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Well, thank you for having me. And I'm sure that you'll hear this port quite a lot of people, but it's pretty much impossible to cover the whole specialty in an hour. So my aim is to just go through the classic. I do have and suck used that we will do. I will. I think I'll there might be for discussion points after every question. Um, it's actually the only thing for you to moderate if it's really if it for if we're really too slow. But feel free to put the questions in the box, and that will go through the questions before moving on to a question to the next. Well, there was stuff. Bit of what? Mg you. Okay, so the first case, um, is, um Well, actually, 1st, 1st question is which of the following is not part of a triple assessment in a symptomatic two week wait Breast clinic for a 58 year old woman presenting with a left breast, um, and present for, um, a month is it's clinical examination. And my breasts, um, ultrasound mammogram on ultrasound guided biopsy. Are you happy for me to go at one minute? Yes, I think that's quite a reasonable representation. Okay, so two thirds got it, right. So the part of my breasts is not part of triple assessment, So trouble assessment is a combination of clinical, radiological and pathological evaluation. Um, imaging consists of mammograms for those over 40 on old, some for all palpable loves. Histological assessment usually involves a core biopsy. Um, MRI is not, is simply not first line, but it is useful in breast surgery because it is used as a screening tool in high risk patients. Um, such a strong family history or, um confirmed braca um, BRCA type one or through, um, you will notice that the mammograms are not used for those old under 40 in the first line because off density off breasts, um, so then pro um arise. Also used for problem solving till end up running, especially lobular cancer with breast density prevents accurate sizing on mammogram. And if there's a discordance between clinical on radiological size, would you do both the ultrasound and mammogram for the patient? Yes, your words. That's a question that has just come in the box. Um, it's it's standard. If there is a probable lump, um, in our breast two weeks. So it basically you see a patient downstairs mixed in the clinic. We will have ultra imaging starts for the patient. I would assess the patient and then say I would like a mammogram on ultrasound and please biopsy if you cannot. If you can appreciate that as well on the on imaging on, then patients come back to the clinic to get the results off off the ultrasound and mammogram on the same day. And we usually make a time to come back for the histology results. Any other questions in on that doesn't look like because I'll have more on to the assessment, but basically triple assessment, clinical, radiological and pathological. Okay, and that is core assessment off symptomatic restorations. So second case is you saw a patient with a palpable lump in your two week weight breast clinic on assessed here with Mom a gram. An ultrasound. Which of the following is most like the represent? It's most likely due for presenting assessment. Suspicious for a breast country. Is it p one m one you one? Or is it p five mg five. You five me to someone. You too. Um, you want them to you three or P three AM one, you three. Okay, so I'm glad to see that this is not the first time this has been shown to you on day and B is the correct answer. So, um, P corresponds to, um clinical assessment and mammographic you ultrasound one is normal or if we do an effort A If you get f one or C one, it comes back as inadequate cytology, but in terms off a PM, and you had corresponded to normal. Um, two is what you think is benign. So if it feels like a fibroadenoma on examination, you will give it a two, which is probably work. C was, um, three you're assigned to suspicious, probably benign breast has a lot of odds sort of pathologies in between that. Such a passion and 88 things like that that are small print, not the main broke bread and butter. Not not focusing on country initially for a Z would apply a sign if it's you think it's suspicious and probably malignant. On key five is something that feels obviously like cancer looks like cancer. On examination on on mammogram and ultrasound. Um, and I said he for examining. You can also see eat for examination. We often use p a small um um should have said sorry R m for mammography, eventually an MD tease. You also get em ardent, but it shouldn't be complicated too complicated in your exams. It's crucial. Truck s. So if you ever turned the breast clinic throes of bread and butter So when you understand these bits, um, to make the basis and structure of an assessment Yeah, any questions of March? Does it look like, um, I will Also. I also thought that this was it's tricky to get you a question just on examination. So I've taken a picture from the companion to sort of special surgical practice how you would perform in. It's a breast examination. I tend to, um he always ask for a sharp pain. Was your hands um, you can do this with a patient at 45 degrees, or ask them to sit on the edge off the examination patch first and then lie back. So ask them to just sit in front of you, hands down, then ask them to raise their arms and then with the hands of the hips on. Ask them to press down when examining you. There is some traditional teaching that you should be using a circular motion, but basically you have to have a system how to examine the breast, Um, in a systematic manner. Some people basically do open out of quadrant upper lower after cauldron, move into the lower in a quarter internal and operate in the quadrant on. But then always on this should be with the arm up 40 above would hands behind the head. Then you ask patients to move the arm downwards that power and you take the patients are before then you let you ask them to have relax the arm. And when you're holding us for you to have a good palpations off the axilla, you also check the super crowded particular fossa. Um, this picture has a patient being examined, but it's like a supine, but it is also you can have a patient up to 45 degrees on the examination couch. Um, so based number 3, 30 year old woman who has had an excision biopsy off a 35 millimeter lesion which has returned a histology report of a stroma off low cellularity and regular cytology consistent with and three dots. Will do you think of that? Is most likely to be. Yeah. Okay, so most of your answered See very well, Genzyme. That's again. Not the first time you've seen now, which is good. Um so fibroadenoma they are benign lumps that arise from the terminal, docked off the lobby, really your unit and are now considered as aberrations off normal breast development. Um, in a study that gets talked quite a lot with the grass if I burn and adenomas. And they followed some patients up on natural history that was observed over two years, and young women under 40 was that majority does did not change in size. Some got smaller or resolved, and only a small number increased in size. Um, and the the majority of which were in the in women on the day just 20. This is really important to know what it feels like. It feels like a small smooth along with the breast. Um, it does called a well, so there's never know if it's correct to call that anymore. But a mouse of the breast, because it does not get it's not fixed to the breast in any way. It is, um, when you move it, you cannot. You move it along the breast? Definitely. At least at least in one quadrant. Um, in terms of our office, you go. Um, we got going lines on when to biopsy or not. Um, basically, um, lungs that look like that on ultrasound You wouldn't during mammogram for a young woman. Um, they have a correct ist characteristic appearance if they're under two centimeters on under 25 years old and have got the characteristic appearance with fuel ovulations, they don't even get a biopsy because we can be very, very reassuring if they're a bit bigger in. It's like your older women over 25 big biopsied to make sure that they're happy with what it is. Any question on fibroadenomas. If any further questions come back, come up later. I can't answer them at the end. Next case we've got a 48 year old woman presents with a four week history of a right breast off on examinations two centimeters in size, feels smooth on feels pee, too. And there was a halo effect on mammogram. On it is a part of just am too ultrasound demonstrated smooth outline with no internal echoes and posterior and Huntsman. What is the most the next most appropriate step in management? Okay, so two thirds answered for a one third for B and just a handful of people for see no answers for D and E on correct Answer. Well, old son guided aspiration because it's symptomatic. Um, and these Air Classic This is classic for Sit for a breast cyst. So the halo effect of mammogram smooth outlawing no internal echoes and know post your enhancement. It's possible for breast cyst, um, to be her. I could have given me a bit more information, but in the question. But if it's, you know, if someone's coming in with fascia and it's getting uncomfortable and it's a small breast for a small breast to send me to, maybe quite large than you would aspirate. Um, if it's small asymptomatic, then cysts should be left alone. So, for example, if it's just a spect up on the breast screening, it won't be, um, it won't be aspirated. Large symptomatic or complex cyst should be aspirated to dryness. And if there's any blood staining on aspiration of the cyst. Then it sits. Fluid gets sent for cytology. If the cyst wall shows any projections dismayed, indicate presence often intracisternal up Aloma or carcinoma. This is if they're a lot more complex than what's in the question, and then that's when we would go. I don't do, um, an ultrasound guided core biopsy off that off that part of the system, for example, you might if if it's aspirated during this. But there is a residual down there, especially if there's something visible on ultrasound. That's when it would get a biopsy. Next case we've got a 56 year old woman who presented through the screening program with an area of abnormality in her left upper outer quadrant. Off the breast is 12 millimeters p one, and for you five. That has been trends. Histology off an invasive ductal carcinoma. Your age of I debate and her two negative, and she was 34. Double Deborah. What do you think is the most likely management to be recommended by the breast mg T. Is it an excisional biopsy? Would you like to do then, or a wide local excision with something a little biopsy? I still have mastectomy with something and no biopsy skin sparing mastectomy with immediate implant based reconstruction? Or would you like to surveillance this patient with the early mammograms for for five years? Okay, so most of you picked answer be, um, if you see or d on the keys here is that this is a small concert 12 millimeters in a reasonably large breast. So for men in the audience 34 36 38 40 relates to the circumference off the chest. And it's the cuts. The cops after the bra size that correspond to the size of the breasts that need to be held in the bra, going from a being the smallest two g f d. And above being the largest. So why the local excision with something simple? Biopsy. It should be possible here because it's a slow concert in the relatively large breast simple mastectomy and some liver biopsy is not necessary anymore on I'm glad that most of you have now picked upon the fact bash this was a cancer there, for it does require a sentinel lymph node biopsy to stage this fully that and whenever we operate, we're up. What whenever we operate for cancer, we operate on the breast. And there was a separate operation on the AXILLA, which in this case is a staging procedure to, um to see whether any concert has gone out out of the breast to make this a locally advanced cancer. Um, the only thing that has some units don't even do it anymore. But we do. We tracked the axilla with an ultrasound before proceeding to surgery. Um, breast conserving surgery should be possible. Here s so this is when we don't do a mastectomy and there's quite a few options. Um, aims off breast conserving surgery are to achieve local control on Kalashnikov control. And that was always the first and foremost and then aiming to achieve good cause, Mrs. Um, as much as possible. In breast conserving surgery, we used volume displacement techniques and volume replacement of eggs. Um, which I will go into a little bit more in the moment when we talk about on Kalashnikov outcomes and oncological treatment. We talk about the wide local excision off the breast cancer. If we do a breast conservation surgery, um, and to keep the patients breast, every patient will be recommended um, radiotherapy to the breast to the remaining breast, Uh, in an adjuvant setting. Um, Brady therapy helps reduce recurrence on improves overall survival. And it is a two least equivalent, if not better than mastectomy. And the reason I say possibly better is there is this really good study that was published in Made last year in, um, Angela surgery. Um, patients now have better long term outcomes, and we think if they kept their breasts and have breast conserving surgery rather than my sex to be, we're not quite sure why that's happening. But there is with it. But there was hypotheses that it is the rate of therapy that is delivered to the breast that actually has a better that has a better effect than we thought it did. Um, breast conserving missed a master. A breast conserving surgery when compared to mastectomy. Whether we reconstruct or not has fewer complications, it is more cost effective, better patient satisfaction and better because Mrs on, we aim for one million eat well in the UK guidance. This is just for us. By association of breast surgery, margins were infer margins. One millimeter. It is a contract conventions issue issue. America has a United States of America has slightly different guidelines. I'm depending on which country in Europe you were cash, they have slightly different margins. A swell. And you are from one to the No humor on ink margin. So yes, what? The soldiers. Few questions in the chart. The first one is what comes first two something them for no biopsy or breast surgery. So it's simultaneous in the same operation, Um, with formal race, with traditional teaching and the initial research that was done when? Because back 30 40 years ago, everyone got an axillary clearance for the lymph nodes that we have moved on quite a lot. And the initial studies, Um, initial studies, uh, that said, that's a lymph node biopsy. It's safe. Showed that when we have the patient prepped, we should be technically during the sentinel node first before we do the wide local excision. Because off the dies and highlighters that we used to show us. Which, um which are the first training center Lymph nodes off the exit. Er on by the highlighters. I mean, we use radio activity or we or some centers still use blue duct patent five blue dye. So we do their sentiment not first at that surgery, because once you start exercising the country, you may technically affect the lymphatic channels. Um, with the lymphatic channels that during the breast, I hope that explained the question. But it's all on. Don't understand. I mean aesthetic sometimes. And it went. It was two incisions, depending on the location of the concert, you're usually well, most of the time you have to separate incisions. One is a lot of the times periarteriolar and a separate incision on the axilla. If it's a very lateral cancer, we can do it through one incision. Second question will have radiotherapy increased risk of other cancers developing those, um, it has been shown that it's actually very safe. And with the antifungal on the progress with our radio, radio radiation oncology colleagues, the rays are very much focused mostly on the on the chest wall on the breast hour. Ever, Um, it's not perfect. There is when you have, really, I've had some quite particular patients where you want to know exactly old risks. Um, there is some radiation that goes onto the heart on onto the long look into the lung fields, and there's a small increased risk off. Unjust Are comas on do? It was a pretty good paper by my colleague on under sarcomas. We're current because they're so over, Um, but they're mostly related. Radiotherapy there is if you want to look past up, that's quite an interesting read, but it has progressed quite a lot, Um, so under, and that's quite uncommon on just a coma. What was the lower next question was what was a lower age limit to know. Biopsy fibroadenoma. So technically is 25 but it depends on the size of the fiber adenoma. Nice guidance. There was nice guidance on who to biopsy and not divisive. If you want to look that up because you may biopsy a three or four centimeter fiber adenoma in a 17 or 18 year old, specially, if that has quite a lot of septations on it to make sure that it is not the fluid is tumor because they may look similar industries percent. But they have so slightly different characteristics and grow a lot quicker right here. I think that's the questions for the moment. Okay, so if you want, if you're interested in starting more advanced spits on breast and why we're moving towards breast conservation surgery. Feel free to take a screenshot on local best Buddy might make you sound really, really smart if you still do long cases in your particular Mets. Go if you were to get a breast cancer patient. Less Case is a 65 year old woman who presented with a symptomatic lump in her right breast. She wears a 38 be bro. Uh, the husband diagnosed as a 30 millimeter 30 weight, too invasive ductal carcinoma. He are eight out of eight, plus positive. Her two negative. He smokes 15 cigarettes a day and has moderate COPD. What is the most likely surgery to be offered at the MG T? Is it a squint skin sparing mastectomy with implant based reconstruction with sentinel lymph node biopsy? Is it simple mastectomy with something simple? Biopsy isn't an excision biopsy. Is that a widely work local excision with something for biopsy? Or would you surveilled this patient with mammograms for five years? I think you can close the pole, Really. So 60% have said be simple mastectomy with lymph node biopsy. There was a few votes for skin's very mastectomy with implants based reconstruction and S and B on D few votes for wide local excision with something for biopsy. The correct answer was simple. Mastectomy with 7% lymph node biopsy, which is B the, um, I'm gonna go back to this because so there was a few answers for D and I'm gonna go wide local excision Seven of the biopsy on It's not going to be that because you've got high race you Hi. Pretty big concert to a small breast ratio after being compressed. When you think that you need to take no clear margins the swelling too. But that's that you're going to take most of the breast away. Therefore, this patient will need a mastectomy in the MDT. We look calm abilities as well. Therefore, the most likely thing to be recommended is something mastectomy with something in your biopsy. Um, the new recommendations from British Association of Reconstructive Surgeons with Nice on the Association of Breast Surgeons would suggest that we technically have to offer each patient of the construction if we're offering a mastectomy. But I don't think we would do that. And this lady in the first in the immediate setting because of her comorbidities. So the fact that she continues to smoke wouldn't make. We're basically preclude me options for immediate breast reconstruction. They have a very, very high complication risks if we see a patient that we think may need, you know, intestine your clinic. If you see a big cancer, the breast ratio Oh, you think that it's very likely cancer. We tell patients to stop smoking right now at that particular clinic. The targets say we've got 31 days to offer them surgery From the moment of diagnosis on, we cannot operate on offer reconstruction unless they're six weeks nicotine free. So she has both. She's calm abilities as well as large, constant breast breast ratio. Looking history as well as needs for a short anesthetic is going to make this patient more appropriate for simplest surgery. First, if rid of her cancer, um, with you know, she's 65. Technically, you know reconstruction should be offered, but it's in this case. It should be offered in a delayed setting because you wouldn't want to compromise any oncological, um, Uncle Odjick, a little factories, and here, any complications from poorly healing reconstruction would potentially delay her start off Brady therapy. Um, I think at the moment we think that she's got negative lymph nodes. I didn't go into that here, but if you have no, No. Sorry. Uh, I'm gonna stop share for a second because I don't want to spoil the other questions. If if, for example, she had positive lymph nodes, we would then if she needed chemotherapy, you wouldn't want any complications to affect us. Sorry, I didn't Look, if we questions answers, I'm just going to start sharing again. So I hope that makes sense. Um, when we talk about recovery from breast cancer, there are physical, emotional, sexual, sexual and psychological factories. Um, we discuss uncle plastic rest surgery, so offer, you know, different types of reconstructions with all of the women who require mastectomy. But it is possible to reconstruct in a delayed setting. And by that, I mean, once it's completed, there are driven treatments, and she may require she would she had an er positive cancer. She will go on hormones. But that's fine, that we can operate on lashed. But if she is very good therapy or any treatment her lymph nodes with us and next delivery clearance or chemotherapy. Any complications from reconstructive surgery may, um, recruited us. So going into slightly the more advanced. But it's, um, which of the following do you think is not a type of tolerance? Breast reconstruction? Deep, inferior epigastric perforated flop. Latest Ms Door say flag prepectoral implant based reconstruction. Um, with a porcine and eight PM until the intercostal artery perforate. It's up. Lover Thoracic are three perfectible. Interesting answer is a moment. So you think you can see the results. The correct answer. What's C and all the other options are types off Tanaka's breast reconstruction. So what? All it is being he, um the implant is the only thing that's sympathetic on that list and all the other potential, um, potential options. So, like I said, we way, we've got quite a lot of options out to reconstruct a Shins on D Options A. D and E are quite recent. Developments in breast surgery have been popularized maybe over the past 56 years, and they relate to the small, the vessels on which we can raise, um, little flaps and move them into the breast. Partial breast reconstruction on that was a bit sneaky of May, because, um, there is both whole breast and partial breast treatment reconstruction options here. Um, so a D and E would allow for partial breast reconstruction? Um, lettuce. Ms. Dorsey flap is quite a, um, quite a useful, autologous free flap, not refractory. Um, rotation a rotational flap. Um, that allows for whole breast reconstruction on this. The answer that was incorrect is actually quite a common. Well, it has become quite a common option for whole breast reconstruction. Where where in the patients don't want the morbidity off off an L D flap or a D m fluff, which I haven't put in the answers. We have got a few questions in the charge, you know, without the few buckling. Yeah, I was feedback like, Oh, so no questions in the trash. Um, it's a really exciting area, though, Um, that's what I'm currently in my final years of training. Learning how to J is for these little chest wall perforated blocks. The names of them rely on the little vessels that supply them. For example, this is an L top. Um, you basically keep the blood supply at all costs, and you take you DPT realized the skin that is going to be moved in on top of the tissues. That's it in that area. But you move, um, you take Dermus and subcutaneous tissues are not any muscle, and you move them on on this on these bit of blood supply into an area of the breast. But actually hope would print off the breast. Which leaves a patient with a small scar, an extra started scar here on the chest. But not much more. More morbidity from us basically just want you to know that. Okay, Plastic breast surgery is progressing. We don't have to do as many mastectomies, possibly on We're pushing the boundaries a little bit with breast conservation by using small perforate er just well perforated flats, um, to preserve the breast. Onda really has asked me to try and cover, you know, mentioned bits of the curriculum, so this is not quite cancer related, but it's something that you may have to do with on general surgical. On calls, we've got a 28 year old woman who is breastfeeding and presents with right breast vein and has associated tenderness on examination. Her temperature is 38 degrees Celsius. And which was the following? Would you not do as part of your initial assessment? Color king management in surgical assessment units. And the question is, which one would you not do? Okay, so history examination, start IV Antibiotics takes a blood culture is incision and drainage on under G A on old stand of her right breast and aspiration of the abscess. I think one person did not fully be the question. Okay, cool. Yeah. I gave you an easy question there at the end so you wouldn't straight. You wouldn't have jumped straight into an incision and drainage under general anesthetic off a breast abscess on D. This is probably lactation. A lot related breast infection. She's worked. This patient is breastfeeding. Has breast pain on associated tenderness on down. Potentially. She's in the you know, you don't have any other observations, but temperature of satiation. That 28 year old you know, you get worried. So must Isis is very common and breast feeding women. And it does not present that often to hospital. And a lot of the time it can be managed in the community by luck stational specialists and the GP tablet antibiotics and continuing to express milk. However, they if if an abscess developed in the breast, patients can actually get quite septic from it. And early recognition on treatment is crucial. Basically, if a breast feeding women it's coming to and she's feeling real well out showing early signs of sepsis did not dismiss her. They need full four. Oh, assessment Onda. If they have got signs off sepsis and start starting to go off on the systemic inflammatory response syndrome spectrum, you follow the sepsis. Six guidelines. So you would who take a history examine, take some blood culture is started IV antibiotics, especially with the red, red hot, swollen breasts tender to talk to you just cannot see if there's different Genotypes is under there. Um, if it's my scientist long, it can be quite, you know, they can't quite sick from that. Um, a lot of the troughs actually worked. Every trust that you will work for and have that has breast unit will have a guideline and protocol to follow. Um, but basically, you initiate, initiate a substance. Six bundle. Um, surgical incision and drainage may be needed, but not usually not in the first line If we think that there is an abscess in not mastitis situation, you get the patient on antibiotics, get some pain relief award and trying to arrange for an old sound off their off the breast. Okay, usually in the rest of the apartment, because they are radiologist skilled Onda, um, praying to hold some breasts. Know every radiologist has dropped training on When you talk to your radiologist, you also asked if there isn't I think there was an abscess I can feel when you please try and aspirated the reason why we do in the show older. So I'm guided. Aspiration of any abscesses is you know, it's the same treatment and you have to drink the puss, but especially in rescuing women, is because a lot bill dog has become blocked on a caused a backpressure into a lobule. And that's you know there's stagnation and it becomes infected. But if we incise and drain under general anesthetic, they can have horrific outcomes. The cosmetic outcomes occasionally that is needed. So if the aspiration doesn't work so basically, you in classical teaching. In general surgery, you go and drink that abscess make a big Christianization and drink a lot of puss and breast. If you do that, you basically George, open up the breast. Uh, well, they do under ultrasound. Guided drainage is if the abscess is there enough breath. You go from an uncle, take the pressure off this again. That's underlying the abscess, and you drain as much process possible to be pre stashed that cavity. Take the pressure off the skin because it can often look like the threatened or even the cross check if it's a very advanced abscess. Where you got black skin is the worst ago with an ultrasound guided aspiration. But you still will worry about the foot of skin and occasionally when you don't take our patients to incise and drain under a general anesthetic. But, um, we will utilize ultrasound of depressant and if possible, um, I focused on like stational my status on an abscess in Latin know lactation. Mastitis also happens. There is also a separate condition called peri doctor mastitis. That, and be non infected, s a non bacterial and then from to process. It's a lot more common in small Curries on. If they have signs of Subsys, it can be infected and caused by bacteria. You have to consider gram negative cover in those patients if they're smokers or even in breastfeeding patients court who are smokers. Because, um, we want to make sure that the right and the bugs are coverage him on with non elective activation mastitis. We follow them all in clinic because to ensure that there's no underlying cancer that initiated that infection. Um, you can imagine that if you got a sore tender breast, actually a little lump underneath ish on, we think it looks like an abscess. Women will not tolerate. Tolerate a mammogram, would you Wouldn't do in. This lady comes to 28 But if you had a 45 year old woman who's a smoker and getting that abscess, you have to follow her up to make sure that this wasn't initiated by a concert. Also, you do not want to miss, um, inflammatory breast country where all the skin is red. You can't feel a lump. You think it's must I just. But that's why we follow them up. Because if we don't get resolution of symptoms, we look for all the causes, especially with inflammatory breast cancer. You can have completely normal blood tests. So beware questions how to prevent a dog from being blocked on that relates to it's maintaining a flow of milk on day. True, we want to wait as breast surgeons, we like trust to have good lactation a lot, um, therapists on D or Aleve Stational midwife. Sometimes so purely health care workers that, um, support breast feeding women, especially in the first few weeks. Postnatally. It's basically to maintaining the flow off milk. Um, depends whether the woman is purely breast feeding or the she's expressing breast bone scan hope, especially if we've got women who need the antibiotics and it stay in the hospital and the young babies at home. Depending on the trust, there may not be a room available for a baby on an adult ward. It complicated situations a very, very patient and trust dependent. They use pumps on the ward. If they're with us, we want to maintain the flow of milk. We moved to massage their breast three of massage that blocked duct in a store, but it may be needed to do if there isn't much infection of the particular time, and a blood doctor has just blocked um, women kind of issue. It's warm compresses to base it. They'll age of little does vessels around that can help us. Well, what else does extension lactation therapists are really, really, really important in useful? Um, yes, he did quite a few things to do. Any other questions end up with my last case, actually, because I thought that this was quite a bit Mm. If you have, if you are quite interested in breast, what I haven't gone into is different types of breast cancer. When we talk about great 12 and three, I mentioned slightly. I mentioned Lobular that MRI's rash. I haven't gone into triple negative, um, countries, but basically there is a lot of little stop sub entities off breast cancer that you can definitely read on. And it will be in your pathology books because it's an important health problem. Um, one of eight women in the country in the UK will get it in their lifetime on, but there is a suggestion bash. It is heading towards one and seven. Any other questions at all? I am very. If it's something I haven't covered, I'm happy to answer as well. It also If anyone is interested in surgery, I will certainly promoted especially breast surgery. But I've got I'm going through general surgery training on. But I like operating. And I like the, uh what general surgery can offer. So, Lily, this was on the temperatures world. Yeah, I think I think we can ignore that. Have just, um, posted the feedback link into the group chat again. If everyone can please just take a minute to fill that in. That we much appreciate is yes. Because the only thing that I get well from the pleasure of teaching aid um, I, um I just need feedback from a portfolio. Thank you. Please. And thank you. Someone just ask. Just electric going to be posted. Yes. So, once I end this lecturer, the recording will be uploaded on to meddle. Yeah, I think apart from that will just stay on for another 23 minutes in case you've got any last minute questions. And, um, I gotta go. Would you advise breast feeding women to use a needle? Never heard of Ash. I'm not a lactation specialist. Um, but I wouldn't advise him to do it because with a needle weakening traduced infection. What you can get is a gun like to seal. That is a where you have a milk. You have a block, doctor, and you get this collection of milk, but no infection. That happens as well. And Kenbrell on quite a significant lump. I would not advise a woman to stuck in the signal. Neither the try breast. We would see them in our clinic on a range for a ultrasound guided drainage of a galaxy. Oh, under aseptic technique. I think you people have left. So I think it's a reasonable time to finish up. Yes, yeah, that's fine. I've just posted the feedback link one last time. So everyone just click on it so you don't need the last gration. If it's all if it looks, especially if it's milky or smelly, it'll get sent for my cross. Be culture and sensitivity. If there's any signs of infection to check, what if there is any books growing? If it's a pure galactocele, it will be a septic, and they don't need antibiotics. Okay, Thanks, guys. All right, thank you. Everyone Put your knee and again. Thanks. Also left were given up your time. Um, I'll send the feedback cling to you, Uh, later on tonight. Oh, there we go. Another question. So it's a seal for triple triple therapy. Uh, you mean triple negative cancer, or do you mean got seal? I think they meant that for the histology or cytology, part of triple therapy. Is there a name Sorry for triple assessment? Yeah. Assessment in breast cancer, It always a biopsy. Um, unless it's assessed on, it comes back with pure. So if you have concordance to your pee pee on a radiological assessment and cytology. So, for example, if you had a simple cyst that was key to no suspicious findings on mammography or or ultrasound and the only hard, fine needle aspiration for cytology because there was a tiny bit of blood. If that shows some normal cells without any suspicious cells, that is fine. But if it's a solid lump, we did not do F in a. A solid lump always requires a core biopsy on with cancers. So on an everyday on cytology, you will not be able to tell if it's if there is invasion. So if the if it's a long um, and it looks suspicious for a concert it needs a core biopsy. No, no, that's okay. I mean, exciting. Such denied a good study to a swell, but I hope that clarified that. I think that's everything. Um right. Yeah. Okay. I'm gonna end. Um, the tree Toro here again. Thanks. Everyone thinks so. So, uh, I hope everyone have a good night. Thanks, guys. All right, Bye bye, guys.