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Uh So hi, everyone. Welcome to our, I think it's our fourth potentially even fifth session now, um for our revision series for the mrcs, I'm gonna welcome back, Lilly Lilly did one of our sessions a couple of weeks ago. Um And today she's going to be doing breast conditions. So as usual, any questions just put them in the group chat on the side or wait until the end. Um and we can, we'll answer them as we go. Uh I think I can see the chat, my laptop was on a little bit of a go slow. So then that's all right. If there's anything, I can always pop in and shout out. So, yes, please do so. Yes. Today we will go through um common breast conditions um basically as relevant as we can for the MRCS. Um So I went back through the curriculum um and sort of looked through curriculum obviously shared for part A and part B. Um But something I thought when I was revising for both parts of the exams is that breast comes up loads um in both parts of the exam because it's, I think quite a nice topic to, to examine uh both in questions and in the sort of clinical side of things. Um there's loads of areas that breast questions can come up on. So, breast pathology, breast anatomy, um and then specifically within the principles of sort of neoplasia and oncology, which I thought there was more than I was expecting in the second part of my exam. So we won't do too much of that today. But it's just the kind of thing of knowing things like the cell cycle about the definitions of neoplasm tumor's what type of tumor's. But there's quite a lot of depth to the breast stuff. So that's why I thought would be a good one to cover. But then in doing that, I kind of went through, it was like, oh gosh, there's actually loads and loads and loads of the breast bits in the exam that we could go through today. Um And for anyone that saw my last session, I tried to do it quite case based and quite interactive and I think it's probably too broad to do that with breast. Uh So we'll probably try and be a little bit quicker than we were last time. But I'm just going to go through what I found was coming up in the exams in both parts and within the breast. Um sort of remit trying to touch on some of these topics and sort of signpost things that might need some extra reading. Um And then just as a pure disclaimer, I'm not a breast trainee or anyone that has a particular interest in breast as a specialty orthopedic themed. I have assisted in a handful, maybe of breast surgeries, um, and a few clinics, but I think it's a really nice topic for the NRCS because you can kind of divide it off, revise it all in a day. It's well documented. There's lots of like nine clear guidelines and I revised pretty much exclusively um of, of past test for my part A and E mrcs or pass mrcs. And then for part B I used teach me surgery, which is the most amazing website. Most amazing resource that's directly mapped to the mrcs curriculum. So if anyone hasn't found that yet, then that's kind of where all the extra reading can be done. But hopefully, I'll sort of signposts and things that will commonly come up. Um And then it would be easy to, to direct a little bit of revision after that. Um I think all my animations have disappeared, turning this onto a PDF. So it wasn't more distracting up from us. So very briefly to start with the anatomy of the breast, there are sort of three main things that come up. Surface anatomy may be more predominantly in part B but still within part A. And sometimes there can be a surface anatomy question the sort of structural or physiological anatomy of the breast and the breast tissue and at the structural or functional unit of the breast and then the lymph nodes, which is always predominantly the axillary lymph nodes. When there's a question about them, breast pathology and breast nodes. So, um moving on just to the sort of diagram there, those are the three main things that I thought we'd talk about quite briefly. So um if we start with sort of the the surface anatomy, um good sometimes be able to rattle off a definition. And if you're thinking of doing part A and part B close together, which is definitely the best way to do it. Um If you start revising with questions and then building in things like knowing definite, then you're like off to a flying start with it at those time between my part of my part B and I almost had to start again learning all the basic science, basic anatomy. So it's really good if you can carry that on. So I just popped in the sort of definitions there from the mrcs curriculum of the surface anatomy boundaries. So, lateral border of the sternum midaxillary line. 2nd and 6th costal cartilage is um the structural anatomy. So essentially these sort of mammary glands being modified sweat glands, they've got a series of lobes and ducts that basically come together to drain uh like the spokes of a wheel coming together into the nipple and the fiber stroma that sort of holds everything into its anatomy and knowing a bit about the lobe and the duct is just useful in understanding the pathology. When we get onto it. Later, thinking about the locations of the breast cancers which will touch on a bit later on. And then thinking about the lymph nodes within the Xeloda. So um while there are more than just the auxiliary lymph nodes that drain the breast, um so there's also the parasternal nodes, the posterior intercostal nodes. But the bulk of questions that I've ever found have been about the axilla because it's what's clinically relevant to us when we're thinking about breast surgery. So that's um a nice diagram just from I think, teach me and ask me or teach me surgery about the three levels of lymph nodes relating to the petrol is minor muscle. And it's a really common question in um part B definitely. And then I think it's probably, you know, likely or able to come up within um part A and understanding the role of the sentinel node and sentinel node surgery knowing about the central no being the sort of thirst node um that drains a tumor and then understanding the methods of isolating that Sentinel node. So um that's a little bit of extra reading that's worth doing. And again, if you're ever going to do a breast job, that's the kind of thing that's going to be really commonly asked. And when you're in breast MDT, um that's the kind of topic that comes up and the discussion of axillary surgery and whether or not there's gonna be no sampling. And I just think that's probably the most clear and simple diagram I've ever found to just look at where the notes are and why that's important physiology. Um, I think is again somewhere where I didn't expect uh, breast to come up quite so much because it doesn't feel may be completely relevant to a surgical exam. But I'm not sure if anyone sort of picked up from their questions and reading so far that the pituitary gland is like an absolute favorite of, of examination topics in the MRCS. And it seems that very niche obviously. But knowing the hormones that are produced by both the anterior posterior pituitary and, and thinking about the relevant physiology of the breast that comes from that hormone access without hormone cycle. Um There's loads of really, really complicated diagrams about, you know, the negative feedback with that. But I think understanding the access of the hypothalamus and pituitary prolactin and then the breast is really important and I've definitely seen mcq questions about prolactinomas. So prolactin secreting tumor of the pituitary gland and the pathology of that. So it's one of those questions that can have to stems almost to it. So you can think about the effect of the tumor itself. So, pressure symptoms, visual symptoms, understanding the optic chiasm, that horrible diagram with all the hemianopia as and then uh understanding the symptoms of, of hyperprolactinemia itself. So the treatment for that being a dopamine agonist working because the lactaid trough cells express dopamine receptors. So you can kind of block that axis. And it's definitely, I think something that I stumbled across and didn't I really want to have to relearn but that diagram of the optic chiasm, it's just everyone loves it. It seems to come up all the time. So yeah, it's, the breast scope does cross over into lots of different parts of the exam. The bulk of what is likely to be examined or likely to come up and likely to um consistently come up though is the pathology of the breast. And if we think back to the sort of um first side on the curriculum, it's within the topics on the mrcs curriculum where they really kind of give you a list of what you have to know and, and you just have to know it. And I've kind of said to lots of people before about the part A exam is that it is a really, really tough exam. There's lots to know. But the curriculum is very uh clear in what you need to know. And if you do the questions, um work hard and get through the curriculum, then it's fairly fair um that those questions will be the one of the questions that are asked. So, um we'll try and spend the most time on pathology, but I will also try not to keep you too long because I understand you just had another session. That's a Wednesday evening. So, um, I divide everything up in my head because it's how I kind of track things down. And when I'm revising, I'll have done some questions or learn to topic and then I just get blank paper and kind of scribbled out everything that I can remember. And when I was revising for my part, b we had groups and we kind of talked through each of these areas. So we'll cover benign breast disease and malignant breast disease, which is the easiest way in my head anyway to break it down, but it doesn't necessarily cover everything. Um There are some areas as well that crossover, but I am breast disease with malignant potential or um this kind of breast outside of the sort of benign and malignant spectrum. So things like gynecomastia, which is on the revision list and then um prolactinemia hypoprolactinemia that we talked about earlier. But we'll try and be as simple as possible because uh that's the easiest way I think to tackle these exams. A little bit of background knowledge about screening is always useful. Um and the triple assessment. So within the questions on sort of statistics and screening programs, um there's not many questions on them, but the breast screening program is one that we all very aware of as well as the cervical cancer and the aortic aneurysm are kind of the three screening questions that come up. It might not necessarily be a breast relevant question, but they might be using a stem as you know, a breast question to then ask you about some of the stats stuff because they do try and keep it as kind of clinically relevant. Uh So um the breast screening is a mammogram for women aged 50 to 70 and then a triple assessment is sort of the process that happens when a GP or another care provider refers someone to the breast connect so history, a clinical exam, um imaging and then some form of tissue diagnosis. And that's another part B common kind of question to come up is understanding triple assessment. And one of the questions I think I got in one of the marks I did was what do you know about triple assessment and tell about triple assessment? So, like I said, if you can learn for both exams at the same time, then it's just uh and not much easier and nicer way to do it because you're kind of tackle both at the same time. So, starting with benign breast disease, I've kind of gone for tumor's or growths and then other um and we'll focus mostly on the two main growths or tumor's that come up very commonly in the part A and part B exams. So, um generally speaking for when you get to the part B, there's quite a nice way to introduce a differential for any lumps is to think about all the things that can cause lumps and bumps. So you could mention um sebaceous cyst abscess lipoma as a differential generally. But thinking of breath rest, we've got kind of the two main examined topics I'd say would be fiber adenoma, um and a phyllodes tumor. And then I've also put ductal um adenoma and papilloma on there as sort of the next two that are most common. And then from my memory anyway, most commonly asked about. So fiber adenoma is the very most common benign growth. And if you've got a question about a fibroadenoma, I feel like they'll often start feeding you some clues that this is going to be a fibroadenoma by the background of the patient. So these are often younger patient's um excited as women of reproductive age. And there's this kind of trigger word in a question about the mobility of the lesion. So highly mobile lesion's not fixed, not tethered. Um And that's where this breast mouse definition or kind of example comes from. So it's a tumor or a growth of the, both the stromal and the epithelial tissues. If we think right back to the diagram of the ducts and the lobules, um they can be multiple, but they have a very, very, very low malignant potential, they're often left alone if they don't bother a patient. Um if it's uh multiple or if it's something that a patient wants removed then it can be removed. And um as with the sort of triple assessment that we touched on earlier diagnosis is um kind of finalized by a pathology. So, biopsy which is the tissue diagnosis, confirming a fibroadenoma. So trigger words, young patient, mobile lesion, thinking of a fiber adenoma. And I always say about the mrcs A questions. Sometimes they were them really weird or like backwards and double negatives and things. So just make sure that you've read the wording of the question. Um It wouldn't surprise me for the exam to say like what is the least likely? Um And give you all of the stuff that's leading towards a fiber adenoma and then you need to think, you know, the other way. So just a little bit of time to read the question obviously, as you always would. And then at the other end of the spectrum, the commonly examined fellows tumor is rarer. Um and most commonly in older age groups, they rapidly grow and they do have a malignant potential, which is where I said the line is sometimes like a wee bit blurred between, you know, completely simplifying, but just my brain works in compartmentalizing. So I revised for loads under benign lesion's and the trigger words for the questions. I'd be looking for our older, older patient's and rapid growing lesion's thinking of the sort of other benign conditions that can come up and this is not an extensive list or an exhaustive list. But just things that I when I was preparing both the exam and then preparing to give this teaching session kind of found were recurring. Um So mastitis and abscess, um definition of abscess does come up a lot in um I think both parts. So having those definitions to hand as part of your vision and going from in part a being able to recognize the definition in a list to partly being able to confidently say the definition just making sure that you're kind of thinking broad term of the mrcs as a whole exam rather than completely two separate points. It just makes it nice. So you can divide both mastitis and abscess into their lactation all status. So the question stem might talk about a woman who is breastfeeding or a woman who is pregnant and the common organism is nearly always staph aureus. Um So you can think then in some of the microbiology questions, what kind of antibiotics are going to be targeting that? But there's lots of ways that these questions can kind of spread out and have a little bit more depth to them, but definitely come up as as sort of that lactation, all non lactation, all cyclical pain, um and Andy or aberrations in normal development and evolution of the breast. Um I wouldn't say that I saw many questions on either of the exams, but just if we thinking about all of the things that could be examined and then gynecomastia as a side effect of medications. Um and as a symptom of other disease such as liver failure. So there's a decent amount to the benign breast conditions. But there are kind of those trigger words that will come up that can lead you to the right answer. Um, the understanding of the kind of um examination and diagnosis of these is is important for both parts of the exam as well. So we can move on and to malignant breast disease. And in my slides before this all came up nice and, and sort of in order, but essentially we'll divide it and then we'll divide it again because the smaller chunks, you can break it all down into the easier it is to learn and then you're only learning a little bit for each thing rather than kind of staring at a topic and thinking, gosh, there's loads to learn that. So, um the invasive cancers carcinomas a ductal unpopular and the insight you are also doctor Lobular. Um It's not exhaustive. There are other subtypes and, but they are rarer and I would say probably unfair to be asked about. But if you come across something in your reading or come across anything in a question and you do even just a couple of minutes of reading about it. It's amazing how much you all have absorbed. And then if that comes up in another question, you'll have it there. So, um I always think that's like the best way to expand, especially when you're really near to the exam. And you're doing question after question after question, if you see anything that you, I think, you know, I've never seen that before. Just five minutes. A couple of papers, a Wikipedia article, teach me surgery article. It'll stick without you having to give too much time to get to the end of the revision bit. And your brain's kind of got this bit of sponginess where it's right at the sweet spot where your learn loads. And then as soon as you've done the exam is everyone knows from all exams, you just empty that sponge and you forget about it, which is the best bit of the exam. So, um if we think about invasive, the most common is a ductile breast cancer. And then the second most common is a lobular followed by the other subtypes which we won't go into today. So, breast cancer itself is the most common cancer in the western world accounts for 20% more cancers in women in the UK, one in 10 women will develop breast cancer in their lifetime. So most of these patient's with an invasive breast cancer will present with symptoms. And that's another thing in the sort of trigger mind, trigger in the stem of a question. If a patient is presenting with symptoms, it is more likely to be an invasive cancer. Obviously not, you know, there's no blanket rule for anything. But being that our most common screen detected breast cancers are insight you, then it's, it just makes sense to me in my head. Anyway, if something has invaded, there are additional symptoms such as, you know, auxiliary disease, you can have tethering of the skin and you can have uh metastatic presentation. So if a question is giving you some triggers, uh you know, key words such as that you can start thinking about the invasive breast cancers. Um in terms of your part B, breast exam can come up. Um and breast like explanation stations are fairly common because it's such a big topic. Um You know, it's a whole surgical specialty in itself. Um There can be consent questions about breast cancers and patient's can ask, you know, what actors can ask questions about. They're kind of a giant therapies, etcetera. And that's the kind of thing we think about with these invasive breast cancers because it's invasive in that it's, you know, outside of the area or the, you know, the region that it's in and then there's metastatic disease with that as well. Um So those are the two that I would spend the most time revising ducks are lobular, but obviously, there are rarer subtypes and within that just a little bit of reading and I just say teach me surgery would be the best place to get the rest of your reading. Um As well as the, I've got a text book for my part. A which is the principles and practice of surgery. Quite nice textbook, quite nice little kind of chunk sizes if you're going to be doing a bit of reading outside, but it's also completely fine to just keep hammering away at questions. I think that's a really good way to learn for the party as well. So, the opposite of the other arm and would be your um in Sichuan insight you breast carcinomas. So, again, nice and easy to remember. Thinking back to the anatomy, there's ductal and there's lobular, the doctor is the most common type of non invasive malignancy. Um So it's contained within the basement membrane and it's often detected during screening, rarely symptomatic. Like I said, that just makes sense to me because it's, it's not, you know, it's not invasive. So therefore, it's less likely to be felt or symptomatic. Um And therefore, we'll, we'll talk a little bit more about surgery. Um just down the line but commonly managed with a wide local excision. But there can also be obviously breast, you know, full breast surgery. So, mastectomy as well, lobular is a noninvasive lesion of the secretary lobules themselves. It is rarer um than a ductal cancer but has a higher potential to developed into a um malignant or sort invasive cancer. So, another screen detected and just having that in the back of your mind that it's the one that has a higher potential to invade than the duct. The big kind of bulk of questions about adjuvant therapies will think about patient's receptor status. And this is something that I, um, struggle to get my head around, I think, and probably still don't fully fully understand. And I think that sometimes you have to take a bit of a hit with revising for something. And if you think if I'm not gonna understand this fully or if I'm not gonna get this topic completely down, then you do occasionally just have to think, right? I'm going to learn this just so that I know the main facts of it. So, um the receptors that, that we test breast cancers for the estrogen progesterone and then the her or the human epidermal growth factor receptor. And so when you hear the phrase sort of triple negative or um estrogen positive progesterone positive, it's about what that tumor has expressed and what that means for the patient and their adjuvant therapies essentially. So this is, you know, changed massively in the last however many years as these medications have come out from our mainstay of management being completely operative to now having a huge amount of adjuvant uh therapies. So as well as our sort of standard for all cancers, we can consider chemotherapies, radio therapies. We've got hormone therapy and it's worth just learning off the drugs and learning what they do. So the ones I'd say a worth learning would be tamoxifen. So that's premenopausal patient's at blocks estrogen. Um Then you've got the aromatase inhibitors. So, letrozole is the one I remembered or anything that ends with an old, I was like, right, that's going to be my aromatase. That's how I remember that. Um So they're more commonly for most post menopausal patient's and then specific immunotherapies. So things like the maps or her, you know, which we can target directly the her uh receptors and these kind of things are like I said, maybe even more pharmacology based questions. Um But definitely important in, in thinking about a breast cancer and I don't know, however anyone feels is most, you know, how easy it is to learn these things. But for some reason, I just couldn't get my head around them. Um And even for the part B which I did quite recently, I just kind of had to sit down at the end and think I'm gonna have to learn a couple of these off and just be able to talk about them in a level, which is okay to get me through the exam and you don't have to be an expert on everything to pass the mrcs. You just have to have read, you know, the curriculum and, and done as, as much as you can to get through it all. So the main kind of bit that I knew from a clinical perspective was about breast surgery because it's what I've been um exposed to in practice and the divisions of breast surgery, if you're talking about it in a part D question and if you're answering it in a part A M C Q can divide into breast conserving. Um So that's why local excision or lumpectomy biopsy to non breast conserving. So, mastectomy and then um the kind of discussion of axillary surgery. So whether a patient will have axillary surgery and that can be a sentinel node biopsy. So, biopsying the first node that the tumor is likely to drain too. And that's commonly done with a chi combination of um methods. So blue dye AM and a gamma counter um where you kind of hold it over and wait until it makes all this noise and you, you're following the note and you take out that note and you send it to the lab and then um they're full clearance. And um in the mock exam, I had, I had to explain to a patient the what a full clearance was going to mean for them. So the risks of that, the complications, um lymphadenopathy. So it's for me anyway, and I probably for everyone because, you know, we're during the exam because we're surgeons surgically minded, surgically oriented. I found it was the nicest bit to learn when you kind of have gone through all the tough pathology and learning. You know, the fiddly bits of what, you know, what's most common, what the symptoms and signs after that it can be quite interesting at the end to go through and, and think like, right, what, what's the actual surgery that's being done? The other things we can consider at the time of breast surgery, whether or not there will be any reconstruction. Um So that's sort of on plastics, whether we have immediate reconstruction and delayed reconstruction. Um Each center that offers breast surgery will have slightly different guidelines for who they would offer reconstructive surgery to in which timing. Um There's things like put choir guided biopsies. There's things like sending off the this the sample directly to the lab and having uh like frozen section reports, things like that. There's loads of scope in breast surgery and it's, it's improving uh little surgeries and technology all the time. But the, the kind of bulk of it I would say for questioning, why is understanding uh what kind of surgery is going to happen? You're importance of margins, your importance of your central node and the importance of your axillary surgery and the complications of that in teaching surgery, which I feel like I should have, I don't know, I need to give them credits for just getting me through both parts of my exam. Um They have a consent section um for lots of common conditions and reading through that, it's useful if you're ever going to be consenting for these procedures. But also just an understanding, uh you know, the risks of things and how that can help your vision because certainly for your part B and there'll be a question or a station at some point about consent and breast is a very common topic to come up as I kind of mentioned before. So I just show that diagram again because I think understanding those levels of limp nodes in terms of axillary clearance is really important um both in, you know, in part A and describing that sort of, you know, sentinel node pathology in which notes you're going to take. Um And then in party, in terms of doing a breast exam, examining the axilla in clinical practice, obviously as well, which is the reason we do all of these exams so that we can finish our exams and do whichever especially were interested in. And I'm sure there are probably lots of people who know masses more about breast common conditions who may have been been able to give you a much more eloquent and um thorough talk. But certainly, I think it's a, it's a good to have a structure to revision. So if I've been able to give you a couple of extra bits that you hadn't thought about before, um particularly for me, I think finding that link between the pituitary stuff and the breast was kind of, you know, an extra string to my bow and I was revising as that right can pull that into that topic. And it's definitely a topic you could sit and get through easily in like half a day and you feel like you've covered the whole thing, um, and then it's all sorted and it's, you know, quite a nice tidy bit of revision, quite well circumscribed. Um, well surrounded and nice to be example because you can easily get it, you know, done and dusted really easily. So my general top tips for the exam use past test and mrcs and if you're, there's a topic that you keep bringing up that you're not getting right, you just, just sit down and make notes on that or you learn the way you normally would to go back to pre question bank days. Question banks are excellent for part A and, um, the similar kind of, you know, asking questions for part B always be careful of the double negatives that they can sometimes ask. And if you're able to sort of highlight the key parts of these questions, they can be really tricky and odd wording sometimes. And a question feels really rubbish and you feel like you're not making sense that just leave it and move on questions that don't make sense or that are being trialed and are rubbish will get taken out the exam. So it can be really easy to agonize about a question that was absolutely awful. Um And certainly you have like a negative bias when you think back to how your exam when, because you're never going to think. I, I easily answered you know the 20 questions that came up on breast pathology because I was such an expert in it. You think? Oh, I didn't get that question. Right. So, once you've done a question and if it doesn't make sense, just put an answer down and move on. If you've got time at the end, you can go back and, and think about it again. Um, and yeah, try and combine both exams in, into one kind of flow of revision if you can because it will, it makes your vision for part A, a little bit less boring and it makes your revision for part B A lot nicer. And you won't like me have to sit back and start everything again because I didn't remember a thing from my party. I don't think. Um, and you use the website to teach me surgery, teach me anatomy because they're both really good and good luck with your exam. Perfect. Thank you very much. Really? Um, does anybody have any questions that they're dying to ask if you want to put them in the group? I'll give it like a minute or so. Um, on the message you can always email me as well. Well, I send you the slides, Jess, I'll send you them for both of the talks I've done because then you've got, we looked load the recording of this as well so people can go back and watch if they want to. Um, cool. So I can't see any questions. But yeah, if you do have anything, our email is on the kind of event page anyway. And you know, we can always forward anything to Lily. I'm just gonna send a feedback form into the group. Now, you also get an email about it. Um We do really appreciate feedback for kind of us for how it kind of has gone and using this system, but also fully as well just for her teaching. So she can use it for her portfolio. So that'd be really helpful and, and once you do the feedback, you get a certificate as well. So it's kind of a double whammy. Um And yeah, so we've not got a session. We have got a session next week. Uh Let me just check the dates. I've lost all my dates, tell a lie. We've not got a session next week. We got a session the week after and we've got two more sessions planned, but keep an eye out on here and on, on Facebook. And it's got basically all of our information. Um and you can sign up to our mailing list as well, which is also attached to our Facebook. So keep an eye out for all of our sessions. And uh thank you very much again. Thank you. Good luck. Bye. Okay.
