Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Right. I'm gonna tell you alive. Now, the thing is live. So I think, uh, when everyone joins in, I'll just quickly introduce you and if you've got any problems, just let me know. Mhm. Good. Uh, but you want to just quickly try and go from side to side just to make sure I can see them. Okay. Is it changing? Yeah. Yeah. Perfect. It looks really good. Hi. Thanks for joining. We'll start promptly at six. Yeah. Oh, he just left. Okay. Definitely. Okay. Okay. Yeah. Hi. Everyone will just give it a couple of minutes before before we start. Just allow more people to join. Yeah. Okay. Hi, everyone. I think we're good to start. Um, so I'm Richie, I'm currently in integrating medical student. At least enough. Lester. I'm also, um, uh, you know, coeducation lead for soup to. So today we've got Amber who's the 50th medicine in, at the New City of Leicester. And she'll be talking about, uh, breast surgery conditions and should be going through what they are. Common, breast surgery conditions, should be going through what they are, you know, um, what the signs and symptoms and how do you treat uh some of them. So I hope you enjoyed today's talk. Uh huh. Okay. So, hi, everyone. Yeah. So I'm Amber 50 year at Leicester. Um, so I was given some learning outcomes and I've kind of just chosen the more common conditions that you're looking counter when you're in the hospital. Um Okay. So let's just make a start. So thanks to our partners, all of these guys, let's just okay. So we're gonna start with the anatomy of the breast. So it's located on the anterior thoracic wall. Um It consists of the circular body and then the axillary tail which kind of goes up towards the armpit, essentially. Um The nipple consists of mostly smooth muscle fibers and the areola have sebaceous glands. Um okay. And now onto the actual parts. So you've got your mammary glands and your mammary glands are modified sweat glands. Um They're made up of ducks and Secretary Lobules. I don't think you guys can see my mouse. So it's in the top corner um is quite clearly kind of labeled as well. Um The lobules then drain into a single lacked if oris duct at the nipples and top diagram, you can see that it's got the lactic for a sinus where they all kind of converge. Um And yeah, and then the areola is lubricated by the areola glands of Montgomery. Um Okay. So there's fibrous and fatty connective tissue stroma and it's there to support the mammary glands. Um essentially secures the breast to the dermis. So the overlying skin and to the picked pectorals fascia behind it also separates the lobules of the breast. Um okay. And then the pectoral list fascia is a base of the breast and it's essentially just a sheet of connective tissue overlying the pec major muscle. Um There's a retro memory space which is between the breast itself and the pectoral fascia and that's normally what's used in like reconstructive surgery and stuff. So like when they put implants in, sometimes they put their and if someone's had a mastectomy and they end up using that space to kind of fill the area out again. Okay. Next slide. So going onto breast vasculature. So the medial side of the breast is supplied by the internal thoracic artery. So, essentially pierces through the first four intercostal spaces and then it trans verses across the pectoralis major muscle and it reaches the medial side of the breast like that. Um Okay, see, lateral breast has quite a few um arteries that supply it. So you've got the lateral thoracic and the thoracic acromial branches and then you've got the lateral memory branches and the main memory branch as well. Um The lateral thoracic comes to the axillary artery and then it goes on to split into the acromial thoracic branches and then the venous drainage essentially follows the same paths and there's a sub Ariola venous plexus. So basically around the nipple and the areola. Okay. So a little bit on lymphatics. So there's the axillary lymph nodes and the Paris stand or lymph nodes and they're the key ones that drain the whole area. Um The skin drains into the axillary lymph nodes, the inferior deep cervical lymph nodes and the infraclavicular lymph nodes and then the nipple and areola drains into the sub Ariola lymphatic plexus. So essentially they all kind of drain into the same area and then back into like the auxiliary. And once uh and this is quite relevant for like metastatic spread of breast cancers because it's quite common way for them to spread. Um So like when you're looking to do surgery to remove breast cancers, quite common thing is to inject blue dye to find the sentinel lymph node and the central sentinel lymph node is essentially the first lymph node that you see that area draining into because often cells will be there from the cancer as well. Okay. So I can appreciate there's a lot on the slides, but I thought I'd just put it all out there. So it's not kind of just me talking um like a bunch of text. Okay. So gynecomastia is the first condition we're gonna talk about. And so it's a mail um condition. It's benign proliferation of glandular tissue in the breast area. And the main cause behind it is essentially an abnormal estrogen to androgen ratio. And this can be caused by so many different things. Um, main ones being increased estrogen levels in males or medications. So, common medications are like spironolactone, metronidazol digoxin. Um, and then there's also like recreational drugs as well that can cause it, um, conditions like liver cirrhosis product in, um, is quite common one as well. Um, and also it can just be idiopathic in nature as well. Usually the cause is reversible. So if it's something like medication, then stop medication, substitute. If something else, if it's to do with actual hormonal imbalances, there's also drugs and things that they can be given to kind of reverse this. Um, it's quite common to be fair, like a third of men will experience gynecomastia of some sort. So there's different grades as well of how severe it can be. I put a little picture there about the grades as well. Um So you can kind of see that it can get quite excessive. Um, okay on examination, it feels like a rubbery firm mass and it's like around the nipple area and like outwards from the nipple area into the surrounding tissue, it's normally bilateral. So if it's a unilateral thing, then you need to be thinking about other things that can be causing lumps and things like that. A differential diagnosis is pseudo gynecomastia and that's essentially just a collection of adipose tissue because of obesity. Um Yeah. So investigations wise, so something you should know is there's some, there's a group of people you just don't investigate and then there's groups of people you do investigate. So the people you don't investigate our adolescents with physiological pubertal gynecomastia. So if they're going through puberty and they started to notice it could just be more of a hormone related thing during puberty. Um, elderly men, we've seen our gynecomastia because naturally their testosterone will be falling. Um So they will begin to develop this. Um men with drug related causes. So if it's like prescribed medication or recreational drug use that they've actually disclosed, then you don't really need to look into the cause of it because it can be explained by um the medications or drugs that they're taking. Um men with obvious breast cancer. So you don't need to investigate them for going to come astor. So if they have like a unilateral lump or any sort of kind of like abnormal like discharge or anything like that, um That's straight away the two week wait referral, that's like urgent investigation. You don't need to waste time doing you using these LFTs to try and find out if there's any sort of like underlying cause. Um And then also men with fatty pseudo gynecomastia. So if they're quite noticeably like they have a high B M I, um then chances are it's probably adipose, you can do imaging for this. Um Again, commonly you can kind of tell that it's due to drugs or something like that. And then just by adjusting the medication they're on you'll reverse it and you can see. So, I mean, if there is any sort of uncertainty, you can do imaging, um again, if there is any sort of suspicion of any malignancy, then a triple assessment is warranted. And I've got a slide at the end on based on the triple assessment, I think. Um but yeah, again, the treatment is reverse the cause. So pharmacological, um they can have, they can be given drugs if it's kind of hormonal imbalance or surgical. So I've got a slide on the treatment options. So, pharmacological treatment consists of things like tamoxifen or raloxifene. So if they're, if it's an estrogen related problem or dihydrotestosterone, if it's a testosterone problem, a numerous other medications that they can be given. Um something should know is that any pharmacological medication they're given um is most effective for recent onset gynecomastia because with longstanding gynecomastia, it can become fibrotic and that's more of a, it's not permanent change because there's always surgery as an answer as well, but it's more of a kind of long standing change. Um So going on to surgery. So they can have a subcutaneous mastectomy um with or without liposuction. So looking at the diagram as well, the incision depends on the individual and their anatomy and kind of what their problem is specifically. Um Normally they incise along the breast and remove the excess glandular tissue. Um if there's adipose as well, then you can use liposuction, which is not uncommon um where essentially they use the device to kind of break up the adipose and just suction it out. Um But yeah, if they don't have glandular hypertrophy, they can just use a liposuction alone if it's like an add opposed related cause too. Okay. So, um mastitis. So this is essentially inflammation of the breast tissue. Um there's two types. So there's lactation allow and there's long non lactation all. So lactation, Eliza's normally do to baby sucking and causing abrasions or wax in the nipple or the surrounding area. And that kind of provides a route of entry for pathogens. And the most common pathogen is staph aureus, uh um presentation wise. So as you can see from the picture, it looks quite swollen and erythema tous, it will be very tender to touch. Um The mother might be systemically unwell. So she might have a fever as well and flu like symptoms. And then often if it's a lactation, we'll cause you'll actually see the cracked nipples and she will be mentioning that she's had kind of problems with expressing milk. Um and it'll be a painful lump because the duct is blocked itself. So this is normally treated with analgesia initially. And if mum is lactating, then you need to let her know that she should be continuing to express milk. She can still feed baby from the side that is affected. And then if indicated, um any signs of infections would like fever and things like that, then she can be given antibiotics. So normally paracetamol is given for symptoms. But if they persist for more than 12 hours, then antibiotics can be considered. So it's normally flu clocks for 10 days or recognized. And if they're penicillin allergic, um normally the oral antibiotics that are prescribed as well shouldn't harm baby at all. So they'll be safe in breastfeeding. So mother can continue to breastfeed throughout. Um Something to note is that if mastitis is left, it can be, it can lead to an abscess which might require some surgical intervention. Let me just okay. So this is what a breast abscess looks like. Um So essentially, it's a collection of pus lined with granulations, tissue. Um It's quite tender, it's fluctuance, it's very erythema tous. Um Again, she can be systemically unwell, should have fever lethargy. Um Normally the choice of investigation is an ultrasound just to be able to see whether it's fluid field, etcetera if it's like a more of a solid lump. Um In this case, you need prompt antibiotics and then you need either an aspiration or incision and drainage and the complication. To note for an abscess is that if it is in size and drained, um it can cause a memory duct fistula. Um So officially between the skin and the sub Ariola breast duct, if they end up with a mammary duct vistula, then the treatment is by excision under antibiotic cover. Still um recurrence is common. So it has to be done by like specialist breast surgeons. Okay. There's a lot on this slide as well, but this is breast cyst. So essentially a breast cyst is an epithelial line, fluid filled cavity. And it's normally when the ducts, the terminal Sinai of the ducts are blocked and it causes the ducks to kind of expand and dialect most common around menopause, you can have multiple and they're quite distinct. So you can feel a smooth mass. Um Yeah, they can be ultrasounded, which is the like the diagnostic decision. And if it's picked up on a mammogram, it's a halo shape. It's just, it's like uh um yeah. So it can be aspirated if you're unsure of the content. So essentially, if it's free of blood or the lump disappears, then it's not concerning at all. If there is any sort of blood or any concerning kind of aspirating, then it's sent for cytology um to rule out cancer or anything more sinister, essentially. Um Normally they self resolve, they don't really cause problems. Um, a very small number of patient's have carcinoma at presentation, but they do increase the risk of having carcinoma in the future. Um But yeah, so they can become fibrotic um and they can mask malignancy because they all present as a lump essentially, ok onto mammary duct act Asia. So this is dilation and shortening of the major active forest ducks. So those closer to the people. So this normally presents postmenopausal around 50 to 60 years old. And it normally presents as a colored nipple discharge. So whether it be green or yellow, there's also a palpable mass around the nipple area and there is nipple retraction. So the mammogram will show dilated calcified ducks, which is what you can see on the image. Um the white being the calcified areas, but there is no other features of malignancy. So, biopsy, biopsy will show plasma cells on histology and it's known as plasma cell mastitis. Um Normally it's a conservative management. However, if the nipple discharge is quite is unremitting, then a cut is made around the areola and the ducts are removed and often sent to be examined under the microscope. And then the wound is just stitched, stitched up with absorbable sutures and dressed with like a waterproof dressing. Um If there is blood in the discharge and that they're having, then they need a triple assessment because carcinomas can present with blood in the discharge. Okay. The next condition is very common. Um It's fat necrosis, it's actually often a static. So a lot of people don't actually know that they've got it, it's basically just an inflammatory response. So the so fat necrosis is a ski mia of the fat lobules. Um it can be caused by numerous things. So most common cause would be trauma to the breast also like surgical intervention or radiological intervention, um can caused the necrosis. So as I said, it's mostly, I think for the most part, it's a symptomatic. Few people actually um can visibly feel a lump and then less common are the other symptoms you can get with conditions. So like you discharge skin dimpling, um any pain or inversion of the nipple, I think over time. So it can cause chronic fibrotic changes where then it becomes more of a solid like irregular lump. And so if you look on the top image, it's a mammogram. And you can see there's a contraction of the parent Khaimah and micro calcification. There's also inversion. You can see um from the kind of dimple on the side of the image. On the bottom picture, you can see the arrow is pointing to like hyper hyper echoic area. So it's brighter because there's edema in that area, um post trauma and then it does say implant on there. So the bottom bit is actually in someone's breast implant. Um But yeah, normally the giveaway to diagnose fat necrosis is the person's had a traumatic history um whether it be in hospital or an actual kind of traumatic event happen um or the hyper echoic mass on ultrasound acutely because it will change over time. And yeah, and then chronic fat necrosis can mimic carcinoma on a mammogram. So in that case, part of their triple assessment is they would need a core biopsy to distinguish the underlying course. Normally, fat necrosis resolves itself you can be given analgesia if there is any sort of pain, post trauma, but normally patient's are reassured, okay, fibroadenoma. So, so this is a very common presenting complaint at breast clinics. So it's the most common benign epithelial growth and it's essentially just excess proliferation of the tissue. Um It's common in all age groups, but mostly in the reproductive age group. So it has hormonal sensitivity which means it will enlarge during pregnancy and then it will shrink after menopause. So they are more rare over like 40 40 45 year olds. Um But this is what everyone refers to when they're talking about a breast mouse. So it's highly mobile, you're able to move it. Um They're quite rubbery, they're well defined, they're not tender to touch, you can have multiple, you can have them bilaterally. They have a very low malignancy potential, I think. And so in the elderly, um as they regress, they can also calcify. Um So that's what this diagram is showing here. So it's a popcorn type calcification in an involuted fiber adenoma. So it started to aggressive it with age, um investigations wise only if you're concerned really. So the ultrasound guided biopsy, if it's like an enlarged lesion, if it's, if there's atypical ultrasound findings. So if it's um irregular shaped or if there are concerned like a concerning age. So if they're postmenopausal and it's still quite a big um lesion, then you'd be concerned or if there's like calcifications present. So normally micro calcifications in like ductal carcinoma in situ aren't seen on ultrasound. But if you can see calcifications, then that is um so that's enough for you to have to look into it further just to ensure it's not carcinoma. Um Also if they're quite large, so if they're more than 2.5 centimeters, then you just want to rule out that it's not something more sinister. And then also if the patient requests for you to look into what the underlying cause is, then that's enough for you to have to investigate it as well. Normally the left you can excite, you can excise it if it's quite large or for like aesthetic reasons as well. So if the patient decides, ok, papilloma, so this is an introductory dual condition. So it's a benign growth in the major lacked if wrist duct. So just behind the nipple where they all converge, it's normally in that region. Um It's common between 35 55 year olds. Um again, sub Ariola region close to the little. So it normally presents with discharge, whether it be bloody or clear or it can present as kind of a mass that you can feel around the nipple. So we need to have an ultrasound and a mammogram. And if they come back normal, then it might be indicated for them to have an MRI to look into it further. Um So on imaging, it actually shows up similar to doctoral carcinoma. Um So they will probably need a biopsy to rule out cancer. And then the treatment is micro does Keck to me or detect a me? I'm not sure how to say it, but essentially what it is, it's removing one or more of those little milk ducts from the breast and it's just taking it out completely, basically. Okay. 12 like poma. So for lipomas, they're very common all over the body. Um It's not something specific to the breast. So I don't have much to say about it, but essentially it's just a fatty lump. Um They're quite soft, their mobile, they're not tender. You don't normally get any associated symptoms with it. It's normally something someone just incidentally kind of comes across um on an ultrasound, they are hyper echoic in comparison to the surrounding fat. So there's a box drawn around on the ultrasound. You can kind of see it, it's a bit brighter than the rest um of the tissue. If it's large, then it can be removed if it's compressing any nearby structures. So, depending on where it actually is, again, they can be anywhere in the body. So if they're ever compressing any sort of nerves or anything like that, um then they're removed or if it's aesthetically displeasing as well. Um, a patient can request to have it removed. Okay. Um Phyllodes, tumor's so Phyllodes tumor is, can be benign or they can be malignant So they're a rare fibro epithelial tumor and essentially, they can resemble a giant fibroadenoma. Um Both epithelial and stromal tissue can be involved. They're quite large and they're fast growing between the ages of 40 and 60 years. So on, ultrasound, they're very nonspecific because they mimic fiber adenomas. So, like both on ultrasound and mammograms, they're very difficult to differentiate from fiber fiber adenomas. Um So they're normally large ovals there, well circumscribed with smooth margins, as you can see on the first mammogram, a third of them have malignant potential and they're normally widely excised or if they're very, very big, then you just remove the entire breast. So it's locally invasive tumor. So it needs removing with surgical excision. Um and both benign and malignant phyllodes, tumors have a tendency to recur if they're not removed by wide local excision. So you need to have very good margins when you're removing them. Um those that do occur. So around 25% ricker locally and those um that and probably about 10% metastasize normally and they normally metastasize through him. A hematologist. I can't say the word through the blood, they normally spread through the blood. Um But yeah, okay. So um onto the carcinomas. So doctoral carcinoma in situ. So it's the most common type of non invasive breast malignancy. So by noninvasive, it means that it doesn't cross through the basement membrane it's contained. So the picture in the top corner actually shows it really well. So it just doesn't leave. So it's surrounded. Um It occurs in the doctoral tissue of the breast and there's quite a few major types. So there's comedo which is like a large cell, more aggressive form, or there's the non comedo ones which are more small cell and less aggressive. So there's cribriform micropapillary pillory, there's solid types, but most lesions are actually a mixture of types. So most commonly D C I S is actually detected during regular screening. So since mammograms became a regular thing, more, more D C I S has been picked up, it shows up as micro calcifications on mamma, on mammogram. So if you have people presenting with lumps with any of the other conditions that we mentioned before, this is the important thing to want to rule out if you see um classifications. Um Ultimately, a biopsy will confirm the diagnosis because it will distinguish it from anything else that we've mentioned. Um But normally it's surgically excised. Um So there's multiple types of surgery they could have so they could have just the lump itself removed or they could have the lump removed and they could have some radiation as well or they can have the entire breast removed. And again, it does depend on the type and extent of what they've got. Um I did put a picture of the histology here of cribriform um type and you can see it's quite clean with, it's not leaving the basement membrane, it's completely surrounded. So it's quite localized. Okay. The other type of carcinoma in situ is lobular carcinoma in situ. So this is essentially of the malignancy of this creature lobules of the breast. So again, it's within the basement membrane. The mean age for this is perimenopausal women. So just before or kind of around the time of menopause, um it's a lot rarer than D C I S. So D C I s is probably about 70% cost name in six cases and this is a lot less. Um This is associated with a greater risk of becoming invasive though. So usually again, it symptomatic. Um it's normally diagnosed as on accident essentially from biopsies for other reasons. Um Even the mammograms are normal because in this case, you don't really have microcalcifications. So, if detected on a needle biopsy, then an excisional biopsy is performed where it's removed and then it can again get looked at under a microscope and things like that. Um If it is very low grade, it's actually just monitored because it might not progress as fast. Um So it might not actually cause any sort of problems. Okay. So, invasive breast carcinoma of no special type. So it was renamed um it was invasive ductal carcinoma before, but now it's known as this. So it's the most common type of invasive breast cancer, accounting for 70% um peak 50 to 60 year olds. Um There's some gland formation, but it's essentially caused nests of tumor cells. Um, so it's normally like a really large palpable mass fixed in place. So with cancers, normally they're quite tethered. Um, or it can be a symptomatic. Again, it can present with any of the other symptoms you might have. Um, so lumps, inversion of the nipple, just asymmetry in general, swelling, discharge. Um, PPO door range where the skin is all dimpled like a orange skin, um nostalgia. Um So just breast pain in general. Um So on an MRI it presents as an irregularly shaped kind of speculated enhanced mass. Um Either the entire thing is enhanced or just the rim of it can be enhanced on arch sound, it's quite ill defined, it's hypoechoic. So it's quite dark. Um And yeah, the nautical prognostic index is used for prognosis of invasive breast cancer. Um Again, so this would require a triple assessment. Um It can be treated with surgery, radiotherapy, chemotherapy, hormonal therapy or antibody therapy or it could be a combination of these. Again, it's an individual case. So any of these kind of conditions, so any carcinomas are definitely discussed in MDT beforehand. Um to decide on the best way forward. So, onto invasive lobular carcinoma. So this is the most common special type of invasive breast cancer. Um So it originates in the lobules and it spreads to surrounding bread, the breast tissue. So the majority of these don't have the E cat hair in specific biomarker, um which is essentially a gene that they can test for as well. Um ok, more common in older women stromal pattern makes it harder to detect, meaning that often detected when they're quite later down the line. And when they're quite large, um more likely to have bilateral involvement than the other carcinomas on ultrasound there, heterogeneous hypoechoic mass with ill defined margins. Um And yeah, the prognosis slightly better for this one um than for invasive doctor carcinoma. Um but because they're so diffuse, it's likely there'll be positive reception margins. So when it's removed, even buy wide like local excision, um chance that any of the tissue that's left around the edges will still be positive for the cells. Um But yeah, the picture shown is an irregular hyperdense retroareolar mass with speculated Martin's. Um and it's on the lower inner quadrant of the right breast, but you can't tell which breast is from. Okay. Um And then I think I've got some of the a couple of presenting complaints people might have. Um And then I'm going to quickly touch on the triple assessment and things like that. And then I think that's okay. So galactorrhea, so this is essentially just a copious amount of discharge, not associated with pregnancy or lactation at all. It can be bilateral, multi doctoral. So it could be quite excessive. It's normally quite milky when you look at it. Um numerous causes again. So it's similar to the causes of gynecomastia. So you can have drug induced causes thyroid induced only this one's hypothyroid and then like liver and renal failure. Um, prolactinomas is a common cause. Again, if someone presents the clinic with the lactourea, then you have to check for any sort of lumps, any breast pain when the last menstrual period was because you need to exclude pregnancy. Um and then you can check for their prolactin and then you can do an MRI head with contrast as well for any sort of attitude to tumor's. So, again, the way to treat this is essentially treating the underlying cause. So if it's a pituitary tumor, then they can try dopamine agonist therapy or they can end up having trans and spin idol surgery. Um if indicated and an ongoing problem, then they might require just having the ducks excised, um just having them removed in general. Another common presenting complaint is nostalgia. So you need to classify the pain. So Socrates or sweaters, um or whatever you use for your history taking. Um Just make sure you cover all of those properly and then check for any of the specific breast related symptoms, lumps, skin changes, nipple inversion, um discharge and whether it's cyclical. Um so it could be cyclical, non cyclical or memory in general. So, cyclical is the most common. Um So normally a few days before a woman starts her period, it's related to hormones. Um non cyclical can be related to like hormonal contraceptives, SSRI s like sertraline or like antipsychotics. Um extra mammary pain can be things other causes of pain in that area. Like in this case, a pain, shoulder pain, anything that can be referred essentially. Um If there's no concerning history or examination, then imaging isn't indicated, just make sure you do a pregnancy test. Um again, so treat the course. So if it's something that can be um changed. So for example, a new medication change the medication or look into changing it at least um address the pain. Um don't just send them home. So, analgesia would be good, could be paracetamol, could be ibuprofen, topical, ibuprofen, um reassure the patient. If there's no response, then they might need a specialist referral for different treatments. So a specialist might prescribe danazol, which is an antigen autotroph in medication, okay onto breast examination. So to conduct a pressed examination. So initially, it starts with inspection. Um so you're looking for any sort of asymmetry, any scars, any swelling or lumps, any skin changes in general, some are specifically kind of links to breast cancers and stuff. So make sure you look into those nipple changes or any sort of inversion um or discharge. If you do feel a lump, then you need to note its location, its size, its shape, the consistency of the lump, the mobility of the lump if it's like fluctuance and any overlying skin changes with regards to that lump again, you can um then inspect the patient while they're pushing their hands on their hips to observe for any tethered masses. And then again, when they're leaning forward with their arms above their heads to exaggerate any visible changes, so you um with, with their change in position, you're more likely to notice any sort of asymmetry. Um okay. And then pal patient. So this includes palpating that um axillary lymph nodes too. So when you palpate in a breast examination, have some sort of a kind of way that you're going to do it. So it's quite easy to just go in a clockwise fashion, I think. So, ensuring to palpate with the flats of your fingers and not like your fingertips. Um and then also make sure to palpate the axillary tail going up as well. And when you palpate axillary lymph nodes, make sure their arm is relaxed. A good thing to do is kind of relax their arm on your arm while you reach underneath into the armpit, to feel for the lymph nodes again check other lymph nodes in the area. The ones we mentioned that the breast can drain into as well. So the infraclavicular one super clavicular ones and the cervical nodes as well are really important to check. And then I've got a slide on triple assessment of the breast and this is the last slide. Um So triple assessment is essentially history examination and then imaging and then your histology. So the history and examination again, look into their specific complaint, their history of presenting complaint, past medical history, past surgical history as well. Um Drug history, family history, social history, risk factors. And then you'd also want to ask about kind of their menstrual history or their obstetric history as well if indicated. Um And then the examination you would do is like on the previous slide. And then the choices for imaging in a triple assessment of the breast is um either a mammogram or an ultrasound. And from the time I spent in breast clinics, I noted that mammograms were used mostly for like older women or women with larger breasts. And ultrasounds were used for kind of more younger women um where it would be more difficult to actually obtain a mammogram from them and then you've got histology. So your biopsy, um most cases it's a core biopsy that's used. Um from most of the clinics I saw it was core biopsy as well and she said the surgeon, I was under mentioned that finally needle aspiration um is more if it's like clinically indicated that it should just be aspirated. Um But yeah, again, remember that any kind of results that come up alarming are then discussed in an M D T before any um management or plans are in place. But yeah, I think that is it. That's all why it references. Um Thank you guys for watching. I'm sorry, I don't have any kind of questions to give. But yeah, that was a quick whistlestop tour. Thanks guys.