. And so it's conservative management, and you can give them some manage easier if they need it. Um, obviously key feature and that question being you're draining it and you're completely removing the mass, so that makes you a lot less worried cool. Next 26 year old woman. She has a new lump in her right breast. She first noticed it when she was shower in in the morning. Um, it's got It's at the three o'clock position. She thought she might have noticed a form of a lump a month ago, but it was at the 10 o'clock position. She's well, no family history, no significant social history. What's the most likely diagnosis? So if anybody wants to put something in the chart a number or a word, have a look See, by the way. Nice, perfect. Cool. We've got a lot of fibroadenomas, which is correct, Um, so fibroadenomas. Traditionally, they call them Abreast Mouse, hence her noticing that there was a form of a lump. Before that, she may be noticed, but it had changed position. You would never get that with breast cancer. It stays in the same place. Young women, so less than 30. They'll come in. They feel a lump there, obviously concerned because they're worried they might be have breast cancer. It will be very, very mobile when you pal pace it, so that's why they call it a mouse. It's not painful It's not tender. It's well circumscribed. You can get your fingers sort of around the whole lump on examination. Um, if it's less than three centimeters conservative treatment, it should shrink. You don't really need to do much for it. If it's greater than three centimeters, you can take it out surgically. Um, but obviously we're not worried. And most women are reassured, and they'll be seen at their G P for fiber autonomous. Next 62 year old women she's got discharged from one nipple. She's had three instances across the past six months, the last of which was bloodstained. She's diabetes, diabetic, and she manages that with diet and exercise. She's otherwise well, she takes calcium and vitamin D supplements. Her mother had a heart attack at the age of 70 to her father is still alive. What's the most likely diagnosis? I'm just gonna flip to my chat. I'll get back on that. This is a slightly harder one. See whether anyone wants to go for it. Anybody brave, brought 34 people. Great, amazing introductory papilloma. Very good. So remember breast cancer questions or breast surgery? I should say, Actually, breast, any breast question can be to do with nipples, nipple discharge and stuff like that rather than just lumps. Um, so here, thinking an intraductal papilloma, um, common in 40 to 60 year old. So it would be a bit strange for a young woman like a 24 year old to come in with blood stained discharge. That would be very uncommon. But Intraductal papilloma is an older woman or middle age. Rather are common. Um, and they are local areas of epithelial proliferation in large memory ducks. Um, they are not malignant, and they're not pre malignant. They're just hyperplasia and commonly in questions, and they'll talk about blood stain discharge. And what you can do is a micro doke ectomy, which is basically where you take out that duct that that's causing the issue. So it's kind of a duct removal rather than any significant removal of the breast or extensive tissue removal. Um, cool. No more questions. This is an example of it, Um, and that's what you would see on a scan in the right. Just displays. It's a diagram I thought was quite It's imaging. OK, case four. Now we have a 42 year old woman rapidly growing irregular mass in her right breast. It's six centimeters in diameter. Core biopsy reveals mixed epithelial and connective tissue elements. Anybody want to hazard a guess? Is it breast cancer? Gynecomastia, Fibber adenoma, Phyllodes Tumor or introductory papilloma? Let's see two. One for breast cancer, too for gynecomastia. Three for fibroadenoma phyllodes tumor or intraductal. Anyone guessing great? Filled's correct, Um, and the key part of that is the mixed epithelial and connective tissue elements. So phyllodes tumor? Um, they are enlarging masses. They're not very common, and they tend to be in women above 50 years of age. Some can arise from fibroadenomas. The majority are benign, so you're not really worried. Um, most of the time they're non cancerous, but some can be aggressive, so you would usually investigate them further. Um, and that may lead to conservative management. If you know you do a biopsy and you're happy, it's likely to be benign based on the histology. If they do need surgery, probably be a wide local excision if you think it's going to be, um, an aggressive tumor. Okay, last case for this kind of chapter of breast surgery. 24 year old man, um, complains of a soft swelling around his left nipple that's gotten bigger. He is a big fan of cannabis. He's got normal body index, Um, and there's nothing really that we see on examination. This is an incredibly easy question. So anybody have any idea which one of those it might be? I'm hoping I'll get some more engagement in this one. We've got one. Anyone else I want to write in the chat? Probably not, but for the sake of time. Gynecomastia. So this is a classic history of gynecomastia and usually unless it's a very where rare kind of Endo related question, which you would never get in finals. If you get a man in a breast question, it's gonna be gynecomastia. So it's physiological. In neonatal, it's, um, in puberty and in the elderly. Most of the time, it's idiopathic. Um, causes can be renal failure, cirrhosis, testicular tumor. So if you've got a better HCG PSA, creating tumor and drugs drugs is probably going to be your most common one. So cannabis actually increases your chance of or risk rather organic nastier, and the other really big one is spironolactone, so always keep an eye out for that one. It's a very common cause, Um, and in the rare rare cases, you might think of an endocrine cause. But I highly doubt they'll bring that up in finals. Obviously, depending on most cases are going to be drug induced, depending on the cause. You usually want to keep the drug because the drug is usually treating a condition of sorts. Um, if it's completely intolerable to the patient and there are alternatives to the drug, you can consider switching. Um, in very severe cases, you might consider surgery or giving them tamoxifen. Um um, but most of the time it's conservative treatment. Obviously, for these cases where you have to keep the drug, you know you can have an impact on mental health of the patient's. You need to consider that, especially if it's a young guy. Um, does it increase the risk of breast cancer in males? To my knowledge, it does not. No, because both of the it's not driven by a cancer risk. It's not driven by a sort of genetic or it's a really good question, actually, because if it is driven by estrogen, if the cause were due to increase estrogen exposure so maybe within the endocrine causes, if it relates to a higher amount of estrogen, in theory, there might be an increased risk. But I think most of the causes of gynecomastia um would not because they're not really caused by things which would increase your risk of breast cancer. But it's a good question. Okay, cool. The final thing. I thought I just pop in there. Um, but I don't really have a case about it because you're very likely not be asked about it. But just to be aware is radial scars. Um, they can present on an X ray is a sort of stellate mass, and you'll feel a lump. They might get some pain. Um, and obviously, if you do get one of these, it's just a biopsy and an excision. Um, but it's more of a very niche breast thing. You don't really get examined on it. So I didn't really want to focus on it much. Want to be aware of cool. We'll proceed. We're making good time. Proceed to inflammatory breast disease. So next case number 7 24 year old, five weeks after birth with her second child, she's got a painful less breast. Um, and on examination, as a four centimeter area of inflammation Erythema lateral to the nipple. She's got an associated underlying lump. Is it mastitis? Is it breast cancer? Is it gynecomastia duct ectasia or a breast abscess? 24 year old women five weeks after the birth of her second child. Mhm. You've got one for mastitis. Anyone else want to put an answer in the chat? Five. We've got a couple for a breast abscess. Really Good. I think both of them are sort of valid answers. But if I You know, the correct answer in this question is breast abscess. Um, in reality, she, you know, most likely has a bit of both. Um, and abscesses can result, uh, because of severe mastitis, so it tends to be driven by staph aureus infection. Um, when you have babies breastfeeding, no staff loves any sort of soft tissue. It's really, really common. So one in 10 breastfeeding women will get this. Um, you are increased risk if you have any injuries to your nipple or if you're a smoker. Um, in terms of management, weirdly enough, I mean, if you if you were doing a short fire question around, You would just say flu cloxacillin. So if you wanted a 11 word er, it would be flu clocks. And that tends to be what you give most women, and I think a lot of it, depending on how bad it is. But given that GPS haven't been seeing patient's over covid and they're not really gonna bring in breastfeeding mothers, they'll probably just prescribe some flu clocks. Um, provided they're not pen allergic, obviously, but you can if it's not very severe. Um, you can just give them some analgesia and warm compresses. And the key point This comes up in finals a lot. You have to advise them to continue breastfeeding so they are allowed to continue breastfeeding, and they can. Obviously, if it's absolute agony for them to do so, they can breastfeed from the other breast, but they can continue breastfeeding from the breast affected. Um, if it's very severe or it's not really getting better, you can put them on some flu cloxacillin. Your second line does line is, um, Caremark's club. And then if they grow MRSA, which is super rare, give them some trimethoprim, obviously, for any abscess. Um, most likely you. They're gonna need an ultrasound. So if they complain of sort of infective symptoms, um, and perhaps they're getting systemically a bit unwell. Um, or you've tried to treat it, and it's not getting better. And you bring them in because most of this will be g p based. You bring them in and you can feel a lump and sort of a focal area of infection. Then obviously, you'll pop them over to, um, ultrasound. And most likely, you'll do an incision, incision and drainage. Sorry, I can't speak this evening. Um, so that's your management for mastitis or an abscess. So both of them fairly correct answers to the question. Next one. So 52 year old obese woman, um, she comes into breast clinic. She's got an irregular two centimeter firm lump in her left breast. She had a recent trauma of the area, and a core biopsy is reported. As be too. Anybody know what this might be? Oh, no. I actually think I may have left the right answer in there. I didn't put the right answer. Sorry. That's a mistake on my slide. How embarrassing. So I'll just skip. It's fat necrosis is what it's meant to be. Obviously, you want to rule out if she's got a hard lump, you probably do a triple assessment. Um, and she's obese, so she's got increased estrogen. So you'd want to rule out breast cancer. Hence why they're doing a core biopsy. Um, but actually, the key point of this question is that she has a firm lump and recent trauma. Um, oops. Sorry. So fat necrosis commonly, um, is because of a recent breast injury, and it happens to women who have larger breasts and who are quite obese. Um, in the question, they almost always mention recent trauma to the breast. Um, you're feeling for firm, round and hard and sort of a regular lump you can. It's rare, but it can mimic breast cancer, and obviously the presentation isn't that different. So you would want to do imaging and a core biopsy on these women. Um, because you have to rule out anything more sinister. But if you were to go for, you know, if they give, you know, obese women who has a recent trauma to the breast and has a resulting new lump but is otherwise kind of well and has no significant history. Then if it's a single best answer for what the diagnosis is, it's going to be a fat necrosis next one. So a 45 year old smoker presents to her G p with a six month history of pain and a cheesy discharge from her left nipple associated with some inflammation of the areola. Um, a mask can be felt under the Ariola, but no other lumps were palpable. Anybody have any idea what this might be? So mastitis. Breast cancer, grinding capacity, Adducted Tasia or breast abscess. Doctor Ectasia. Great. So, Doctor Ectasia, I thought, this is a really nice diagram. Obviously, the breast is loads of different ducks all feeding into the nipple where milk can be released. Um, but isn't obviously all the time I mean postpartum. Or if you've weird under crying conditions, what can happen? Inducted Taser is basically you get dilated and clogged ducks. Um, it's most common in menopausal women and commonly in smokers. Um so always look out for the smoking history within your question in terms of discharge. So this may not present as a lump. Um, in a question, they may talk about a woman coming in because she's got a green or a cheesy discharge, and the other thing you can get is because you're clogging up the duct. If you get resulting inflammation, you can get a peri doctoral mastitis. So she also might have a kind of tender breast or slightly hot. If you allow this condition to fully run its course, you end up actually getting fibrosis of the dark two nipple retraction. Um, the thing you want to rule out is, if it's sort of spontaneously discharging all the time, then you might be a bit more worried. But say if you get, like an incidence of isolated discharge or, um, then it's more likely to be duct ectasia, but you would investigate it more if you just get continuous spontaneous discharge. Um, in most people diagnosed with duct ectasia, you would conservatively manage them. Um, in younger patient's, you might remove the duct that's causing the issue. Um, but do microdose checked me, Um, in older women, you would do total duct excision so you wouldn't just remove a small part. You would remove the whole tract. Okay, now into malignant breast disease. How we do making good time. Um, does anybody have any questions? Am I going to quickly Any comments? No. Okay, I'll continue. Um, there's obviously more like, if you're interested in breast surgery, there's obviously more, um, detail for each of these that you could go into. Um, but like I said, I'm trying to make it as high yield as possible. So I've included the stuff that I think you really should know. And there's finals like breast with and Finals is so tiny, you only get a couple of questions, so I don't think it's worth kind of learning crazy amounts for it onto the good stuff. So malignant breast disease, a 50 year old woman presents with a four month history of a firm three centimeter lump in her right breast with associated nipple inversion. A bloody discharge and auxiliary lymphadenopathy F N A was reported as C five. She has no Children, and her bm is 32. What do we think the diagnosis is? An introductory rel papilloma breast cancer, Gynecomastia duct ectasia or a breast abscess. Anyone have any idea given the slide before this one and he take us to cool breast cancer? Yes, I agree with you. Um, to what are the really worrying things in a history if somebody told you this? So four month history. It's a firm lump, which worries you immediately, so it's not going away. It's seemingly, um, firm. It's It's always there, and it's stuck in her right breast. She's got nipple inversion. Very poor sign. A bloody discharge. Okay, Could be something else. Um, Could be an introductory papilloma, but unlikely, given the rest of the history and auxiliary lymphadenopathy, then your red flag should be waving. Um, she also has some risk factors. So nulla parity. Um, and her b m I is raised so big breast big risk factors for breast cancer. The key ones, obviously, to be aware of our breca one and breca to, um, there's a 40% lifetime risk of breast and ovarian cancer is very, very high. Obviously, there's loads of press around it, and usually you would do either a mastectomy or a double mastectomy, um, prophylactically or in a preventative way for these women, because there is such high risk. Um, P 53 mutations can also be arrest factor. Um, if you have a first degree relative, then you're at risk of breast cancer and taking any breast history is really important to check for any all of these risk factors. But obviously a family history is very important, and you want to check not just for breast cancer, but for ovarian and also for pancreatic. I think it's Bracha three three that you have an increased risk of pancreatic cancer as well is rarer, like Braca one and racketeer, the main ones to be aware of so mainly looking for breast and ovarian cancers. But you'd want to do a full cancer history for the family on women who you think might be at risk. Um, estrogen exposure is very key risk factor, so nulla parity is a very big one. Any early menopause early men, arch and late menopause because you've got then a prolonged period of Eastern exposure. Obviously, you do increase your risk by taking the oral contraceptive pill and by combined HRT. If you've had breast cancer in the past, unfortunately, you're at increased risk. Um, for the rest of your life and again, previous surgery to the breast because of inflammation and things like that will increase your risk. You actually lessen your risk slightly both by pregnancy and by breastfeeding. Um, and I guess some of your, uh I don't know whether you're a contraceptive pillars it should not be in. Decreased risk is increased risk. Maybe if you take the progesterone one, it might have the opposite, but I can't remember that. Um, and any ionizing radiation or obesity also increases your risk of breast cancer. Um, next case, a 62 year old woman complains of dry crack skin around the right areola. On examination, there's a discrete firm nodule underlying the affected area. What is the most likely diagnosis? Is it Paget's disease of the breast po'd orange breast cancer mastitis or an intraductal papilloma? So she's got dry cracked skin around her right areola and a discrete firm nodule. Anybody have any idea to dry cracked skin on the right areola and a discrete firm? No double. Anyone wanna has it? A guess. Cool. Nice. So Paget's disease, um, is the most likely diagnosis. You might be led astray to put breast cancer, and you know it. Most likely underlying Lee is breast cancer, unfortunately, but in these questions, you know, if you had to choose between the two, the most likely one for the diagnosis of the cracked nipples. Paget's disease. Um, and sometimes in finals, they can put these ones where you're down to two, and you could argue it either way. But you sort of want to be going for Don't overthink it. So you're going for the direct diagnosis rather than something longer term. Um, this is what Paget's disease looks like at quite a severe level. So it's always a presenting feature of breast cancer, and it's basically an exematous sort of condition of the nipple. It would have to be quite bad to look like this. So, um, that's obviously not looking great. Um, it's almost always associated with an underlying breast carcinoma, um, and traditionally attached to an underlying lesion directly. So as we saw in the question, there's a discrete firm nodule underlying the affected area. Um, and of those cases, which will be about 50% of cases, 90% will be an invasive carcinoma, and 10% will be a carcinoma in situ. So obviously prognostically it's It's more than localized disease. It's invasive, which is not great. Um, if you did, let it progress, which you wouldn't. But if you did, um, you would get erosion completely of the nipple until it disappears. And obviously, the whole point in a woman like this who has a discrete foraminal jaws that you need to biopsy that lesion and then initiate breast cancer treatment fairly swiftly. A 72 year old woman went to her GP complaining of swelling in the left breast. On examination, you noticed dimpling of the skin in the left breast and a firm three centimeter lump in the lower outer quadrant. Um, anybody have any idea what I might be going on about? Is it Paget? So what we just saw. Could it be Po'd orange? Could it be breast cancer? Could it be mastitis or an intraductal papilloma? Anybody want to hazard a guess? Po'd orange Cool. We've got a couple of votes for that. I agree. So Po'd oranges, another presenting feature of breast cancer, and it is cutaneous lymphedema. And you? The the key feature is dimpling essentially, um, because the skin is tethered by sweat ducts that have been infiltrated with cancer. So that's how it occurs. Um, and that's commonly how it presents so dimpling within the skin again pretty much always associated with cancer. So it's it's, uh, not a good sign, but it's one of the presenting features of breast cancer. Okay, um, I tried to make it as interactive as possible thus far, but for a little bit now, I'm just gonna give some brief information. But again, I've tried to not just have words on a page, So I'll, um yeah, try and make it minimally didactic. But in terms of types of breast cancer, the most common is invasive ductal carcinoma. The second is invasive lobular carcinoma. Um, you can then have ductal carcinoma in situ and lobular carcinoma in situ and then some rare A types. But those are the four. You kind of mainly need to know the most common being invasive ductal carcinoma. Um, how do we traditionally investigate breast cancer? So would you do mammography? Would you do a triple assessment? Would you get a CT? Would you do an ultrasound, or would you do a fine needle aspiration? Anyone have any idea which one of those? If you had to choose one of those five investigations, you might do cool. Everyone's pretty much agreed Triple assessment. So any question automatically is triple assessment if you see breast cancer. Um, I will talk about screening first, though, so screening as tradition is mammography. Um, and it's for 47 to 73 year old women every three years. You get a scan. Um, and obviously, if you have a family history or significant risk factors, then you might be offered screening at a younger age. But that tends to be the way that it works. Um, if you do have a patient at your GP practice, um, or even in hospital, you know, if you palpate something on the wood and they're in for a different reason or something, um, you have a two week wait referral pathway. So if you have anyone over 30 who has an unexplained lump, with or without pain, you would to eat weight them or above 50 with a nipple change. So discharge retraction or any other change to the nipple. Um, you might consider to eat weight in patient's that have skin changes suggestive of breast cancer, Um, or if they're above 30 years old or more with a lump in the axilla, because obviously you're worried about spread a non two week. Weight would be, um, a woman who is less than 30 who has an unexplained lump with without pain. So if they're less than 30 you would probably, um, get an ultrasound for them, but on a non two week wait pathway if they're above 30. So that's, um, then you probably would do a two week wait just to rule anything out. And with any significant family history. Of course you would, in terms of how we investigate. So initially, you would take a full history and you would examine them. So you perform your full breast examination. You need to identify where the lump is, which breast it's in the location of the lump within the breast. Um, whether it's mobile or not, whether there's any skin pop oring, whether it's tethered to the skin. Is it hard and craggy? Is it painful? Is it tender and then so you you really take through all of the features of the lump itself, then you want to be looking at the nipple itself. So any discharge and in a full breast exam you are supposed to squeeze the nipple. But obviously you would never do that in final euros keys, but you often would ask your patient to squeeze it to check for discharge. Any nipple retraction obviously changes like, um, puckering of the skin or Paget's disease. Um, and then you work your way through your axillary tail and within your armpit, having a look for any nose you might feel. And big things are looking at all of the risk factors in your history and then any familial risk factors as well. Then you do some imaging, so if they are less, if they're younger, you're going to go for an ultrasound. If they're older, you'll go for mammography. MRI is the best, um, way of looking at any women with or looking at their breasts if they have breast implants. Um, because you won't see it otherwise on the other mediums. If they're young, you might obviously go for an ultrasound, um, and do a biopsy because you don't want to give them radiation. Um, if it proves up, if it proves to be benign, obviously, if it is proven, then you would fully work them up to do mammography and an MRI. But you need to get your imaging first, and then you do your pathology, and this is, you know, part of your triple assessment. So either if I needle aspiration or a core biopsy, Okay, I'll just check for questions, Know Cool. No. In terms of whoever wrote all of them, it's not completely wrong. Um, there are parts of working up, but your big thing for any investigation of a woman with potential breast cancer is to do a triple assessment. So receptor status Anybody have any idea which you would be very worried about or prognostically is not great. If you've never heard of receptors, we will go to that on the next slide. So don't freak out. But if you have anybody have any idea which of these just wait for one or two more answers. Anyone else? Okay, um, so one is low grade, so one is prognostically sort of the best. Um, your second one is high grade, and your third one is a basal like carcinoma. Um, so it's not great. The way I think is really helpful thinking about it with respect to receptor status. So any breast cancer is given a receptor status so positive or negative for these three receptors estrogen, progesterone and her to, um, if something is positive for receptor, you can target that receptor with treatment. So that's why prognostically It's often more difficult if their receptor status is negative. Because then any treatment you have targeting that receptor, um, you can't use so that's one way I think is quite helpful to think about it. Obviously, it depends on the individual cancers. Um, you know, we're talking about breast here, so it will change somewhat. But with the respective breast, it's actually worse, um, to be e r and PR negative and all negative. It's not. Not a good prognostic sign. Um, okay, management. So management encompasses lots of different things in breast cancer, and I think for finals it can be a little bit difficult from my experience. I don't think I even got one question, Um uh, Imperial on management of breast cancer, because it's quite a personal decision. Um, and it's also completely depends on the women and their risk factors. But initial management might include surgery, and then it also might include radiotherapy. Um, then hormonal therapy. You can have biological therapy, and you can also have chemotherapy. Um, so it can encompass any if not all of these 35 things. Rather, um, we'll talk about surgery in a moment. Radiotherapy you tend to consider, either after a wide local excision can be quite common or after a mastectomy. If they're quite a high, um, tumor. Great. So T three or T four or they've got a lot of lymph nodes involved, or it's quite a big tumor hormone therapy. If they're premenopausal, you would go for something like tamoxifen or grow Zarella. Mom, Um, there are contra indications to both of these drugs, as with any other drug that you need to be aware of. But I'm not touching on them today due to time, um, post menopause. Or you would consider anastrozole or lecture result, then biological therapy. You consider trans to trans to Zuma Bob if, which is Herceptin, if it's her two positive. But if they have a history of heart disorders, you can't give them that. But otherwise you give them her septum. If it's her two positive, and then chemo obviously can be considered as neo adjuvant. Therapy is adjuvant, um, and you tend to use it if you have lymph nodes involved. If they're triple negative, because you don't have any other option because hormonal therapy won't work and biological therapy won't work. This is why it's such a shit. Diagnosis, um, or if their hair to positive, which is also not great, um, and again neoadjuvant as possible and adjuvant as possible. But all of your management will encompass a form of these five things. Surgical management either tends to be a mastectomy, and obviously you can have a double mastectomy, um, all wide local excision. So if you have a solitary lesion to just one lesion and one of the breasts, um, and it's quite far away from the nipple, so it's a peripheral tumor. Um, you might consider a wide local excision, and you can do that if it's a ductal carcinoma and see two of less than four centimeters. Mastectomies, um, tend to be considered if it's multifocal tumor. If it's very central tumor or very close to the nipple, if it's quite a large lesion in otherwise a small breast or if it's quite big, so uh, ductal carcinoma in C two of greater than four centimeters, then one of the biggest things with breast surgery is obviously you often will get plastic surgery involved. Um, and you need to think about what you're leaving, what it actually looks like and patient's will have their own, um, ideas and concerns about what the surgery involves for them is pretty devastating. Not only having a mastectomy even having a wide local excision, because you're permanently sort of changing the way that their body looks in the way that their breasts look. Um, so you need a lot of input from the M D t to manage that. And you also have to give them, um you know, their their own choice in terms of how they want it to be managed because, um, it's not. Yeah, it will permanently change the way that they look so and the plastics team often will will give advice in terms of what will look better afterwards as well. The other thing you have to consider is if there's any lymphadenopathy within the axilla. So if you do have it, then you need to do full sort of eggs Ilary node clearance and you take out all of the nodes. The risk of that is lymphedema, which we'll talk about in a second. Um, if there is no lymphadenopathy in the axilla clinically. Um, then you will do an ultrasound, and you might do sentinel lymph node biopsy. Um, to consider sort of what you need to clear or not. And so you would consider axillary lymph node clearance. But you might not Necessarily. The whole point is you're trying to figure out how far, um, it's spread. If it has spread far or not, it may not have spread. It may still be localized. Um, let me just check my chat. What did I say about three? I don't know whether I missed the boat on that one. So three is what we call triple negative, um, cancer and still say not a good prognosis. OK, Nearly done. I think we're doing really well on time, actually. So, um, the main complication we're talking about of treatment, um, is lymphedema. This is a very severe case, but essentially, you're completely. If you remove and do eggs, Ilary know clearance. You're removing the lymph nodes. So then you prevent lymphatic drainage within the axilla. So you can get massive swelling unilaterally of an arm, which is again not great. Um, there are obviously some medical ways of managing this, and it would hopefully never get this bad. But it is possible. That's your key complication. Um, in terms of prognosis of breast cancer. So we tend to use the Nottingham Prognostic index tool, uh, which encompasses the size of the tumor, Uh, the lymph node score and a grade score. And the most important prognostic factor is axillary lymph node spread. So you're a lot more worried about your patient's if it's spreading to the axilla than not. Okay, I think this is our last question. Um, so a 52 year old woman attends the breast clinic with a four centimeter lump in her left breast. Finito. Aspiration was performed in the cells were sent a cytology. Um, it resulted in dysplastic cells. What should you do next? So should you do nothing? Um, should you do an ultrasound? Should you do a core biopsy? Should you repeat the fine needle aspiration? Or should you do an MRI? Anybody have any ideas? Three. So we have a vote for a core biopsy. Anyone else have any ideas? Three. Fab. Yeah, I'll take that. You should do a core biopsy next. So you know she's 52 she's got a lump. Four centimeters is quite big. Um, and you have dysplastic cells. So you are worried, essentially, that this woman has breast cancer. So if you're not really getting, um, much from a fine needle aspiration, you need to court, and then you need to send it for histology. And you would work her up for a triple assessment as well. Okay, um, I think that's it. Does anybody have any burning questions? Um, I'll leave that there. There's like a QR code for feedback. I don't know whether you get sent a separate one, but this is like for me to collect as well. It will take about two minutes. And if you wouldn't mind doing it now, I'd really, really appreciate it. As you guys will become aware, you need all of this stuff for your portfolio, but also, it's really helpful for me doing teaching as, um, I go forward to see whether you want more detail or whether you want it slower or, um, whether I gave too much detail or whether you like the case learning or not. So any feedback would be really, really helpful. There are a couple of questions in the chat. Okay? He escaped from there. When do you choose between core biopsy and fine needle aspiration? And how would you recommend or leave that there? Um, initially, most of them. You tend to do a fine needle aspiration because I think you can do it in clinic when you examine them. Um, if it's a larger mass, to be completely honest with you, I can't 100% answer that question because I haven't done breast surgery in, like, two years. So I can't quite remember the indications between the two. Anything that you think might sort of be where you can aspirate cells from or that you think might be cystic or something like that or you're sending off cytology. Okay. No, actually, I'm chatting. Crap. I do remember the difference. So a fine needle aspiration, you tend to send cells off to cytology to then examine them. Whereas a core biopsy, you can actually look at the tissue. So, um, any you you'll begin a lot of them with fine needle aspiration. Um, anything where you want to examine individual cells and look for dysplasia. And that tells you whether cell zometa plastic dysplastic Ceni cellular changes, whereas the core biopsy, you're able to take a lump of the tissue and then section it and stay knit and basically look for receptor changes. Look for invasiveness of the surrounding structure. Um, look for muscular invasion, etcetera, etcetera. I believe that's the case. And then do do do Nicola White. Fine. Needle aspiration may not yield enough tissue for receptor status. Great. So then you go for a poor biopsy. Um, thank you for that input. And how would you recommend practicing the breast exam for paces? Um, that's a good question. My breast exam was an absolute joke. My examiner actually got reported because he was so crap. Um, I would say if you're a girl and you have girlfriends that will let you examine each other, it's actually really helpful. So you can do that. Even you can do it on if you have a brother or something. You can. Everyone has nipples. Basically, everyone has a form of a breast. So practice on friends or family if they'll let you, uh, which sounds a bit strange, but it's really helpful in terms of, um, the work up. You tend to get asked on how you would investigate patient's what receptor status sort of means. I think I did actually get asked that in my exam had my examiner was like, Well, what do you mean by that? And was quite sort of pressing on individual features. Um, I think learning really intense management for like when you would do X y Z. It's probably a waste of time. You need to know the court management, but the issue is patient. Decision is such a big part of it. You know, aesthetics is such a big part of it. And also it depends on so many sort of histological, um, receptor status on histological features on spread, etcetera, etcetera that it's a bit difficult to say. Um, definitive management. It's not like appendicitis where you can take the appendix out and you're done. So I would know the key elements and when you would use them. So, like, if it were this receptor positive, you know, if it were her two positive, I can give Herceptin and stuff is quite important. Um, think about key vie the questions they could give, I think, at least for anyone at Imperial, there are PDFs of previous questions, people have been asked, Know your triple assessment really well, because that's going to be the main thing that they can sort of quiz you on. Management is less interesting for breast surgery because it is, um, differs so much between patient's, uh, you would be very unlikely to be asked about Micro Do checked me, or however you pronounce it within a fiver for paces like that's not really going to happen. The Viber for paces is mainly going to be breast cancer orientated. Um, if they were to ask you about benign disease, it's more likely to be like mastitis. You know, common things are common, and they want to know you're safe and a good doctor for the common stuff. You're not really going to be dealing with introductory papillomas or duct ectasia or those kind of things. Um, the wide I mean wide local excision is not just I don't think it's a, uh, you know, you would just talk about the difference between doing maybe a wide local excision versus doing and mastectomy. I think that's the main, um, thing to know the difference between the two, um, other niche procedures. I don't think it's worth noting huge amounts about because they simply just don't come up. Um, and I think if they're asked if they ask you to describe differentiation between management or things like that, it would actually be mainly orientated of like, How do you differentiate between a fibroadenoma and a potential breast cancer risk? Or, you know, when might you investigate a patient? Further, if you think it's a fibroadenoma, but they have loads of tenderness, and, uh, I don't know, they have an extensive breast cancer history. Then you might do the referral pathway. So I think key things are know about breast cancer more so than any other condition. Um, no. About the referral and the screening pathway. So I think I got asked about screening. So what age group it was for and how often they're screened. Um, know about your triple assessment as well. Those are the key things. I'd sort of look at anyone have any other questions? No. Um, what if there's no other questions? Thank you so much for delivering this lecture. Um, and thank you for making it so interactive as well. Um, everyone, please fill in the feedback. And so There is also a feedback form that med would like everyone to allow, which I'm putting, which should have now been sent into the chat. Yeah, the recordings will be released. Should be uploaded straight away to the platform. And the slides should will also be uploaded later on as well. Okay. Okay. Thank you, everyone for attending. Uh, presumably you'll send me the feedback that you get as well. Amazing. And if anyone has any questions, then you can ask my emails. Well, I'm more than happy to help. Or if anybody has any, like, burning a p or some questions to I'll put my, uh, came out in the chop. Oops. There we go. Yeah, if anybody has any finals or like, F pass any questions at all? I'm really help. Like, I'm really glad to help, So just drop me an email. Cool. Okay. Thanks very much. Take care. Thank you.