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So generally, surgery and um other allied specialties and women's health more generally. So, if this is something that you'd be interested in, please go on the union website and become a member and we should hopefully have um future events as well coming soon. So, yeah, thank you so much and I hope you enjoy the talk. Ok, without further ado um miss, do you want to get going? Ok. Thank you. Thank you for that. Laura. That sounds like it's a very promising thing to encourage people into the field of breast surgery so well done for that. So, hi, everybody. My name is Sabina Rashid, as they've said, I'm a breast surgeon at Norfolk Park and this is, should be everything that I think you need to know for finals. And I hope for the rest of your career, as I say, um, if you're not going to be a breast surgeon or a breast oncologist, for those of you who've done senior surgery firms at Norfolk Park, you will have had something that is very similar to this lecture. I've adjusted this a little bit and I've put in some extra questions as well. So hopefully you guys will be able to challenge yourself a little bit and I won't be repeating too much of what you already know. Um And hopefully a few extra nuggets of information. Um It would be really great if you could be a little bit interactive and hopefully you can put some bits in the chat, um ask questions, feel free at any point. I think I can't see the chat, but hopefully Manish will be able to um tell me if there is anything. Um And hopefully you will also be brave enough to make them, give us some answers. Please feel free to get them wrong now because you don't want to get them wrong in the exam. So the main things that I'd like to cover today, oh, I can't get my screen to go. Uh How do I get technical issue? It's all right. My screen is not moving forward. No. Uh hold on a second. What am I can't even escape from this now? Mhm Sorry guys. There we go. Got it. Uh Right. Sorry. Um So what I'd like to do is uh get you to be able to know what you need to do in a breast examination that will make help you pass the exam rather than anything else. Um We'll talk a little bit about benign breast disease and treatment and uh we'll talk about the treatments for breast cancer. Um This is essentially to set you up for being a doctor in the future. Um, so hopefully that's what you'll take away from this and hopefully you will all pass the breast paces question in the exam. Um I'm gonna go through history taking, although that is, um, not usually something that you, um, get asked, um, it's unlikely that you'll have this, um, but it should be straightforward if you are asked it. Um, so, uh, there are some common presenting complaints that you get. The main ones are pain lump and nipple discharge. These are relatively straightforward histories to take. So you should take the history for a pain as you would for anything else. So you go through your Socrates site, um onset character, all those elements of pain and similarly, for a lump, you want to know when it started. Has it changed? How long has it been there with nipple discharge? I would be a little bit extra cautious. Um Sometimes you may get nipple discharge as the presenting complaint. Um Does anyone know what is um the most worrying type of nipple discharge to get? I don't know if you wanna put that in the chat but have a think about it. The least worrying one is having bilateral milky discharge when you're not breastfeeding. And if you do get this in your history taking station, what you do need to think about is prolactinomas because there is, I think a question that does focus on prolactinomas. So, rather than focusing on the breast you need to think about taking an endocrinological history and you need to think about asking questions that are relevant to someone who may have a prolactinoma. As with any cancers. You need to think about risk factors and those risk factors are generally, I talk about significant ones and that is age, obesity, alcohol intake, previous cancer, family history and being a gene carrier. Oh, sorry, unilateral single ducts bloody. Someone's been to my lecture and listened. That's great. Thank you. Well done. So well done for answering that. So that is your clear. Uh Whoever's put that, that is what you would worry about if you were a breast. So if you get unilateral bloody um spontaneous discharge, then you, you need to be worried about a cancer so well done. Um Great. Uh So um risk factors going back to that. Um So you've got your significant ones, which I've just covered and then you've got your less significant ones which are all to do with estrogen exposure. So you'd need to ask about when they first started their periods, how many Children they've had? And the most important fact is that is the actual, the the the eldest child. So they have to have carried the pregnancy to full term and you want to know what the name, how old that child is now or adult is now. Um You also want to take a history on breastfeeding and whether they use contraception, HRT or menopause Um Now you would, if you have a breast history, you would get points for asking those specific questions. Basically is what I'm saying. So that's why you need to ask those questions. OK. So you just need to learn those. There's no other way of doing it. Um It is also important clearly to have a general overview of medical conditions. And I tend to tell people the most thing, the things that are the most important to us are things like whether they're on anticoagulants, for example, um or their general mobility. Does anyone know what position mammograms are done in and put that in the chart and we'll come back to it. We've got just a question as well. Um In the meantime, someone's asked, what is the relevance of the eldest child's age? So it's about exposure. So if you've had your first pregnancy um at the age of under 30 it's a protective thing is what they say. So that's the specific thing. Um If no one's answered the question about mammograms, mammograms are done in standing position. So if you have somebody who is not able to stand, they're not able to have a mammogram. So these are the sort of things that you need to think about specifically when you're really referring patients to um the breast specialty because knowing those can help us decide what, how we can investigate the patient if needed. Ok. Right. So let's focus a little bit on the exam. So clearly, this is um partnered up with your vascular station. Um This is five minutes for breast, five minutes for vascular in those five minutes. They expect you to do your breast examination within three minutes, which includes you presenting them and then have two minutes for your questions. Um It is quite possible to do a breast examination in a minute if you are slit. Um but I think for you guys getting it into two minutes is more than acceptable. Um, top things, you are almost certainly going to have a simulated patient because it's very difficult for them to find uh patients who are willing to have their breasts examined, you know, 30 or 40 times during the day. Um A lot of this is about how you approach patients, your confidence and your fluency and this is in general terms for any examination, you can watch the videos. And I think there's one on Medlen and I think there's a geeky medics one. I'm not sure if the one on Medlen is the one that's done by Dan Leff who and if it is, it's very good. Um I've seen the geeky medics one. It's ok. Um I think that's reasonable if you did that in the exam you will pass. Um but it's not like how I would necessarily do it. That doesn't matter. It's about passing the exam at the end of the day. Um In terms of um palpation techniques there are lots of different ways of doing this and I think you just have to choose your preference and hopefully you'll have all, have had a chance to try them and see what works best for you in. Um When you're actually examining patients, biggest thing is do not squeeze the nipples. It's not part of a routine examination. Um If you have a nipple discharge, that is spontaneous, it will come out just when you're palpating the actual breast tissue. There is no need to squeeze the nipples at all. If you haven't done it, you need to go to a one stop breast clinic. My experience is for those of you who've been coming to the specialty surgery firms from coming to clinic. Your first examination that you were asked to do for breast is usually borderline or a fail. And then by the time you've got two or three under your belt, it's definitely a pass. So essentially, it's just about practice. So examination essentials. Um I'm just gonna go through the bits that I think you really must cover because these are the bits that will get you points basically. So you need to have an introduction and an explanation. Easy points. Ok. Sorry, I just need to let my dog out for a second um inspection. You need to do that on sitting up and on movement. Ok. So I would do it while they're sitting up, do your hand movements, which is raising their arms and putting them on the hips. And that is it. I don't think you need to do any other movements if you choose to, that's absolutely fine. But you don't need to palpations should be done with the patient lying at 45 degrees and you can pick the technique that you do and you just need to look reasonable at doing it. And then the approach that you do for your axillary lymph nodes is very important. So they will like to see and bearing find that a lot of the examiners who may be examining in the station are not breast surgeons. They will want to see you examine the axillary lymph nodes as they would in a textbook. And that generally has been by putting the forearm of the patient on your forearm and then feeling with the opposite hand into the armpit. Um They do show those in the videos. So watch them if you don't know or go to a clinic and watch someone do that in terms of completing your examination. I have just flashed up the answer there, but I don't know if anyone can tell us how would they complete their clinical examination for um breast? If you suspect that someone has a cancer, I don't know if anyone's gonna put anything in the chat there. Any answers? Uh Nothing so far? OK. All right. OK. So, um I would say to you that if you examine someone with a suspected cancer. And this is what I would probably say in the exam. If I suspect that this patient has a cancer, I would like to complete my examination by assessing for liver enlargement, pleural effusions, and spinal tenderness. Ok. Um How do you assess for liver enlargement that if someone would like to put in the chat, how they would do those three things? That would be great. Um And if you, if you do that, then I will carry on, but I'll come back to it. Give you a bit of a moment to go through that maybe give you some an give us some answers. Ok? So while people are trying to think about that, uh in terms of um triple assessment, um this is a a requirement and I think it's a very common thing that's asked in the paces exam. Ok. So uh clearly, I think you should all know this. Um Is there anyone online who feels confident enough to talk through triple assessment? Actually? Well, if no one else, I'll give it to go on. Um I believe that you do a, a physical examination, some kind of imaging and then some kind of either histology or cytology. Perfect. Well done. OK. That's all I that's all I want to hear you say. Um the step beyond that, which is what I talked to. Um talk to the to the guys at park about is also the grading system that we use. OK. So we have a prefix system for grading these, so that we the both the clinician. So that's myself who does the physical assessment, the radiologist, who does the radiological assessment and the pathologist who does the histological assessment use the same grading category to assess patients. And what we're looking for is correlation essentially. Ok. And that grading system means one which is normal and generally, if they have a normal physical assessment, they don't really require any further investigations. Uh Five is a cancer. OK. Uh Two is benign, three and four is inter dominant and suspicious. So if you can actually um elaborate on talking about triple assessment and talking about this, that would be amazing. Um Basically, if you have a lump, whatever you feel it will need to be imaged. Not all lumps may need to be biopsied. But um the decision for that biopsy will most likely um rest with the radiologists who are doing the scans very, very occasionally. It may be that we do what we call a clinical biopsy. So as in I would do a biopsy of some sort. So that might be like a punch biopsy or it might be a core biopsy because I can feel a lump, but the radiologist can't actually see anything when they scan the scan, the patient. Um essentially that's what happens. Ok. Um mm ages for mammograms can vary from unit to unit, but in general, most places will not do mammograms in anyone under the age of 35. Um, but it's acceptable to say that you wouldn't do that in anyone under the age of 35 or even under the age of 40. So we use 40 in our unit, but you would generally, what you need to know is that mammograms are not something that we do for younger women. Um If they do, they may uh if they do need imaging, those younger women will have ultrasound as their initial assessment. So that's important for you guys to know. Um Just before we move on to the next slide, I'm guessing that no one has responded to how you assess for. I'm just going to go back a slide. I will awesome. We've got some good answers. So OK, go on. So someone said abdo exam, listen to the chest and then palpate along the spine and then someone said pleural effusions, listen to the lung bases and then liver enlargement do an ABDO exam. Perfect. OK. So that's absolutely fine. So that's good. Uh My general thing is I percuss for the liver, I percuss for the pleural lesions. And I feel for spinal tenderness, as you've said, that's perfect. The reason why I'm just taking I'm really emphasizing that point is because actually, if you have got a patient who you suspect has a breast cancer because you can see and feel a mass in the breast that looks like a cancer, you do need to check for this because if they do have bone mets, which is one of the most commonest places that breast cancer goes to that and they have tenderness that is a medical emergency. So that has to be dealt with there. And then by the general medical team, the emergency department that does not come to us as breast surgeons because the problem is called compression. Um So that is something that everyone needs to be able to assess and um manage. So that's why it's important. So that's why I sort of emphasize that point there, right? OK. Let's move on. So uh there's some questions I think next. Uh So there we go. It, can you put the answers in the chat because I don't think we managed to get this onto ment meter. So answers in the chat based on what you know, so far. Can I ask you a quick question whilst uh people have answers? Um When I went to the first um kind of the first visit clinic uh breast clinic, um I saw that women over the age to over the age of 40 were getting mammograms and ultrasounds. Yes. Is that standard just generally that they get an ultrasound as well as a mammogram? Or can it just be just a mammogram? No, it would normally be just a mammogram and ultrasound would only be performed if the, if the clinician has felt something. So the difference between the two different types of. It's a very good question. By the way, for you to ask it, it's very specific. So this is not something that you'd be expected to know for the exam, but just for general sort of knowledge kind of thing. Mammogram is a screening thing. So mammograms will find early cancers in the breast that you cannot feel. Ok. So that's why we use it as a screening. That's why it's used in the screening program to look for breast cancer. It looks for basically microcalcification. So it's looking for white little dots on a black background. That's what a mammogram does. An ultrasound cannot usually pick that up. An ultrasound is used to actually uh if you like um look at something that you can feel in the breast. So it is much more accurate at looking at a lump in the breast that you can feel and telling you whether that's solid cystic benign or cancer. Ok. So if they are having both, it's much the reason the ultrasound is being requested is because they can feel something in that breast, both breasts will not have an ultrasound scan. Does that make sense? Yeah. Thank you. Good. OK. Any answers for this question? Yeah, we've got a lot of CS Perfect. Good. Right. OK. So that's, that's good. Uh We're learning, we're learning. Oops, that's not what I want to do. Here we go right next question. Then what are we gonna do with this? Lady on the basis of what we've just discussed any answers. Not so far. I think we were thinking, OK, give you a bit of time to think. OK, so we've got some people say mammogram and some people say MRI, OK, fine. OK. Uh Anyone any, any more advances on B or D any others. So based on what we just talked about when you asked me about patients going for mammograms and ultrasounds. This lady is 48. So clearly she is well above the category where we would do a mammogram and she has something that we can feel. So there is a lump we can feel in her breast. The answer to this question is e she's going to have a mammogram and the ultrasound scan. OK. The mammogram because she's over 40 that will tell us about the microcalcifications. And if there's any other problems in either breast that we haven't felt and the ultrasound because that's going to center on the actual lump, we can feel and tell us what that is, whether it's solid, whether it's um fluid or whether it's benign or whether it's cancer. OK. Hopefully that makes sense to everybody. If you've got questions about it, put them in the chat. Um OK. So this is the next question. So it's a 92 year old with a hard lump in the breast and ulceration of the overlying skin. What imaging would we order in this lady? Any answers yet. Not so far. Ok. Oh, we've got, um, MRI. Ok. Right. Anything else, any advances on MRI? So, and so said no imaging? OK. Any advances on A or D? Oh, we've got G Yeah. OK. All right. OK. All right. So whoever's put the G, you are? Absolutely right. OK. So 92 year old, I haven't told you anything about this 92 year old. So, I mean, clearly if she is got um dementia is bed bound and um she's going to die in the next six months of just being old, then I would agree with a but I haven't told you that. So that's not what's the information given to you in, in, in the um in the question. Um So there are some circumstances where it may be appropriate, but that would not be here. And the, and the question would give you that detail if they were trying to guide you to that answer. The answer is g she's over 40. So mammogram, she's got something that we can feel in the breast. So, ultrasound scan and she's got ulceration of the skin that generally means that her breast cancer is very advanced. And in those circumstances, we would do a CT as well because we need to know what's going on in the rest of her body and um whether she's got any metastatic disease, given that that's the clinical picture. Um OK. Next question right. There we go. 32 year old that's referred from the genetics team. Uh, so she has a BRCA one carrier. So this might come to you as a GP or it might come directly to us as a, a breast surgeon in the one stop clinic. She's got no symptoms. So, what, uh, imaging would we do for a 32 year old? Let's see if you've got any answers for that. Oh, ok. We've got an A, ok. Yeah, so, so far. Ok. All right. So, um, the answer is D it's an MRI. Uh, do you know why does anyone know why? Ok. You may not know is, is, uh this is just to illustrate the point that as a BRCA one carrier, that means she's a gene carrier for breast cancer, she's got an 80 to 90% chance of developing a breast cancer at some point in her life. And even though she is young, she would be eligible for screening. So she is somebody who would be eligible for MRI screening and that would start um from whenever she's identified. So, actually quite young, usually in the late twenties or 30. Um So she would also have potentially be offered a discussion about risk reducing mastectomies. But in this scenario where she has no symptoms and she is just referred through because she has just found out she is a gene carrier. She needs an Mr to see whether she has got any changes. And the MRI is used in younger women rather than any other form of imaging because it is much more sensitive at picking up things in a young woman's breast because the breast tissue is very dense. And so therefore, on a mammogram, it just looks very white and you cannot pick out the microcalcification that you would normally pick out. Ok. If there's any questions, then do feel free to ask. Um OK. Next question, one more. I think about the triple assessment and then we'll move on. So a 53 year old that attends screening, what uh imaging would be ordered. Does anyone know the answer for this? So just screening is the key here. Oh, in the meantime, while um while people are answering, someone's asked, how often would uh for the last case, how often would she get screening for the BRCA one annual every year? Ok. We've got uh ba well done. Excellent. That's exactly what I want to hear. Good. Excellent. Right. Does, is everyone happy with that? So mammogram is your screening? Um Basically, right? OK. Next question. 01 more. Yes. One more. 25 year old with intermittent pain and heaviness in both breasts, but more in the right, which is worse before her periods and has a normal examination. What imaging would be ordered? We've got an A Yes, well done. Well, we got better as we went through that. Well done. Excellent. So a she doesn't need any imaging, right? We'll move on. So now I want to talk about the benign conditions that I expect you to know about and this is all I expect you to know about um fibroadenomas, ok. Breast cysts, uh mastitis and abscess because that can be managed by anybody and everybody and chronic inflammatory conditions that you might get and that's mainly um chronic mastitis. So we'll talk a little bit about those in detail because sometimes if you get these cases, they may ask you questions about them in the actual cases about how we manage them and what we do about them. Uh So a little bit more talking from my side. So there's no so many questions. But hopefully, this will be nice and straightforward for you guys. So a fibroadenoma is a benign solid lump that is usually painless. Ok? It is commoner in Asian and Afro Caribbean women. It does not require treatment. There is no increased risk in developing breast cancer if it does get bigger in size, which very occasionally it may do for a number of reasons. There is the indication to biopsy it if it changes. And the other thing that we do do is we offer an excision of the lump if it's more than four centimeters. Um I've explained this to people who've come to the lecture at North Wick. But the reason for that is sampling error when we do the biopsies. Um So if you have a small lump and you take some biopsies of it, you are likely to sample a larger area. There's, if you have a big lump and you take the same number of biopsies from it, if you're taking a very small area and sampling it, so there may be changes in other parts of that lump that you do not know about. And that is why we would remove it if it's over four centimeters. And the main reason for that is because fibroadenomas can even pathologically ie down the microscope look like a phalloides tumor, which is generally benign, but can occasionally be malignant. Um You do not need to know about phalloides tumor. I don't think you will ever get asked about phalloides tumor in an exam. Um And I wouldn't talk about it if you um were asked to, um because you'll probably dig yourself into a hole but knowing about what a fibroadenoma is, is important, ok, breast cysts again, definition, it's a benign fluid filled lump. Um Usually with an epithelial lining. Um We um they can be influenced by hormonal changes. They can be painful because they are influenced by the hormonal changes that women have. Um most of the time they are very small. Um And that's what sometimes people will refer to as fibrocystic disease, although I don't really like that term. Um There are sometimes large ones as you can see in the picture here and that's very easy. All you do is you can pop a little needle in it and you can take the fluid out, the cyst will go away on its own. These are not dangerous and there is no increase risk of developing breast cancer for the woman. And so that's how that's managed and that's all you need to know about that particular thing. Now, in terms of other things that you need to know, we, we're going to talk about mastitis and abscesses. I'm going to bring all of these points up. Now, actually, so again, definitions, if anyone asks you about any of these conditions, if you can come out with a definition first, that's the best thing to do. So, if someone says, if you say mastitis and they say, tell me about mastitis, mastitis is an infection in the soft tissue without a collection, it's like cellulitis anywhere else in the body. It just happens to be in the breast tissue. Um an abscess, the definition is the same for anywhere, an abscess is a collection of pus, but it's in the breast. Ok. Uh Clearly, you can have um either lactational or non lactational. Um And we'll talk about those in a little bit more detail. So lactational mastitis is generally caused by skin organs such as staph aureus. Um The advice is very straightforward and you probably will have heard this more from the midwives um when you were doing your obs and gynae firs, but actually, you continue to express or feed most of the time you can get some advice from the health visitors or the midwives. And they will tell you just to either use avoid cabbage leaves or put warm compresses on the breast. It will generally resolve with antibiotics and you just need to use something simple like which is perfectly safe for mom and baby. And they don't necessarily need to come to the breast clinic unless they get complications. So, unless an abscess develops or there is no response to the initial treatment of antibiotics and things are getting worse, right. So, non lactational mastitis that can still be caused by skin organisms and still it will be staph aureus, that's the most common, but sometimes you can get other organisms that are causing it. And for that reason, it's much better to use a slightly broader spectrum of antibiotics, something like Augmentin or coamoxiclav, whatever you want to call it. It's slightly more common in women who may have skin conditions, autoimmune conditions, granulomatous disease who are smokers. So it's often very good to know if they are smokers and it will happen in women who are slightly older usually. So this is usually quite common in women who are in their forties. So therefore, when you see a woman in your forties and you see this and that's why sometimes people worry about things like inflammatory breast cancer because it could be confused with that. It's not usually inflammatory breast cancer because that's usually very rare So usually it's this, but you just have to have that in the back of your mind. So if anyone asks you what the diagnosis that you want to exclude is it's inflammatory breast cancer because it can have the same sort of appearances as this. Um regardless it should resolve within a, a couple of weeks of treatment. And if the symptoms are going on for longer than that, then yes, you do need to refer them on to the breast specialist. We're going to talk a little bit about chronic inflammatory conditions. And those are basically, you just need to be able to name granulomatous mastitis or idiopathic mastitis. They are two separate things in granulomatous mastitis, you will clearly see on the biopsies, granulomas and you look for TB because that would be a cause of it. And idiopathic mastitis will be basically a chronic condition where you can't really identify an organism or why it's happening. Um, they are often very similar in clinical appearance to a breast cancer, but when they scan them, they can often tell um that it's not a cancer. Generally, women will end up having biopsies so that we know by looking down the microscope that this is not a cancer and it's a chronically inflammatory condition. Um Does anyone know who treats these? Because it's not generally us may not know actually. Um so these are generally treated by either rheumatology or infectious diseases because this is not surgical intervention surgery is not going to help here. Um In, in, in most women, this will be self limiting. So it will resolve on its own without any treatment in about 12 to 18 months. In some women who may have a lot of problems with it, they may need some medical treatment and that would normally be a course of steroids, sometimes that might mean long term steroids. Um But generally we wouldn't manage that. We would be referring that on to a medical team to manage. Um And that's what you need to know in terms of managing those. So hopefully there's no questions, right? So I've got some questions now about managing patients. So the question here is which patient needs to be admitted? I know it's going to probably take you a little bit of time because uh the stems here are a little bit long. But if someone could think about which of those patients need to be admitted, that would be good. I don't know if there's any answers can tell me when theres answers. Yeah, I'll, I'll shut out one off. Ok. So we've got um an answer that's saying that we got a few saying three. Ok, good. Well done. Can I ask anyone who's answered three? Why they've said three? Just because I want to check that you've got the right explanation for it if someone's brave enough to put that in the chat? Ok. So um someone said tachycardic, so they're querying sepsis. Perfect. Good. Well done. Oh, so you're, you're not far off. It's just as well. You're only about six months away from being doctors, aren't you? So, right. Ok. So that's right. So, number three, she's actually pyrexial and she's got a tachycardia. So she clearly needs admission for IV antibiotics. Um, the others are generally well systemically. Um, they should have, they can be given oral antibiotics. They don't necessarily need to have intravenous antibiotics. And the other thing that you have to be sensitive about in a woman who has just had a baby very early on, they, um, will want to be at home with the baby. Um So if you admit them, they're not going to be able to be, um, with their baby and especially if they're breastfeeding their baby. So three is absolutely the right answer here. Good. OK. Right. Next question. How would you manage? So, not the one that's being admitted now, but how would you manage this postpartum woman who has quite clearly got some mastitis? So lactational mastitis, but it probably systemically well, give you a chance to and shout at the when you've got some answers. So we've got quite fast. Uh Ones. OK. Good. Anything else? No, just a lot more ones. Good. Excellent. Right. One ones, it is well done. Good. We're, we're, this is good. So your, your, your, your management is good. I'm impressed. Right. Excellent. All right. So the next question is a 35 year old with a well defined area of erythema and, uh, she has a non fluctuant mass. She's already had some antibiotics. There's been a little bit of improvement in her symptoms, but it's not completely gone. So, what would we do here? Which option would you go for? So, this is about, what would you do with this lady? I've just spotted a, a typo on the slide. But go on. Yeah, go on. Have you got an answer? No, no, it's taking a bit longer with this one. It's taking a bit longer. Ok. We'll give you a, we'll give you a little bit longer. I don't know what the time is actually. It's uh 743. Ok. Ok. We've got someone saying three, excellent. Whoever said three is right. So this lady needs to be referred. She's 35. She hasn't had a response to her treatment. She's systemically. Well, there is a mass that's non fluctuant. The most likely thing that's going on here is just checking my next. Yeah, the most likely thing that's going on here is probably granulomatous mastitis or idiopathic mastitis. So a chronic inflammatory thing rather than a cancer, but I would be a bit cautious here and I do think it needs to be ruled out. She's clearly not got an abscess. So ultrasound and aspiration is not going to do anything. So you're not going to get anything out of that. Um, giving her more antibiotics is not going to do anything. So the only answer really here is three. OK. Right. So we are now progressing a little bit. So this is a little bit more challenging. So she's had some imaging and it shows that she's got an irregular mass which is about 47 millimeters and it's solid and she looks like she's got some nodes that look prominent in her armpit. So they've graded her AU three, excuse me. So that's ultrasound three. So when we go back to that triple assessment slide, you remember I said um that those gradings were one, two and 34 and five. So three is indeterminate. So on imaging, they're a bit, they're indeterminate. They're sitting on the fence about this. So they take some biopsies and those biopsies are showing that she's got some lymphocytes, she's got some granulomas and she's got a lot of fibrosis. How is this going to be managed? So, bearing in mind all the information that I've given you in the last 45 minutes. Which option are you gonna go for? Still? Not clear? Yeah. Three. Ok, good. Well done. Excellent, good. I'm I'm liking this. This is good. You guys are clearly going to pass the exam. So surgery we said not appropriate for this kind of condition. Um And we've already said that antibiotics is, isn't going to help. But we did say that if she's got what we've seen on the biopsies here, which is granulomas, then she needs to have possibly some steroids or needs to at least see the medical team about that. Excellent, good. Right. So now let's talk about breast cancer treatment really broad terms. This is very easy. Um You just need to learn this slide. You don't, the other slides don't worry so much about. I think I've got some questions about treatments but let this is all. You need to learn to know how to treat breast cancer. We talk about local treatments. Local treatments are basically surgery and radiotherapy. Ok. Any type of surgery and radiotherapy. And then we talk about systemic treatments. So systemic treatments are chemotherapy, endocrine therapy or anti estrogen tablets, immunotherapy, which is anti her two treatment. So in terms of treating breast cancer, if you are asked a question about how you would treat it, what you should, what you should say in the exam is there are local treatments and there are systemic treatments and we choose these and target these at the biology of the cancer that the woman has and we will know that from the biopsies. So for example, if they have something that is only in the breast, something like DCIS ductal carcinoma in situ, they only need local treatments. If they have something that is an invasive cancer as in it has the potential to spread to other parts of the body. They need systemic treatments. You need to treat their whole body. Some patients will need both and some patients will only need one of them, but it's ok. You just need to be able to decide based on what they have. So based on their biopsies. Um So just to just to illustrate these, we'll do some questions which I want you to tell me what the treatment options are gonna be. So you're probably gonna have to try and either keep this in your mind. Um as we go through the questions. Ok. So first question. So we've got a 41 year old lady. She's got a small breast um, with about 4.5 centimeters of invasive disease. She's hormone er, is estrogen receptor positive and she is her two receptor negative and she's got normal nodes in her axilla. What's the likely treatment plan here? So you've got some options there and I want you to think about it. Ok. We've got two excellent. Can someone explain why they've chosen to? Um, I was thinking because she's got a small breast, a wide local excision probably wouldn't be appropriate for her. So you'd probably want to opt for the mastectomy and because she's er, positive, then she'd respond to endocrine treatment. Very good. Well, well done. You, you've gone one step beyond what I need you to do, but clearly, and this is the way the question is designed here. It does not matter if you don't know what type of surgery. So, for all of you who are listening. It doesn't matter if you didn't know what type of surgery she needs to have. Number two is the only one that has endocrine treatment in it. And if you remember, I said she's estrogen receptor positive. So she will have to have endocrine treatment. None of the other answers have it. So, um sometimes answering questions are all about how you read it and looking at the answers and saying, well, which one of these, you know, has what, you know, what really this patient needs and this patient will need endocrine treatment. Ok. Hopefully, that helps um others who may have been struggling with that question. Ok. Next one. So now we've got a 68 year old lady and she's got a small so six millimeter grade one invasive ductal carcinoma. Again, this is estrogen positive, it's Herceptin negative or her two negative rather and she's got normal nodes. So what's her most likely treatment plan? Four? Excellent, brilliant. So, very correct. She's got a small cancer. So surgery is perfectly reasonable and it can come out with a wide local excision. Even if she had a tiny breast, six millimeters would be easily taken out. Um It's an invasive ductal carcinoma. So she needs to have the sentinel node biopsy because we do that routinely for anyone who has an invasive ductal carcinoma or an invasive lobular carcinoma. Ok? Even when we're doing a lumpectomy and like the previous lady, she is estrogen receptor positive. So she needs to have endocrine treatment. Ok. Well done. OK. Next one. So this is a 59 year old and she's got a 26 millimeter grade three invasive ductal carcinoma. That's what IDC stands for. Again, this is estrogen receptor positive and it's her two positive and she has nodes that look like they've got cancer in them. So, what's her likely treatment? Plan three? I'm having to read my answers just to double check. Uh Yes, you're quite right. Well done. Um So uh the giveaway here, I'm trying to figure out what, what the giveaway here is. The giveaway is because it has every treatment that she needs. Ok. I don't think any of the answers have chemotherapy and immunotherapy together except for two, but it doesn't have the surgery in it, does it? OK. Yeah, that's right. So three is the right answer. She's got a small cancer. It should be perfectly amenable to have a wide local excision. But because she's got cancer in the nodes, we wouldn't do a sentinel node biopsy. We would do an axillary dissection. So we would remove more than just a couple of nodes. We'd be moving at least 10 or more nodes. Um She needs immunotherapy. We know that because she's got a her two receptor positive cancer and like you've also identified, she's got an estrogen receptor. So she will need endocrine as well. The big key here is that um immunotherapy can only be given at the start with chemotherapy. So the studies when immunotherapy came into existence, so the anti her two treatment came into existence were done when giving it with chemotherapy to patients. And for that reason, patients who have her two positive disease will need to have some chemotherapy. Ok. Um and the radiotherapy is offered to women who have lumpectomies, so she would have radiotherapy as well, so well done. Ok. Um I'm going to just expand a little bit and probably just take a couple of minutes just to talk a little bit about breast cancer surgery. So I would say all of this is a bit more advanced. I do not expect you to talk too much about this or be asked too many questions about this. So I would say these are bonus questions. So that's if you're going for gold medal finals kind of thing, breast cancer surgery, you've got things like a lumpectomy. Um, or what we technically call a wide local excision. Um, and some women who may have a mammoplasty. So in that first picture, uh the lady with the dark skin, can you see my arrow? Hopefully you can, um, she has had a therapeutic mammoplasty on this side and that's, um, you can tell that because obviously her breast is a lot smaller. Um So it's quite possible to do that. Um, you've also got a mastectomy. A mastectomy would leave someone flat or if they have an immediate reconstruction, they could have a breast that um is there straight away. And so we'll talk a little bit about reconstructive surgery because that is another thing that um some women may go through. But essentially this is what you'd be looking for. And these are the kind of scars that you might see on women. Um If you do see women who've had treatment already, most women will be recommended to have some form of the lumpectomy wide local excision or mammoplasty. Ok. The reason being it's less invasive, it's a quicker operation. Um it's much more straightforward and although your breasts may look a little bit different, most women would prefer to keep their own breast tissue rather than lose all of their breast tissue. Some women may have to have a mastectomy and the women who we would recommend having a mastectomy to are those women who would have either um a lot of breast cancer. So in terms of the volume of their cancer that we see on their scans to the volume of their breast. So for example, something like that 45 millimeter cancer in a small breast would probably mean a mastectomy, but a 45 millimeter in a huge breast like a double G cup could have a wide local excision. So it's the ratio of how big you think the cancer is to how big the breast is of the original breast is of the women. Some women may have lots of areas of breast cancer in the same breast. So they may have three or four different areas which are in different parts of the breast. And that's why they need to have a mastectomy. Other women may have actually the skin involved in the breast cancer and that's why we have to remove the skin and therefore, they will end up with a mastectomy. So there's those are the main reasons for having a mastectomy. Um There are some women who, regardless of being able to have a lumpectomy will choose to have a mastectomy. That is their choice and they just, they do that on their own basis. Um And that's absolutely fine. So if they choose to have one, they can have one. But if you're asked about the reasons for a mastectomy, those are the reasons um in terms of reconstructive surgeries. Well, let's talk a little bit more about those um using um the ladder. Um So there is a reconstructive ladder. So we can have localized dissection that resect the breast. That essentially is the mammoplasty, which is what you saw in that picture. Sometimes you can have local flaps using advancement techniques. So we might use a bit of tissue. So maybe from just under the breast or just to the side of the breast and um almost dissect that free and into the breast. Um We used to use quite a lot of pedicled flaps. So that's basically keeping the blood supply of um muscle or tissue where it is and just moving that entire um muscle or bit of tissue into the breast area. And the most common thing that we used for that was the Lasinus dorsal, which is one of the back muscles or you can have the free flap and the free flap is generally taking your own tissue from somewhere else, completely different and replacing it and rep plumbing it. So you will have to dissect out the artery and the vein and then replumb in the artery in the vein. Um Most breast surgeons will do localized dissections, local flaps, pedicled flaps. Um The free flap is generally the remit of plastic surgeons. Ok. And then finally, um other than that, we also can offer women implant based reconstruction. And so that's obviously putting a silicon implant into the skin, uh the skin envelope of the breast that's left behind. Um That will be done by breast surgeons should they wish to. Um And so that's the only other thing that we may also offer women. And that's probably what you need to know about in terms of a reconstructive ladder for breast. So I would talk about that if you need to and that's it. I think that is the summary of everything that I think you need to know. I think I've stuck to about an hour or so. Um Are there any questions? Thank you so much, Miss, that was really good. Um I'll keep the chat open just for the meantime. So if any questions come up or if anyone wants to just ask out loud as well, feel free to um, I'm just gonna link the feedback form into the chat as well while we're here. Ok. I'm just gonna bring up my uh uh chat as well. Now that I finished that, I guess I should stop sharing. Let me see. Yeah, you can, I'll, I'll just share the um the feedback QR code as well. Thank you so much, Miss Rash. That was really good. Thank you. OK. No problems. It was a little bit more detailed than what I usually do. But I think I thought perhaps maybe we should try something a little bit extra and give you a little bit more um to think about. Yeah, I thought that was really good. I mean, I think it was perfectly pitched to where we are and everything was explained really well. So, thank you. That's OK. Well, good luck guys. Oh, there's a question. There's a hand up somewhere. Yeah. Uh Yeah, Miss like you explained about like if the cancer in involved the skin. So in that case, it's possible to reconstruct by the silicone or not very good question. A very advanced question. So I don't think you would get asked it. But um so the answer to that is actually no because um in terms of the skin being involved, um it needs to be removed. If we don't remove that skin, then we cannot, we haven't cleared the cancer at surgery. And obviously, that's the whole point of surgery. Um And that means that I, we would not recommend having an immediate reconstruction. So the in those circumstances, which is essentially what you're talking about is an inflammatory breast cancer. You would remove the breast, you would complete all your treatment because you would need a lot of systemic treatment in those circumstances as well. So, chemotherapy would be essential and possibly even radiotherapy. And then you would consider coming back to do a delayed reconstruction. So you wouldn't do it at the time you would do it delayed. And in those circumstances, what I would recommend is not having an implant, but actually using your own tissue. If possible, if people have the ability to use their own tissue, I would use their own tissue because using an implant in putting an implant in a woman who has already had radiotherapy carries a lot of risks and has a lot of complications and problems with it. I understand, Miss. Thank you so much. So, any more questions.