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Uh Hello, good evening. Uh I'm Mr Mali. I'm one of the consultant breast surgeons and I have James with me, James. You can say hi, hello there. I'm James. I'm one of the SDA Post Frcs breast registrars in Eastern England. So let's see, we can start with the paper we, we have chosen, which is something that actually was quite significant. Uh Can you see the slides uh is a webinar. So I'm not sure. Uh Let me see if anyone can speak with the Q and A if they say anything or if they send a message. Um I most um maybe you can do a full screen, but before we start, I just wanna uh welcome everyone to the 25th year virtual journal club. Um uh My name is Marita and I will be sharing to tonight's session. Uh It's fantastic to see you all um joining um in this journal club today. Um Mr Malis and James have introduced themselves and in addition, we have ana and to that and we, they are um our sponsors from Advanced Medical Solution. Um So I think uh I would like to thank you all for um coming tonight and uh for supporting tonight's events. So with no further due, let's start today's session. So if you wanna maybe put it as a full screen so people might be able to see a bit better. Thank you. Yeah, that's what I'm trying to. Two James. Do you know how to do that if you take over? And then we just, if you click on present at the top of your screen, Miss smear, I think it will um make it full screen. Yeah, that's what I tried on your current screen on your desktop. Yeah. Move along the top bar across it says comments catch up and then present. Mm Thank so wait, I'll stop sharing. And he go to me not to the sharing you say because now we will say a PDF you. So now that should work better. So this, well, I can start talking about it. So what we're going to see, we're going to see something called the sound trial. Uh The full exa full name of it is Sentinel lymph node biopsy versus no axillary surgery in patients with small breast cancer and negative results in ultrasonography of axillary lymph nodes. So the idea is this is a a non inferiority trial they were trying when, when we do breast cancer surgery, we always check the lymph nodes. The the first check is an ultrasound check and uh if that is negative, then we will perform what we call a Sentinel node biopsy for whoever might not know what this is. Uh We use some tracers to identify, use the lymphatics and identify where are the first lymph nodes that drain the breasts or where cancer would go. Uh And if we find these lymph nodes then and we take them out, we send with the microscope. If cancer is not there, it shouldn't have gone in the armpit. Uh And the most common use tracers, there are, there are a few different ones, but the most common ones used in UK are the uh the blue dye and there is an isotope which is technetium 99. Uh There are some other iron based ones or other colors. Uh There is red, there is blue, there is green, but these are the most commonly used ones and this is still saying uploading which I don't get it. Ok, let's go back to the powerpoint. Uh James, what do you suggest? I do? I do again, present now and now share entire screen and your, your power, the, the page with your powerpoint will come up once that's entire screen. Yeah, let's do an entire screen. That would be easier. No. What? So can you see it now? And then if you click on present, er missus, if you go to the far, right on the top bar, keep going, right, keep going, right, keep going right present. That's it. So there we are finally. Can you see it? Yeah, I can see it. I'll just ask people to put a message in the group. If they can see we can, we can. Yeah. And James, you check the messages with 12. There's not too many of us. So we will be able to have a chat if needed. So this is us and this is what we're talking about. Let's go and talk about it. So, uh well, it's kind of, we want to do a critical appraisal. That's the main uh aim of what we're doing tonight. And then we'll have some preparation for Fr CS. You should be already aware about this. So I'll pass through and, well, what is a critical appraisal who has written it? What is the topic when it was published where it was published? Why it was published? And uh what are the results? And do you think this is a, a good paper or not? So, let's keep going. Uh One part of it is the impact factor, impact factor of a journal. There is this nice equation. Uh How many citations have there been? And then uh connected, uh and the rate with their publication they have done this is not, uh this is just an example, is not the one even though it's quite good what this uh has. So the, the lead investigator was Gentilini uh there, they don't have any bad reputation. They, they have done some good uh other papers. And what is the point is to it's a non inferiority trial to try to see if we do not do the sentinel node biopsy in small breast cancers. Should, is that in equally good or is it uh are we missing something and we're causing trouble in the treatment of our patients? There has been around uh a long time now that what we do in the armpit is not actually treatment, but it is mainly diagnostic and it can guide further treatment. So the the study is trying to say, well, if it's not gonna change the treatment and for further treatment, do we really need to do it or can we omit it in some cases? It was, it's quite recently, it was published 2023 which, well, we're 2025 now. So it's not a year. It's more, it was published in the journal of American Medical Association Oncology. And uh the impact fac factor for them is 33 which is quite high. The, the British Journal of Oncology. Uh it's about three or four. So this is a quite high impact factor if uh to, to my knowledge, why do you want to do it? There were some, also some further, some some trials. This uh as O GZ 11 was a revolutionary trial that has shown that uh for some patients, uh we do not need, even if there are positive lymph nodes uh on sent node, we do not need to proceed with axiliary node clearance, which is the standard afterwards uh because, and this would not change uh the long term outcome unless if it is the information is needed for uh mainly answering. Do we need to do chemotherapy or not? And instead of that, we could do radiotherapy to the armpit? And this has been found to be equally good and that is becoming common practice more and more uh all around the country. So following this is again the idea that, yeah, do we actually need to do more and more in the armpit? How did this happen in four centers, Italy, Switzerland, Spain and Chile. They were looking for uh ladies with small cancers under 20 millimeters which is considered a small cancer and uh it has to has had to be node negative on the preoperative ultrasound and the eligibility. This were uh then separated randomized to uh two groups. One that would proceed to have the sentinel node biopsy, one that we could omit the sentinel node biopsy in the end. Uh There were 1400 patients included. Uh And uh we'll see what was the outcome? There was very similar randomization. Uh The primary endpoint had to do with uh distant disease free survival and uh how many events of uh recurrence we would have. There were some exclusion criteria. I don't think I need to stand so much on this. Uh The median age of women was around 60 the range 52 to 68 there were almost similar numbers in both groups, 708 in the ones that have sentinel node biopsy and, uh, 697 the ones that didn't have any surgery, the median tumor size, we s, we said it had to be under 20 which is considered a small, very treatable cancer. And the median tumor size was 11 millimeters. Uh, most of them was, er, positive, which again, we could have a discussion uh about the er negative ones. And uh from the sentinel node group, 97 patients had po positive sentinel lymph node uh biopsy. So there has been cancer found even though the ultrasound was clear, sometimes we do find cancer when we do the sentinel lymph node biopsy. This is the same with some information on the protocol, the two cohorts and the two branches which uh then ended up with the numbers and why some had to be excluded. So, again, 708 and 697 what were the results in the sentinel node group? There were 13 events with distant metastatic disease. 14 on the non sentinel node uh group, local relapse 12 on the sentinel group 11 on the non sentinel group. And there were 21 grab deaths in the sentinel node group and uh 18 on the non sentinel lymph node group, uh digit free survival for five years, very similar 97.7 or 98. And uh the accumulative axillary recurrence, not 0.4%. So, very similar numbers and uh was the power of the, of the numbers enough, they have been statistically significant and equal to prove that it has not been inferior. Was it good? Uh Well, yes, it is an important topic which has been changing uh and allowing to change the, the practice because, well, yeah, we can do studies in numbers that make no difference. Uh But this has been like this at 11. This has been changing practice and say actually sometimes we can omit uh what we're doing. Hi. Do you want, do you want to be here in the, in the teaching? Stay here with me. No one here, stay here with me. So, but you have to be quiet because we're doing a, a study. OK. Yeah. So uh this happened in Multicentre which is good. It's always good. I cry, I will cry. But uh well, one of the critics that we can do is that well, there haven't been any UK I do. Do you want to go to Mommy to, to go for, for you to, we will go, we'll go in a little while. OK. Do you want to go to Mammy? And then I'll come, I'll come soon. OK. OK. Thank you very much. I'm doing some work and I'll be with you very soon. Go, go, go to Mommy for you. OK. So, and the power calculation has shown that, yeah, it is non inferior. Uh So it was, I'll come soon then improvements. Uh would it be different if we had the more years of follow up? We don't know, but there is a plan and I'm sure there will be the report when they get the 10 year results. There was, they have said themselves that there is uh late registration for the trial. However, this did not uh look to affect the results of uh reporting. And as I already mentioned, yeah, it has not been in UK centers which is considered different in countries. Uh most likely not. But at the same time for our population, it would be better if we also had local control and local uh groups which, well, we might get some time. The is also what is uh there has been other uh trials and other suggestions. One is, which is very important is the choosing wisely, which is from the Americans that they have also been suggesting in ladies over uh 80 you can not do, you don't need to do something, not biopsy, but this has to do with small low risk cancers. Uh It has to do with uh patients with has negative uh lymph nodes and uh it could be one centimeter up to two centimeters. It's, they did include some er, negative patients, but we could argue and I think everyone would be happier if we do it on er, positive patients because you know, they will be having some systemic treatment which even in the few cases that you would have uh uh a surprise in the lymph nodes, the anti estrogen tablets should be able to uh sort it out. It needs to be discussed with the patient. And so the data and why we should or shouldn't do that. And it's always patients, uh well, we're very happy in this country to have patients involved uh in the decisions and we need to explain why we would want or wouldn't want to do. And uh there is all, there is the, the, the where, where we're heading is the escalation of what we do in the armpit. And uh there is more and more radiotherapy or even nothing uh in the armpit. And this has been shown that it is not uh getting our patients into trouble. Uh That's why this trial, uh actually, when we said like what we're gonna do, I said, yeah, that's a very recent one that has actually changed our practice, any questions or anything anyone would want to or if James wants to add something. Thank you, Mr M. This really nice overview of the paper. I think this is very relevant for the Fr CS part two. So if anybody's planning to sit that soon, this is a nice way of going through the paper. That's easy to remember that one of the first slides I copied when you get your exam invite, they actually send you away to take a paper. But it's very complicated. I think if you can remember who, where, why, how you can use that for any paper and then go on to the results. What's good? What's bad? That's very easy to remember that structure. Even when you're a bit nervous during the exam, and you can break that down for the initial introduction. And then you can also think about it in terms of the individual patients in the study. So who were they, what was the inclusion criteria? What was done to them? Which groups were they put into? When were they recruited? And what was the follow up? And where was it? So, locations? Because if you're critiquing a paper like this, it wasn't done in the UK, I think this paper is OK, but some of the surgical breast trials in patients in countries that don't have the same anatomy as ours or the breast volume is very different. You have to wonder if it's applicable in our patient population. And then it helps when you critique the validity internally and externally. So I think it's a useful way. That's what I use for the exam. And I find it quite helpful. I don't think there's any questions in the chat at the moment. If anyone has anything they'd like to add about the paper or yeah. So then if someone wants something to discuss or even in the methodology act because yeah, actually, I would agree this uh slide that uh if we haven't mentioned, uh James went through this Fr CS process very, very recently. So his experience is very viable. So, actually, yeah, this is very, very helpful to remember. OK. What, how do I talk about? Uh how do I uh do the evaluation of a paper? Ok. Then I'll stop sharing nothing. We can have a word from our sponsors. OK. And we'll start, can everyone hear me? OK. Yes. OK. Uh Thank you very much for inviting myself and DPA to present um Excel, I appreciate because it's quite late and I promise that we literally shorten our um presentation to to a very minimum. My name is Anna and I work as a surgical sales executive covering east of England. And my colleague DP A is global product manager for topical scheme, application products. It's our pleasure to be here and together with DP, we represent advanced medical solutions. Quite often people call us liqui colleagues or Liqui people as well. That's what we keep hearing. We're proud to work for a British company with global reach. Our market share within the UK is quite high and it's still growing. We are growing as a company too. Our recent acquisition was Peter Surgical. So we keep adding to our portfolio as well. We are a wound closure company, manufacturing lots of different glues, mainly we've got the whole range. It's a good range with a variety of different sizes depending on the procedure surgeons. Um and I can guarantee that it will match your clinical needs as well. So today, we would like to tell you a little bit more about liquid Band Excel apologies for, for those that have already heard our presentation, but I'm pretty sure it will be quite useful to hear it again. This is the latest addition to our range and it's becoming very popular within the UK market. Um I would say it's not just a glue, it's a skin closure system and I'm sure that da can fill you in with uh more details and a video as well over to you. DAC. Thanks. Good evening everybody. Um This, I will keep this very brief and what we'd like to do is if you're having any questions, um You'll be able to send the questions over to a and then we'll be able to share those due to um you know, the limited time we have tonight with you. So I'm, I'm hoping you can see my screen. OK. The screens come up now. Excellent. So um Liqui Band XL is a skin closure system. What that is, is basically a, it's a mesh and glue combination skin closure system. It's to hold long incisions which are large and high tension incisions such as the breast around the breast augmentations, excess in terms of breast procedures. The idea is that you use the mesh to hold the skin edges together and then you would apply a ser acrylate glue over the mesh which which entered onto the skin over the mesh and it seals the mesh over the incision and around the edges to keep that close for up to 14 days. The system itself, as I mentioned, it consists of a mesh which is polyester Bova mesh with 2.7 g of Sino Ary glue, which is quite flexible. It's an oct S Ary glue which is very flexible. In terms of sizes. We have them in three sizes 2244 and 66. That's the mesh sizes. And you can use to overlap the mesh by one centimeter from a continuous layer of, of the mesh. It's strong and durable wound closure. It dries as inconsistent as in as fast as 60 seconds. So that's the glue polymerizes of the mesh and reinforces the mesh on the skin and it in as fast as 60 seconds and it stays on for 14 days. We do have an effective microbial barrier and we have the best application in the class applicator in the class also. So it's ease of you. It's a true one handed application below a short video just to show you what that means is that the product itself comes. The mesh itself has two release liners and the application of the applicator itself has the, has the glue within the, within the body of the applicator. And at the same time, it consists of the 2.7 g of glue. The white release liner allows you to remove that and it allows you to manipulate the mesh over the, over the edge of the incision. So once you've cleansed and you've prepped, the, the, the, the incision site has played protocol, you to release the white release liner from the, from the mesh itself. The diatal lines that you see on the mesh that is just a standard bandaid type of adhesive. The job for that is to hold the edges together initially. So you would apply one half, half the mesh lengthways as shown here and then you roll over, you go over your fingers and make sure you've got an intimate um seal onto the skin and then you would pull towards you which brings the edges together and then push the mesh down. It's as simple as that. And then once you've got a, an intimate um uh adhesion to the skin, you then release the clear release liner by the white top that you can see on the screen, you tear the clear release liner away from the mesh and that's your mesh element done. So you can see the incision there and then the ampoule of the glue by facing the tip up, you'll be able to feel it, hear it and then invert it down about 3 to 4 pumps that you would have to give to ensure that the glue see glue is passed through. Um the chemical exel that we have in within the applicator which actually polymerizes the, the glue effectively over the mesh. And then once you have complete the mesh coverage as shown your weight for 60 seconds. And once you've done that, you can then touch to touch to dry and, and that would be up on the skin for up to 14 days. There. It's an ideal alternative to sutures or staples. Um, there is no need of secondary dressing or bandage. You'll be able to see the incision as well and it has and it provides that daily activities. It doesn't, it provides the approach for daily activities for the patient and it's a water resistant barrier as well. So patients can have a shower and continue with their daily lives. And that's in short today, this evening is Liba XL. Does anybody have any questions or do we have time for a couple of questions? Yes, sir. I think. Yes. Yes. I was looking for my M microphone, which II can make a question which uh, well, a common thing with a wound, a wound might start getting infected might get a collection. Uh What's happening in that case? Is it something that we, you can still drain part of the wound or it's intended for cleaner clean wounds? Of course. And absolutely, you're right. You know that what you can do, you may have a, uh, you don't, you can't use it over the drains because we need to have a clearer, a clear closure and hold the edges together. Now, if the wound does get infected systemically and if you do get a surgical site infection, we're hoping it doesn't because, hey, these things happen, then the only option, the alternative way is to remove the mesh by using mineral oils, creams or ointments to basically break the bond of the mesh and then remove the mesh and then make your entry forward drain if required. Now, obviously, sometimes it might be, you don't, you don't have the luxury of having some time. You may have an emergency and you have to enter into the incision as an emergency, then you would simply cut through the mesh. The mesh is all fully intact. It does a frail fray any um particles because the glue is holding it all together. So when you make that incision, you then as an emergency, you cut through the mesh and go and do what you need to do and then remove the mesh once you've completed your work. Um But again, it's not suitable with a drain. Yeah. And have you seen any change uh on incidence of surgical site infections when using this uh dressing compared to while a standard dressing or any other closure option? So we have seen infections when um when we speak to our clinicians in terms of other alternative closure methods such as sutures or staples, certainly through sutures. Because if you're using sutures and then you apply a secondary dressing on top predominantly. What happens is the secondary dressing such as a film, POSTOP dressing, sometimes can fold on the edges and then make a channel that allows bacteria to enter. And that's normally the common theme how a um an incision or a, an incision becomes infected. And it's usually because of the second dressing rather than the sutures. Um That's, that's the feedback we get from our clinicians. Um However, using XL, we have had um we have had a very positive um outcomes due to the fact that we have an accelerant in our uh in our glue. When that dries, it provides a good um adhesion of the mesh and the glue and provides a microbial barrier. We have testing and we have done lab testing for grab gram positive gram negative and fungal microbes. Whilst the glue is intact and not tampered, you have 100% protection again, surgical site infection of day three and 100% protection. At day seven, we tend to go up to day seven in terms of by that time, you know that your skin has almost particularly sealed, so therefore, reduce, reduces the risk of surgical site infection. But we, we continue, we continue to monitor that. We take that very seriously and we continue to monitor the outpatient outcomes. And we have sold um 100s and 100s of thousands of these since we've launched in 2021 and our um rate, incident rate. And that's usually what we're hearing in terms of um adverse events is around 0.04%. So it's, we have a very good outcome using our um our blues. Good. Thank you. No problem. Thank you for the questions. Great questions. So we'll move on to the second part of the talks for tonight, which there is a question on the chart uh after the recommended 14 days, does the mess simply peel off or you need to uh recommend a particular product to the patient for them to? Sure, Rebecca. Um After 14 days, the product is um durability is up to 14 days and the mesh simply peels off, it doesn't fall off. So you don't feel the the mesh itself will not fall off. You will just hold the edges of the mesh and simply peel it off. No need for a second, any other product to remove the dressing it itself uh the the mesh itself, no secondary dressing required. So it simply just peels off? Ok. Thank you very much. Thank you James. Do you still require hanging out myself to stay on or? No, I think that's absolutely fine. Thank you very much for that. Thank you. Lovely to meet you all and thank you for the opportunity. Thank you so much. Thank you very much. See you again. Thank you. Bye bye. Yeah. Um You see my slide. Ok, Mister Melius. Uh Yes, I can see it. Ok. Um So we'll move on to the second part of tonight's talk, which is, um, looking at the Fr CS and some tips and tricks particularly related to breast surgery. Um I know we didn't check at the beginning, but this should be relevant whether you're doing the breast subspeciality or the general surgery. One of the other subspecialties I did the exam in September. It is quite a challenging exam in terms of the amount of preparation required, particularly the part two, I think the part one involves a lot of time on the data banks. But the part two, you really need to practice formally conducting viers and have a study group I would suggest. But I think for me, there is not a huge amount of information available about the exam in terms of the structure. So I really wanted to understand how is it marked and how can you maximize the marks? So when you look at the examination, the exam, each question is broken down into four areas, basic knowledge, higher order thinking, clinical skills and professionalism. It scored from level four, which is the worst possible marks. So you can't score zero, you please. No. Um and an eight which is essentially four marks. If you score eight on every single domain in every station, you would get the 100% on the exam. Um six and above is a pass. So I'll put six on here now. But it's interesting to see that you don't have to be perfect to pass this exam. So, for example, basic knowledge, competent knowledge and no major errors and safe practice that is enough to pass this exam. So, bearing in mind it's much better to put something across that is safe and competent than it is to try and put out some wild kind of very unusual management plans that actually because you're trying to get that level eight and get it wrong. So just think about that, you can find this all on the Fr CS website and they actually send this to you when you get the invitation for the exam. So I wanted to understand a bit more about the structure exam. It's quite a stressful exam on the day. So you go up to, I'm not sure where the next one is. I was in Newcastle for mine. You're away from family up in a sort of, I would say questionable hotel. The exam split into two days which day you do would depend on. I think they do it alphabetically. So where your name falls in the alphabet, whether you do the clinical half day first or you do that second. So I did the clinical half day first, which is the sort of middle day of the exam because they bring in patients for you to be discussing with and you'll have a long case in general surgery and two short cases in general surgery and you'll have a long case in breast, for example. And two short cases in breast for the long case, you'll have a real patient that, that directs the focus of the questions in the short cases. The examiners pretend to be a patient for you to interact with and it can be quite difficult to switch from them being a lady person and then they switch back to being the examiner. So just be careful about whether you're describing something to a simulated patient or you're giving an answer to an Fr CS question is I would imagine the way you approach that would be very different depending on which one it was. And then on the vi a day, you've got four broad areas split into 65 minute stations. But the fourth of those is the academic paper, which you'll have 15 minutes to present and then they will ask you questions, basic science type questions which is specific to your speciality. The individual paper is generic now it's no longer directed at your specialty. So when you're preparing, read the sort of latest general surgical papers from say the B Js or from the R CS Ans and try and just get as many papers as you can on the belt. These subspecialty papers are useful to bring in as evidence for your subspecialist questions. So I put this in particularly for people who aren't doing breast directly because you can be asked about breast scenarios So I think for breast disease management in general, you need to discuss a history from the patient and that would include their personal history of presenting complaint, but also any family history and risk factors for breast cancer. Um presenting complaints generally be broken down into lumps would probably be the most common reason for referral um nipple discharge, um Gono maia in male patients, some patients will present with skin changes and nipple changes. So for example, Paget's disease of the nipple. You need to have a, I think in the exam, it doesn't hurt to have a fairly low threshold for wanting to rule out cancer or a sinister diagnosis. And those kind of statements are very helpful in the exam. You need to talk about your clinical examination. I think generally speaking, you can break these down into fairly simple phrases. If they want you to give more information, you can go into more information. I wouldn't you think about a five minute Viber? I wouldn't waste time saying I'm initially going to inspect from the end of the bed. I'm going to do this. It's not a medical student exam. It's much more focused and they can ask you for elaboration if needed um in terms of investigations. So most patients with a lump, if they're below the age of 40 we would think about an ultrasound scan. If they're above the age of 40. If it's a palpable lump, you'd be thinking about both the mammogram and an ultrasound scan. And you would also want to mention that if you're concerned about malignancy, you would perform an ultrasound of the axilla and you would examine the nodal stations as well. In terms of biopsy, we do a triple assessment. So the radiologist would perform a biopsy if there was concerns. Um And that would be an image guided core biopsy. If they'd like to put things in the gray area for the exam, they want to test you, they want to see how you deal with slightly challenging scenarios. So you need to be aware of what is safe. So if I've got clinical concerns, but the radiology is normal, I'm going to do a free hand clinical core biopsy. If there's discordant results based on my clinical judgment and the investigations and they certainly will tapap into that gray area and then you can talk about taking a punch biopsy. If there's skin lesions, some people perform nipple cytology. I think the latest evidence is there is no evidence for it, but it's the benefits are a bit contentious. I guess if you find malignant cells and it's helpful, if it's indeterminate, it may not add much and delay the definitive management. So I think if you are doing any scenario for breast, these are the key things to have in your head and they will particularly in the short and long cases. There is a lot of information to get across and cover. But if you remember these broad areas, I think you'll be fine, particularly if your subspecialty breast. So you, you want to have a brief landing statement, I would take a focus history. I'll perform a clinical examination and relevant imaging. Depending on the findings, I would proceed to biopsy of any concerns completing a triple assessment. I will discuss the results in the MDT and then the MDT are going to make a plan as to what am I going to do with the breast? Am I going to go for surgery for the breast upfront? Am I going to think about a neoadjuvant treatment initially? What am I going to do with the axilla? So what did the axillary ultrasound show? You need to have asked for that for them to give you those results. Um Was there any palpable nodes on examination? Um if the axilla was positive, is the patient going for the avant treatment? And then you know, you could think about the apneic trial. Is the patient going to need an anxi lymph node clearance as the initial surgery alongside their breast operations? And then you'd need to look at whether or not this patient will require staging in order for us to make those decisions so that you'll be able to find on the A BS guidelines, the specific staging requirements for breast cancer. So, breast cancer is not the same as colorectal and some other malignancies. Lots of our patients will not have formal cross sectional imaging of the whole body. In terms of staging, it would depend on the presentation, the number of lymph nodes that are abnormal on their ultrasound scan. And then most patients staging wise, most units would consider a ct scan of the chest abdomen and pelvis and a bone scan. Not everyone does a bone scan. Some radiologists feel that the CT scan is sufficient, certain types of breast cancer, for example, inflammatory breast cancer, um often the staging modality will be a pet CT scan. So there is some nuance to the staging, but you need to think about does this patient they've given me scenario wise, need staging or not. Then you come on to the a and adjuvant treatments and try if you can to shoehorn in some evidence as you go, it's very difficult because they're firing questions at you. But if you've got the evidence to hand and you're confident that it fits with the question, put it in there to justify your decision making because that's how you would score level eight on those scenarios. It's part of the marking scheme evidence, a good understanding of the evidence. So II put a few cases on here that cover some of the broad topics that um we cover. I don't know if mile if you can, you see the messages in the chat, I kind of keep an eye on this. We don't have anything for now. Just keep an eye on this, I might ask some questions if people are happy. So for this first case, we've got a 25 year old lady, you've examined her in the clinic and there's ap two lump. You've organized a ultrasound scan. It showed au three lump. Slightly bizarrely when I wrote this, they've done a mammogram. Maybe they thought it was U four, but they finally called it U three. They've done a mammogram and it's M three. So hopefully, people are familiar with the numbered numerical system for breast cancer. So it allows us to with a number essentially convey our degree of concern about malignancy. So if someone has ap five lump, that's essentially you're saying they've got a clinical evidence of malignancy. If it's M five, it's mammogram, suspicious high degree of suspicion for malignancy and U five would be, it is essentially your concern. It looks like a cancer on ultrasound scan P two is you're saying it feels essentially benign. So it doesn't feel P three and above would be sort of indeterminate more towards malignancy and P one would be normal, completely normal breast tissue. So your clinical examination is of a benign lump, you've organized some imaging and investigations and they've essentially found that it's indeterminate. So, and that's something that they will ask about in the exam commonly. So if you've got an indeterminate lump, usually you would consider proceeding to a biopsy of that and the biopsy in this case has come back as a B3 lesion. Um Hopefully, people are familiar with what that means. Can people just write in the chat? One example of a B3 lesion? Just it will help me to understand where you're at with this. I'll just give her you 60 seconds or so to do that. Just let me know if any responses come in. Uh Miss, so I'll, I'll give an example, say a papilloma can be a B3 lesion. So any other examples people are aware of, I'm assuming from the silence, there's nothing in the chest. It's just a very old scar. OK. Yeah. Very good. OK. Yeah. And so and fibroadenoma came on the chart. This is uh a benign lesion even though there is uh on the breast cancer. Now leaflet it does say about some naughty fibroadenomas, which I don't know where to find them. But this is something we do give to patients. But fibroadenoma is considered a B2. So it's a benign lesion in B3 with this system, it practically means a lesion of unknown malignant potential. And then, yeah. So essentially B3, there's a heterogenous group, there's a large number of different types of lesions that fit into this, but essentially it's indeterminate based on the biopsy. So most of the time you're going to need to do something else to make a definitive decision. Is this cancer or is this a benign entity or is this something in between? And there's a nice algorithm that was produced, that essentially differentiates all the different types of B3 lesions. A lot of those types of lesions can be, this would be based on a core biopsy. The next step would be to do for most of them is to do a vacuum biopsy to take more tissue, which will then allow you to upgrade it. To say. Now I've got more tissue in my hand. It's cancer or now I've got more tissue, it's benign and I'm happy that it's benign and I can manage it accordingly and you'll be looking on the biopsy to see if there's any atypia or not, which can increase the likelihood of needing to do a surgical excision biopsy. So there are certain B3 lesions that once you get the initial biopsy, you need to actually take them to surgery and excise the whole area because the risk of upgrade is higher. So each type of B3 lesion has a different risk of upgrade. So when you look at this next slide here, this is some of the examples. Um If you take, for example, um atypical ductal hyperplasia, a DH with atypia, which is the column on the right, that has a 22% risk of being upgraded to a cancer when it's excised. So for that reason, the recommended treatment for that would be surgical excision as the next step, if it's a larger size, as opposed to a smaller size, potentially would be manageable with a vacuum assisted excision. Same with a papilloma. You can see the rate of malignancy is much higher. If there's Atypia and 32% for those, you would be looking at the surgical excision and annual mammographic follow up for five years. However, no, atypia has a much lower risk of upgrade. 7%. You could manage that with a vacuum assisted biopsy provided it fell within the safe parameters for a vacuum biopsy. Sometimes if it's too close to the skin or too deep in the breast, it's not technically possible. Um But you think about the difference for a patient being able to go in and have tissue vacuumed under a local anesthetic compared to needing a G A and a surgical excision. Um and this is something that very commonly comes up in the exam more so for breasts trainees than in the general section. So um another area that is commonly examined is the management of oncoplastic um breast cancer cases. So this is another case would be similar to something you might receive in the exam. Probably the best piece of advice I had for the exam is when you're receiving the stem from the examiners write down all of the information because they give a lot of information and you waste time if you have to ask them to repeat it. But if it's written down in front of you, if they ask you a challenging question, you're not sure you can just refer back to your notes and you may find something in there that, um, you haven't paid enough attention to at the beginning that actually answers the question they've given you. So I would definitely get into the habit of writing it down and then referring to that if you need to. But, um, for this case, we've got a 45 year old lady who has toxic breasts the size f so she's very generously breasted. She's been diagnosed with two separate lesions in the breast. We'll call it in the right breast. So there's a three centimeter lesion at six o'clock in relation to the nipple areola complex and there's a two centimeter lesion at four o'clock. And the immunohistochemistry has shown a her two negative cancer and she's er positive. So, in terms of the management for this lady, she's got multifocal cancer. It's in the um both sort of in the lower quadrant of the breast. Can anyone think of what might be a suitable surgical option? If you just write in the chat, one option that you might consider she's very to breasted and she's got two lesions. So, what surgical treatment might you offer this lady if you're doing an operation as the first step of treatment, a child breast mastectomy might be overkill. But I don't, I don't know. So mastectomy is certainly an option for any breast cancer patient. So we have to remember patient choice. Um, however, someone has very large breasts when you think about um that decision, you want to think about what is the volume of breast that needs to be removed to safely remove the cancer compared to what is the volume of breast that remains? So this lady has a lot of breast volume. Um she does need a reasonable amount to be removed. But um there's different techniques. So if you need to remove a large volume from the breast, obviously, if you don't do anything other than what's called a simple wide local excision, you're going to have a very large defect and hole where that's been removed from. But is there anything you think you might be able to do with the remaining breast tissue in order to um allow you to take more tissue away, um but still preserve a reasonable breast shape. Have you heard of a therapeutic mammoplasty? So, essentially a sort of breast reduction, but the reduction tissue rather than removing benign tissue, that would be to reduce the breast, the tissue you remove can include the cancers. Does that make sense? So, you may have heard about a breast uplift or a breast reduction. Um This is a technique that allows you to remove larger areas but reconstruct the shape of the breast by moving the tissue within the breast around. So that in this case, I would be considering a therapeutic mammoplasty on the right. Then you can make a decision with the patient about performing a reduction on the left breast because otherwise you'll have very significant difference in the breast volume on each side. So, even though that's benign, you can do that for symmetry and the NHS will fund that. And then um she will need a, a sentinel lymph node biopsy, assuming the ultrasound of the armpit was negative. And then um you would want to decide where you're going to take that tissue away from. And when you do a breast reduction as a therapeutic procedure, you need to consider where is the blood supply coming to the nipple at the end of the operation? Because not every reduction or cancer surgery needs the nipple to be removed. Um And you, you probably James, you probably, I cannot see. Uh So just to add, because basic knowledge, just to make sure everyone is aware and basic knowledge can get you out of a difficult situation. So, on the mastectomy and breast conserving surgery followed by radiotherapy. The classic knowledge is that this is oncologically equally good. So, well, the chances of cancer coming back, it's the same. This is the traditional knowledge. So there's no need to do a mastectomy. If you can avoid it, there's no treatment benefit. Uh If, as they said, if by removing the cancer, what is left, you can make it look like a breast. Now, there is recently some trials leaded by the soft trial that might suggest that actually keeping the breast and the following radiotherapy might have even better results than the mastectomy. Uh And you don't, none. I don't think anyone would expect that you would know the details about it. The basic knowledge is that and then, well, if now you also get in your head that actually might be better to keep the breast and it also adds the quality of life. Uh There's no real benefit in doing mastectomy if you can. Yeah, thank you for that. Yeah, I think that's, that's very helpful to add in there. So quite often in the exam for breast trainees, they will ask you to draw the draw the breast and talk about the operation you'll perform and particularly as a breast trainee and a breast surgeon. I find it very helpful when planning operations to draw the location, the breast shape and the location of the tumor. So this is a visual representation of the case I just showed you there. So she's got one tumor you can see at six o'clock just below the nipple and one tumor at four o'clock. And they're both in that lower aspect of the breast, which would lend itself to a therapeutic myoplasty with a supramedial pedicle. I'll show you a bit more about what that means. So there's a type of breast reduction called a wise pattern mammoplasty. So if you look at the middle image there, that's how you mark out the skin shape in order to perform the operation, you would also add a dome at the top of the um incision to allow for the nipple to be moved from the lower part to a higher part. And where the two arrows are in the first drawing with the two can still on the picture that is the blood supply to the nipple that will remain in place at the end of the procedure. So even if I cut the whole of the lower kind of crescent of the breast away, I can move the nipple on that arrow blood supply up higher redrape the skin over the top. And what I'll be left with at the end is the final picture, um which looks like an upside down, looks like an anchor with a circle all the way around the nipple. And that's a new nipple position. If you're a breast trainee, this should make a lot of sense to you. If you're not doing breast specifically, I think it's less likely to come up in the exam. But oncoplastic breast is the is a lot more recognized for breast cancer patients. So I don't think it'd be unreasonable for them to expect you to have at least a basic understanding of what options there might be to avoid mastectomy in these types of patients. And uh same thing, different words because well, we all understand things differently. So I want to say the same different words. So this wise pattern marking on the skin allows to reduce the skin envelope both in the vertical and horizontal pattern and with your markings, it allows more or less and then the nipple will need to be moved. We need to be moved to a new position and we need to consider, ok, where will it stay attached? So the blood supply comes from there. Uh and these are the consideration we have to do. And again, if someone is not a breast training, you don't need to know it. Mhm Yeah, thank you. Um So these were the options I came up with for that case, I think. Yes. So mastectomy can merit discussion. Although we've talked about why we might not offer that as a first option. And then if you're talking about mastectomy, you need to have a discussion about whether you reconstruct the breast, either with an implant or with a tissue based reconstruction, which is not something, there's not time to cover that tonight, but it's something to bear in mind for the discussion. Chest wall perforator flaps, a very sort of popular option for different patients, but not so much in a patient with this amount of breast volume particularly. Um it's often better for a patient who doesn't have much breast volume to move around and allows you to replace some of the volume you take out of the breast with tissue located outside of the boundary of the breast. And then you need to think about. Am I going to offer this patient surgery on the other side for symmetry because the concern is if they get complications from that operation, you might delay their adjuvant treatment. So, if you need chemotherapy, but you've developed a stonking wound infection, then you may not be fit enough to have that done. And now your cancer outcomes could be jeopardized. So that's something that merits consideration. And then am I going to remove the nipple? Is the cancer too close to the nipple to preserve it? Does the patient want the nipple to be preserved or want it to be removed? And then what am I going to do if I once I've taken everything out, if there's still cancer at the edge of what I've taken away, because if you've done a huge complicated procedure, it can be difficult to potentially go back and find the margin which you know where the cancer was sitting before to take more breast tissue away. So breast cancer management very much need to think about what is Plan A. But if Plan A doesn't kind of go to the plan and you run into complications or there's margin issues, what am I going to be able to do once I've already done plan A. If you burn too many bridges, you may find yourself struggling afterwards. And then does the patient need adjuvant radiotherapy? Say, for example, you're thinking about an implant, you may not want to mix an implant with radiotherapy unless you need to. And then I'll put in bold there, patient choice because that still is very important. Um We give them all the information and they will make an informed decision with our help. But if they want to not have radiotherapy, for example, and want a mastectomy, then that's a perfectly reasonable thing for them to decide. Um The next case I've put on is about a screening patient because breast trainees will be asked about the breast screening program in the exam. Um So this is a patient who's been gone for a one of their three yearly mammograms, which ladies are asked to come for between the age of 5070. And when she's had that mammogram, it's shown a two centimeter area of calcification in her breast. She's been asked to come back to the breast unit. That's the normal protocol and she's had a further assessment and they decide to proceed to take a biopsy and that has shown high grade DCIS, which is um stands for. Um I won't say actually I ask people to tell me. Um so can anyone does anyone know what DCIS is? Hopefully that people are familiar with that? If someone just write out what that actually stands for the abbreviation in the messages, I at least know we're on the same page there. Thank you waiting. Have you got any takers? Yes, there it is D in situ. That is correct. Very good. So essentially you need to have a way of explaining this. You know, I said in these short cases, sometimes the examiner will pretend to be a patient and sometimes they'll be the examiner. So anything like this, you've got to have a way to explain it to a patient. And you've also got to have a way of explaining it to an examiner. So I think um the easiest way to explain it is a very early breast cancer has change, the earliest possible detected breast cancer has change, which is non invasive. So I've got a picture I'll show on the next slide which helps to convey that. And it's a picture I used to show to patients as well. But essentially what that means is if it's left untreated over the longer term, there is a risk that this will progress to invasive breast cancer and particularly high grade DS. Most patients will be recommended to have treatment for this and it's likely to involve a depending on the amount of volume excision. Again, a either a wide local excision. Um And in that situation, you don't need to sample any lymph nodes from under the armpit. Because if you can tell from the biopsy, you're confident it is not invasive and it hasn't invaded below the basement membrane. There's no way that it would have found its way to the armpit or very low likely unless the biopsy had missed an invasive cancer. Um However, for an invasive cancer, there is the concern about a lymph node involvement, which is why we think about sentinel lymph node biopsy. Although not for everybody else. The sound trial has demonstrated tonight. Um and then there's a new for the breast trainees. There's a new discussion around whether you do endocrine testing. So, hormone receptor testing on D CS, some patients may benefit from adjuvant endocrine therapy. So whether that's aromatase inhibitors or tamoxifen after ADCS treatment, and then there is some research about doing oncotype genetic testing on D CS. Although that's not common practice in the UK at the moment. Um this is just a slide about the NHS breast screening program that we touched upon. They can ask you what this involves. So it's every three years between the ages of 5070 women are invited for a mammogram and they do the standard two views, which is what's called a craniocaudal view, which is a view from sort of top to bottom of the breast and a view which is called media lateral oblique, which is looking from the side of the breast. So if you're interested in breast surgery, just next time you're seeing patients in clinic, just ask someone to show you the different mammographic views. If someone has an implant in to a breast implant, because where the implant sits, these views mean you wouldn't be able to see the breast tissue. So they have a special additional view where they push the implant out of the way, which is called an ELAND view. So if you've got a patient with breast implants and you're treating them, you just need to mention that in the exam. I would also like an Eland view. Um So patients get recalled if they find concerning abnormalities. The mammograms are dual reported by two separate radiologists. And there's a very closely monitored system which allows people to look for patients who may have been missed. So if someone gets diagnosed within a certain time frame of their screening mammogram, they would look back at the latest screening and see. Did we miss a cancer here? And if we did, it would need to be discussed and reviewed with all the normal governance. But the aims of the programmer for early detection, reduce the mortality associated with breast cancer. I think most people assume it's completely brilliant idea and it goes about saying, but you have to think what are the potential harms of the breast screening program of which there's been a lot of reviews, particularly a few years ago about what the potential harms would be so, over diagnosis. So essentially, you've got a 70 year old woman who's very frail otherwise, and you pick up a small layer of DCIS, is that ever going to be a problem in her lifetime? Perhaps not. But now we're going to treat it and she would never have developed a problem from that. You get a false positive from the scans or the tests. And you need multiple additional tests and cause anxiety or the alternative. You miss a cancer and you falsely reassure them because now, you know, I had a mammogram a few months ago. I can feel a lump now, but my mammogram was clear, I'm not going to get that checked and then there's false reassurance and it's uncomfortable and painful potentially for some ladies to have regular mammograms and they may not be keen to have that done or they may develop psychological distress as going through that process. This is a picture that looks at DCIS. So you can just see, I'll show this to patients all the time. So you've got a normal breast duct, you've got DCIS, which hasn't penetrated the basal membrane. And then you've got evidence of invasive breast cancer where it's gone through. So that helps to explain why sometimes we might need to sample the lymph nodes and why sometimes we may avoid that in D CS unless you're doing a mastectomy. Because to do a sentin lymph node biopsy, we talked about those tracers, you inject in the breast if you've removed the nipple and the rest of the breast, if you say you do your first procedure and you find invasive cancer, you can't go back and do a sentinel lymph node biopsy. If you've done a mastectomy, you can, if you've done a wide local excision, but you can't if it's a mastectomy. So if you're doing a mastectomy, even for DCIS, you would take a sentinel lymph node biopsy. If you're doing a wide local excision for DCIS, most of the time, you would not choose to do a sentiment from no biopsy unless it was more than five centimeters or what we call mass forming DCIS. Because chances are that the core biopsy is just taking a piece of the lump and you've just not had enough tissue to diagnose cancer, the risk of it being a cancer much higher. Um So something to bear in mind. And then there's a small note there about grades of different which can affect the adjuvant recommendations. Um So this is the last case I've got. So you've got a 52 year old lady who's been referred to you by the GP. So she's the next patient for you to see in clinic. You read the GP referral. She's been on oral flucloxacillin for mastitis. There's been no improvement and the GP sent her in because he thinks she just needs some IV antibiotics. Um The history says that she's got sudden widespread skin changes over the breasts and she's got some small pits appearing in the skin. Somebody just writes in the chat. What do they think the diagnosis is here? We've got two with inflammatory breast cancer. That was a unanimous decision. Very good. That's exactly what I was hoping to hear and that you're thinking like you need to think in the exam, what is the worst case scenario here. You know, there's multiple things here that are ringing alarm bells for me the presentation. The fact there have been no improvement with antibiotics. So that's very good. I mean, I suppose playing there advocate, you consider it a sort of deep seated breast abscess, but it doesn't really fit with the history. So that, that's exactly the way you need to think in the exam. Very good. And how, how I like to say about inflammatory breast cancer is that everyone needs to be aware of it. Uh Most of the times the red breast is infection, but if it doesn't improve, definitely send to a specialist. Uh let them, yeah. So this was just a stock image I found online of inflammatory breast cancer. But you can see there the significant widespread skin changes. You can see some pitting edema in the skin. And essentially to say that you can't just chalk this up as mastitis because you cannot afford to miss inflammatory breast cancer. It's often very aggressive. It can have a very poor prognosis and it means, and you can see how it could be missed by somebody who wasn't familiar with the condition. So you would take this through the M DTI think if you do any Fr CS part two question for breast surgery, you don't hear the phrase I would discuss this and the MDT come out of your mouth. You need to think carefully because that's what we do in clinical practice. And that's exactly what you need to mention in the exam. So you would think about further imaging, you would do an ultrasound scan of any focal lumps and you could organize a mammogram. Um You would want to scan the axilla because a lot of these cases are associated with axillary disease. And then you can take core biopsies from the breast or from the axilla if there abnormalities there and you would discuss it at the MDT. So this has its own individual staging, which is T four D disease is inflammatory breast cancer. And the staging modality for these patients will be a pet CT scan. Um I've mentioned there the normal staging for most other breast cancers if required would be a chest up and pelvis and a CT and a bone scan. These patients often are treated with neoadjuvant chemotherapy. A lot of them are associated with triple negative disease. But I'm glad that people put that in the chat because that is definitely the way you need to think for the exam. I'll just put this here because I think when you're working in a job, I think you may find that you're very happy to manage most of the presentations and your clinical knowledge for this exam will be very good. By the time you do the exam you'll be ST seven or eight, the areas where you get caught are where you make assumptions about the knowledge you have in terms of very basic, some of the basic science and particularly when you're looking at the trials and the evidence, the T staging as we've seen today, the sound trial included T one tumors, tumors less than two centimeters unless you know that. And you've got an intimate knowledge of that and you just, it just rolls up the tongue. You may find yourself getting into pitfalls when you'll be asked questions about. I was asked, what was the inclusion criteria for a certain trial? Would that apply in this situation? Yes or no. So that's how they can get it out of you. So, T one tumors less than two centimeters. T two is 2 to 5 centimeters. T three is more than five centimeters. I didn't put a picture of that on there. But, and then T four is divided into A to D so inflammatory carcinoma is T four, DT four A is, it's in the chest wall, T four B, it's in the skin and T four C, it's in the skin and the chest wall. So if they showed you a picture of a cancer that's eroded through the skin, you could say even from the clinical examination, I'm concerned this is at four B breast cancer. It's P five and you know, I'll proceed from there. So there are, it also makes it a bit more slick when you answer some of the questions. Um That's the um breast sort of advice covered um in terms of more general tips and advice for the exam, I think writing down the stem is incredibly important. You'll misinformation. If you don't do that, you need to think about what is the theme of the question. So that stem I gave you about inflammatory breast cancer. The reason I asked, what is the likely diagnosis is because that's the sort of thought that will come into your mind. As soon as you hear that you think this could be inflammatory breast cancer. I think this is gonna be a question on inflammatory breast cancer. I need to get, you know, what does that mean for me? What do I need to convey to the examiner? Um Very important answer the question the examiner asks you because they will be firing questions at you quite rapidly. Don't start making assumptions based on what they've said. Just answer the question if, if you've missed the mark slightly, they will just rephrase it. That doesn't come as prompting unless they kind of have to keep going over it again and again, it's just they will rephrase it because I had a few questions where I just misunderstood what they meant. And you can see from the expression on their face that there was a misunderstanding. And then I just paused, they rephrased it. I got, I got the question, sort of the reasoning there, a evidence where possible, but I wouldn't get too hung up on that, but it does in the mark scheme, it definitely does appear for level seven and eight in some of the questions, practice, practice, practice with colleagues. And particularly you need to be aware of. There is a difference between VRS which are kind of short five rapid questions and the clinical day, which is they have more time to give you the narrative and make you I had to sort of say for example, give a diagnosis to a patient, explain what a prognosis is. So you need to be comfortable, simulated giving results or giving information to patients in lay terms. Um And then definitely make a group with other candidates. I revised a lot with friends over teams even we didn't need to be in the same region. And if anyone is doing the exam soon, I wish them the best of luck and I'm more than happy to be contacted by anyone doing the exam coming up if they have any logistical questions or any other information. Um I'll just put a slide here about some of the resources I use from a breast perspective. So there are some very good books out there. I won't go through all of these. I will highlight the best of breast resource, which is an online website which was fantastic and it's regularly updated. The I breast book is good for the oncoplastic procedures. I actually used chat GPT to generate some virus scenarios when the book had finished. So you can actually write in chat GPT. Please provide va scenario on um oncoplastic breast surgery and in the style of the Fr CS part two and within five seconds you'll have a vi appear there for you to practice with your friends. So that's something I used. I'm not sure if anyone is using that, but it was very helpful. And there are lots of courses that can be expensive, but I used all of the courses I put on there for breast. Specifically, there's a course organized at the Royal Marsden, which is a practice which was fantastic. Um and very, very helpful. And I did the alpine course, which I found very useful as well, but it is expensive. But I mett colleagues there who were doing the exam and I was doing it and we formed a revision group from there. So that was useful as well. Um If anyone's interested, not related to today's session, but a good friend of mine is an RD U consultant who did a critical care scenario via with me just before my exam. So if everyone's doing the next exam in the February sitting, we've organized a repeat session. He basically did it for me and some friends before, but we enjoyed it so much. It was so helpful. I said, can you do it for other candidates coming up for the upcoming exam? So if you are interested in a session on um critical care cases for the Fr CS not specifically breasts but general as well. Um Please do email me my email address is there um, and I can try and get you added on to that as well. Um And that's, that's everything I have to say. Um Thanks very much for your time. I don't know if miss me, if you want to add anything else at all. Um I think, well, I hope, I think that was very helpful. I hope our colleagues at trainees found it very helpful as well. I want to, to add a bit on the, on the start or something that might get you out of jail sometime because safety is important. If someone says there is an examiner who says, well, you're a bit worried about this symptom or mainly something you're feeling it doesn't have to be breast, it could be something else. And uh but then imaging is clear and then you're not too worried to do a biopsy though. The, the get away option could be, you can ask for a second opinion or ask for the follow up. Uh normally would be three or four weeks and then that will also show you have something changed or not. Definitely we use the load in breast. I mean, something. Is it something or not? And then, well, let's see it. And if it's still prominent, yeah, we can do a, a clinical course. It's just second opinions are allowed when something if you say, yeah, something still worries you. Yeah, you can, you can ask a friend uh or bring back uh in a few weeks to see if something has changed. But other than that, yeah, I think that was uh thank you. Does anyone have any questions at all um specifically to the um upcoming exam or for, for management of breast in general? No, I while we wait for questions, can I just um thank you both very much on behalf of the um steer collaborative? Thank you for both extra talks and um for your time as well. Yes, thank you. It's, well, it's a pleasure. Thanks very much. That's fine. I mean, I don't, I can't see any specific um er questions there. No, that's great. Should we bring things to a close there then? I guess I think um yeah, I think if there's no further questions, what I can do is again. Thank you so much. Thank you everyone. Well, it's been always a pleasure. Thanks very much for having us to speak bye-bye. Bye.