Transcript for:
Insights on Benign Breast Pathologies

I think the chat function is not functioning yet so I'll I'll I'll activate it sorry for that for people that are online just give me a couple of minutes and YouTube seems to be working today which is perfect let's go on the chat function because I don't think that you're able to send anything yet let me correct that and then we go live count everyone can you check that that your chat function is working do you want to put something in the chat so welcome everybody with the first webinar for 2024 this is number 55 and for a change we thought we'll be looking at B9 I think you're on English Ricardo because yeah because you have to put it again thank sorry oh okay no no it's fine it's fine it's fine perfect sorry for that working okay now yeah you don't listen to me yeah okay okay I still can hear you yes so can you do it again I'm supposed to be in the Spanish Channel but you're listening to me okay let's uh manage language interpretation apologies for that uh add interpreter sorry that's uh first time this has happened to us Ricardo isn't it I know uh update shall we go back to the English Channel and Ricardo do you want to try to go on the Spanish Channel yeah that's perfect yeah that that I think so for people that are listening to the Spanish channel can you just let me know that you can hear Ricardo it's great to have you all online uh we thought we'll do something a bit different we haven't addressed any of the benign uh pathologies in the past webinars I think it's it's time to start looking at that so we're doing rare but benine I have a co-chair erini Pont who's one of the surgeons from OBS and Sweden it's great great to have irini with me and we have one of The Usual Suspects always and the serial offenders is Ricardo Paro as Ricardo is a translating to Spanish so if you want to listen to the talks in Spanish please go to the uh uh Spanish Channel with Ricardo we have four talks great speakers we have Maggie Banis p Chi from Germany we have Michael B from Ireland we have Victor akosa Marin from uh Venezuela we have Salim T from the UK and hopefully we will have also na kadogo also from the UK who's going to be in the panelists uh Ash kotari might join us later but let's start with the with the talks the first talk is about Noma and it's going to be by Victor aosta Marine from Venezuela Victor the next 10 15 minutes are all yours hello thank you Jan thankk you for this invitation for me is an honor to be here um I would also like to thank I should start sharing my screen right yes please okay here we go I would also like to um thank Ricardo Paro for making available these webinars for the Spanish spoken Physicians all around the world um I'm going to stop my video now so it doesn't get in the way of some of the slides can you see my presentation now I can see the presentation it's in full mode looks perfect all right without any delay any further this so let's start talking about nipol adom so npom is a very uncommon condition of the breast it represents a benign proliferative process of electrif dots as we all know it's primarily seen in middle age women it's exceptional in men and children Dr Rosen as you can see down there classical paper 51 patients reported two men who had carcinoma rising in florid papilomatosis and historically npad denoma has been known by a variety of other names in the literature including florid papilomatosis of the nipple as you saw in the previous slide we could be a while here just naming all of them the thing is that since the fourth edition of rest tumor classification by the World Health Organization in 2012 the current accepted definition of this Legion was designated as you can see there neom ratified in their latest edition the fifth edition which you can see in your screen the earliest published NAD denoma appeared in a paper by kman Dr kman Haggins in 1952 and his colleagues from Presbyterian Hospital in Colombia here was labeled as introduct of papul of the electrif ducts but it was it was until 1955 when it was first described in detail by the pathologist Dr David Jones from New York State University since then and because of its low incidents there have been not many papers I'm going say about and most of them in case report or at least 13 18 cases at the most and again the paper by Dr Rosen with 55 cases but including including other histological subtypes more recently Dr Shir Roman from kin Clinic published this very nice paper well structured almost say the review cases from 2003 202 22 important fact regarding the data resulting from this paper Lo down here the cases in which no skin was present no leion was visible on the slides or the diagnosis of Noma was questionable were excluded so we can be 100% sure that all these cases are indeed nio adom in this paper they describe the three major histopathologic grow patterns at the nois filter tip and papillary like pattern they also describe very detail the features of niad denoma and noted that more than one hop histopathologic pattern could coexist in the same condition at the end of this description the authors concluded that with the current available data the nomenclature and definitions of these patterns are inconsistent and confusing hence there is no data supporting the importance of identifying each subtype as it doesn't affect the prognosis you can also see that during medium followup of 66 months there was not recurrence one patient developed invasive doctor carcinoma adjacent to the exision site but there is still no solid data at this moment that sustain the development of a malignant Vision arising from AOL another interesting fact from this paper is this even though the preop diagnoses with a core biopsy a cytology or even an incision of biopsy to remain the gold standard look here at the bottom of the table and the right side of the screen about a quarter of the cords were diagnosed with exisal biopsy so we know that the method for diagnosis could be somehow related to the clinical presentation it affects part of the nipple 100% of the nipple it also affects part of the ARA and look here in the in the bottom um almost all of the imag started resulted in a negative finding by this uh clinical presentation it is often asymptomatic but it can behave in a locally in Fila Manner and please hold on to this for the up coming slides hence patients sometimes present with swelling and complain of itching also often associated with pain and or arthemia seros anguinus discharge may lead to a formation of a superficial crust now for this clinical presentation not necessarily the size Matters or at least not only the size matters but only where is located in the nipple whereas the duct affected by theion may affect the clinical scenario this is the section uh cut perpendicularly through the nipple you can see here uh a very small superficial npad denoma and depending on how we grow the outcome of the clinical presentation as it is it could grow towards the exit of the nipple and even though being very small its clinical presentation May mimic resemble a very different Legion let's say a malal for example in the other hand and again this is another perpendicular cut of the nipple so you can have the same size lesion but deeper in the nipple finding yourself a gr zone right here which is a narrow area of the papillary dermis un involved by underlying pathology here you can see it uh and does the growth the initial growth actually of the denoma may turn the nipple firm noler or even de form rather than erosive or fragile and here you can see a microphotography from a patient that present at the end of his trun look here here is the ad denoma here is the thermis and here you can see the smooth muscle bundles and between of them um this leion the gr zone so the lesion is far away from the surface and it's grow just pushes the tissue ahead just evolving in an ular not erosive lesion like this this is actually that patient another clinical cat is that most cases are unilateral but there have been reports of bilateral and clinically all always remember niod denoma May resemble a Paget's disease of the nipple which is actually regarding def diagnosis the most important pathology to think about NE Noma could be confused with pets due to his similarities as the ruos charge erosion and pain however the peak incidence is later in life approximately half of the patients also present with the associated pable Mass now there are even before getting to pets for the differential diagnosis to consider and the leas is definitely not short again the clinical presentation of pets diseas and npad denoma may sometimes confuse us as clinician but for our colleagues experienc breast pathologist as it could be sometimes very straightforward P disease is characterized by the presence of byet cells as we all know you can see some of them here in the blue circles in contrast NAD denoma the growth pattern is completely different you can see here this papillary light pattern is way different than the other microphotography and the my epithelium in the outer layer complete is also one of the key points of differentiation of the pets the pathologist can see this AED by the imunohistochemical staining as you can see here and this is again another microp photography from that patient present at the end you can see the cell sustain with p63 these little brown dots the lack of my epithelia cells um in the specimen are a positive staining for malignant cells markers as we usually do let's say ki67 or two hormone receptor um erpr can help distinguish Noma from malignance uh disease now this will be definitely help for luminal lesion but what about triple negative breast cancer so even though we already said that there is no point on reporting histological growth patterns this is still crucial for the pathologist to be familiar with this morpholog iCal growth features as it remains very important to wait on this differential diagnosis and last but not least pay3 and Ras mutations are frequently identified in Nomas there is even a serious from taian with over 50% of those cases with this mutations I've said a couple of slides before that there is no clear data supporting malignant arise from nipol adenoma but what we do really need to consider with the diagnosis of this is that the real independent risk factor for cancer in such a diagnosis is being associated with atipia we know this for a long time now and this is one of the reasons why the Imaging findings is so important to loot out other entities in the breast this is a paper by Wendy Burg from University of Pittsburgh published a couple of years ago after a 32 case review from their database from 2007 2021 they came up with a description of npom on ultrasound mamography and MRI being ultrasound the most helpful Imaging method regarding nadom characteristics in most cases they found a slightly increased internal vascularity when using the Doppler nor the mamography MRI demonstrated specific findings according to NAD diagnosis just on MRI a hyper intense signal on pre contrast T1 and T2 weighted Imaging but again not not a specific for npol adenoma diagnosis the complex suris since Dr hain's paper is still the go standard until today remember it's Bion and simple exision is Curative recurrence has been rarely reported after partial incision it is important trying not to lose all nipple projections of course it will also depend as I stated before on the clinical presentation and the compromise of the nipple partially affected total affected like this case where we were um we needed to resect Almost 100% of the nipple and there is no projection remain compared to the controlateral nipple as you can see there and this is are my last couple of slides look at this other case we had a couple of months ago a 34y old patient with a lump in her left nipple there were not nipple discharge reported by the patient no relevant familiar our personal history physical examination show a was CCRI nodule on her left nle without any positive finding Adent to the Neola complex here um is a closer look to it on mography look there is only the enlargement of the left nipple and there are some micro classification superi near the nipple but not even suspicious but look on the ultrasound performed by our radiologist of kar Martinez there is a slight abnormal increased flow just like we saw on the paper previously mentioned so this was the plan using part of the healthy nle to preserve uh the projection this is the surgical specimen from our Pathology Department look how it grew towards the base of the nipple as it was deeper rather than the superficial and of course as I said before it affected the clinical presentation so what we did is a loose strin suture at the base of the nipple on once the adenoma was reected and again use the remain healthy nipple to cover the defect again showing the microp photographies on your right the fluid papillary pattern here the adenoma the gr Zone the smooth muscle bundles the healthy um dermis and how it pushes towards um the surface and here the immunochemical staining with the p63 and the my epithelial layer complete and this is the post up you can see the right nipple the projection here at the right nipple and then on her left nipple how it is pretty much preserved with an acceptable um result so I have am time thean these are the conclusions and to take on message niad denoma should be considered as one of the conditions in the differential diagnosis of patient with an Rosy Nole of the nipple histological examination is essential to rule out um breast malany such as do carcinoma or page disease and avoid unnecessary additional treatments simple exision is Curative recurrence is rare and there's no solid data to suggest any link with invasive carcinoma uh this is my team I'm sorry this is my team and the clinic these are my colleagues from the board of director of the Venezuelan Society of mology and with this picture of my beloved kakas well I finished I hope um I was some time I just stopped sharing and I remain for uh comments or questions that's perfect Victor we'll take all the questions at the end when we finish all the talks uh but it's great presentation up to the point with a lovely conclusion slide telling you all the important bits uh for people that are on the Spanish Channel I think Ricardo had an issue initially but the Spanish channel is working all fine so if you want to listen to the talks in Spanish just choose the Spanish Channel and if you have any questions some because some people are raising their hands nazina chat I think it will be difficult to take the questions from Raising hands if you have any questions please put them on the Q&A section and the next speaker will be introduced by my co-chair by erini pantora irini right thank you yazan and hello everyone uh thank you for joining us our next speaker is Salim T he's one of the breast surgeons on homerton University Hospital in London and uh his presentation is focused on breast infection and absess management Flor is yours Salim thank thank you very much um can you see my presentation looks fine yes yeah okay great uh so thank you very much for the invitation uh so uh good morning good afternoon good evening to everyone uh I'm going to talk the next 15 20 minutes I'm going to talk about uh breast infection concentrating on uh mamory fistulas and also touch on breast absis and our experience with establishing a pathway for the management um so m fistula um fortunately it is a rare disease it's also known by other names that zuska zuska Atkins and and I'll come to that uh in a minute when I explain in the next few slides um as I said it's a rare condition and therefore there wasn't much in the literature definitely not an andise control trials under management so I had to dig a bit deeper in history to get the uh see the description how was it first described I came across this book by the famous French uh surgeon vpu who described the condition in his book in 1856 where he was describing the condition in lactational and non lactational fistulas and in this case he was describing the fistula in Madame C uh a 68-year-old lady who was um diagnosed with a fistula which he treated with compressive clasp um and also I found a um what was hinted as a correlation between the mam Fist and the absis and we know that absis uh an incision in drain of absis can cause fistula and Thomas nun in his book in 1853 uh advised against the early incision of the absis to avoid uh the mam fistula and it was not until the 1951 when this Landmark paper by zusa and colleagues describing the condition and describing the pathogenesis and the treatment and they um uh um advised for the excision of the terminal portion of the memory duct to ensure uh the decrease of risk of recurrence uh interestingly zuska's wife was diagnosed with bilateral breast fista and he got interested in the condition and he then for further patients before the publication of his paper um and that's why a um this condition is all usually can be named by zus disease or zus Atkins disease because in four years later in 1955 Atkins a surgeon in G Hospital in London described the condition and the treatment in 28 cases where he opened a the fish and let it heal B intention and he had no recurrences in his series um M fistula what is it um it's a classical description fistula is a communication between two epitelial services in this case one opening will be in the duct and the other will be in the skin usually around the edge of the um of the arola why does it develop um incision and drainage of ansis is a is a risk of developing a fist also spontaneous discharge of a inflammatory Mass can lead to fistula and rarely a biopsy of a mass can also lead to that uh how does it happen uh the pathogenesis as described as we know that the normal ducts are aligned by cuboidal epithelium in case of seus metaplasia a condition condition associated with the periductal starters uh the uh cuboid epithelium will be replaced by Seamus epithelium which secretes keratin and that lead to keratin plug blocking the docks and then with the stasis and in the bacteria Invasion you'll develop microabscesses there which will open and discharge usually at the edge of the skin because this is the least uh resistant area remember there is a smooth muscle uh layer there which has made it tough for the secretion to go through this way so that's why they will choose the least resistant area and once the block is uh released then you got your fistula um smoking is a risk factor uh we know that it is well established risk factor for the developing of the perod mtis analsis in 90% of about 90% of cases uh congenital Cliff clip is another risk factor for developing of this condition now the management uh there are no under m control trial but basically the um treatment should concentrate on excising the fistula with the abnormal with the the abnormal duct and correction of the uh of the nipple um I looked at the literature and summarized the techniques described to treat the fistula into fistulotomy uh appro the U fistula excise it and then leave the wound open for secondary intention or excise it and then primary closure either with a circum arol or radial incision or a total duct excision again using circum arola or radial incision and then some oncoplastic techniques are used so I'm just going to show you some pictures from the series po publish this is the Atkins series uh he described the opening the fistula leaving open by secondary intention and uh he had no recurrences in 28 patents uh and then the uh group from the same Hospital guys Hospital in uh headley's Atkins unit described the same procedure in 59 patients and they had five recurrences uh Snider described a radial incision where he excised the fistula and then part of the nipple and um approximated the edges of the nipple to keep the nipple in shape he described this in 18 cases and he had no recurrences uh Lannon started with um a circumoral incision excising the fistula in eight cases but he had five recurrences and then he moved to radial elliptical incision and he had two recurrences after 26 cases um uh Dixon and colleagues advocate for the circumoral incision uh they've exed the fistula um alone with antibiotics covering 15 patients and they had no recurrence and also combined the fistular exision with total DX exision in 28 patients and they had no recurrences and I know that Mike dexon is a is a a big fan of a circary order incision because he um thinks that it improves the Cosmetic outcome uh which I agree with um and Lee uh and colleagues from my clinic also excised the fist also excised part of the ni nipple and 33 cases and they had three recurrences uh Jamal almad from Jordan uh described the total ttic exision in 11 cases where he modified the technique by De epithelizing the area above of the incision there and then attach the arola nipple complex to this part uh and he advised that this will create a new vascularized bed reducing the chance of esia and it also provides support for the position of the he had no recurrences in his 11 cases um um also a group from Italy used the enoplastic technique here some sort of um um round block where they excise the fista and part of the nipple and they describe this in 27 cases with one recurrence a groups from China Zang and colleagues uh used a derog glandular flab for the treatment of 47 cases and they had two recurrences so as we can see there are a few techniques described there but fortun unfortunately there are no randomized controlled trials but there is a meta analysis by group from China zo and colleagues uh so what they did they uh grouped the interventions into four groups um minimally invasive group that's group one including incision and drainage incision alone and group two included the patients who underwent excision minor excisions which means excision as the fistula trct uh by leaving the uh wound open or closing so in minor exision there were four subgroups wound packing primary closure with antibiotics or without antibiotics and then minor excision with excision of part of the nipple the third group was the group who had a major exision either with circum marola or radial incision and the fourth group was the group with um who had enoplastic techniques uh so this is the um this is a busy slide with all the uh studies included uh but this is the important um table here are the results so they described uh or they calculated the treatment failure rate we can see in the many many invasive group incision and drainage um has a high recurrence rate but we know that we know incision and drainage is not the treat M and in fact it can cause the fistula so uh um so that's not treatment of choice coming to the minor excision if you excise the fista and leave the wound open they have a good success rate if you want to close the um the wound make sure that you put them more antibiotics because if you don't then the failure rate is high moving to the major excision it seems that the C the radial incision has a better success rate than the [ __ ] marora incision and um the major plastic techniques uh had a good success rate so uh so that's the talk about the fistula which is the rare disease but I think we also I need to mention the next five minutes or so about the prevention prevention is better than cure uh um trying to the next few slides talk about the management of breast absis which is a common condition but by properly managing the absis hopefully will avoid the development of fistula um quickly go through the timeses of infection there the types of breast infection can be divided into four groups lactation and non lactation and skin Associated and postsurgical lactational is common uh non-lactational can be divided into to Central um including periductal matis uh and this is the concentrate of the talk is mainly about the periductal mystis that develops the fistula and the peripheral infection which is less common but the ethology is less clear could be associated with diabetes rheumatoid arthritis um um skin infection like any other parts of the body I'm going to skip that and the postsurgical infection I'm going to skip that to concentrate on the man M of absis management of absis basically the um principles are to aspirate the p and put the patients on antibiotics ideally the patient should have ultrasound guided aspiration because it is better than open incision uh of the absis and I'll explain why uh there are National guidelines by the National Institute for Health and Care Excellence uh in the UK um to advise on the management of breast infection and and absis um in the UK most of or all of the patients with breast uh infection and absis will be um initially treated by emergency physicians emergency doctors or general surgeons on call so we thought by creating a pathway to guide our colleagues at the management we should have a better outcome uh I'm briefly going to describe the pathway so the priority of course to make sure that the patients are assist for for sepsis if they are septic then they need to be treated accordingly with antibiotics and admission and Etc then assess the suitability of ultrasound gu guarded aspiration if the skin is necrotic then they need to have incision and drainage and in my experience most of the patients will be suitable for ultrasound gued operation and they we provided the um extension and who to contact UM to arrange for that and once that's done then the patient will uh be um booked into the breast clinic for a followup summary of the management that's based on the noise guidelines includes analgesia antibiotics aspiration of the uh pus and lactational mtis first L treatment is flu floosy and continue breastfeeding non lactational first line is coox clav and stop smoking if there are smokers uh did this pathway work yes it did uh we audited our results and um looked at outcomes before the implementation and then after the implementation of the pathway uh we looked at a few outcomes uh after the introduction of the pathway way all patients had ultrasound scan done the average time decreased uh waiting the average time waiting for ultrasound decreased uh almost all patients had antibiotics prescribed appropriately uh for me the most significant outcome was the that patient the decrease in the rate of surgery uh before the implementation of the pathway uh nearly 40% of patients had incision and drainage once after the pathway that dropped to less than 10% reduction in surgery okay well done but so what we are surgeons yes but um I was told that a very good surgeon is a surgeon who knows when not to operate uh so is aspiration better than uh incision and drainage yes it is but don't take my w for it uh there's a recent meta analysis done on the effectiveness of incision of need respiration compared to drainage and um that included nine randomized control trials including 703 patients the outcomes cure rate was similar so both procedures cure the condition recurrence rate again there is no difference but healing time was better for the aspiration group incidents of breast fistula and that's the monster that we want to avoid was less with the in aspiration group Interruption of breastfeeding was less with the aspiration group satisfaction with the rate of the appearance was better with the aspiration group so no difference in cure rate and recurrence rate but the benefits of the aspiration is that better healing time avoidance of fistula and less Interruption of breastfeeding and patient satisfaction um and uh the last uh two three slides I'm going to talk about first how are we doing uh I don't think we're doing great this is a recently published audit done uh to describe the current practice uh of mystis and breast absis in the UK and Ireland the overall rate of incision range is 21 in my opinion this is high there is also a um um huge variation uh ra between centers ranging from zero to 100% so some centers still treating all their in abscesses by incision and drainage and um and I think there's more work to be done and the authors concluded that National best practice tool should be uh utilized now I'll finish with a couple of slides uh and breast absis um I would advise for the S rule for the management of breast absis oh it's nothing to do with My Name by the way but I've just noticed that absis has few s's in them so the treatment should be there and SES so I would suggest to symptoms relieve stick and need the sterilized bacteria start antibiotics suck the milk and stop smoking and if you don't like the S rule then I would suggest that you treat absis with absis antibiotics breastfeeding suck the milk clean the area educate and establish your own pathway using your own resources stick a needle and stop smoking and that's my 18 minutes and thank you very much for your listening and I'll be looking forward to any of your questions thank you very much Salim it was a great talk about the clinical challenge I really like the the absess uh acronym in the end very interesting and now back to yazan to introduce our next speaker thank you thank you AR and thank you s for the lovely talk and sticking to time now it's Maggie Banis poosi and Maggie has been here before she's one of the surgeons in Germany she reads lots of the studies in Europe with the EU breast and it's great to have Maggie with us again today and she's going to talk about grattis mastitis so Maggie in the next 15 minutes are all yours thank you yaan dear colleagues it's always a pleasure to be here and thank you for having me and particularly thank you for inviting me to talk about granal M mastitis and the opportunity of presenting an upcoming trial um focusing on this rare disease uh Guided by the EU breast study group so most of us have uh has have um treated at least once someone with granatus metis and most of us will still remember the patient because this is quite rare but might be um very uh discomforting for the patient with symptoms stretching up to months or even years and becoming a chronic disease um the prevalence is actually very very low uh two to three per 100,000 uh women in uh between 20 and 40 uh and there are very different hypotheses as to how granus M matis occur most of them assume that there is some abnormal immune process as a reaction for example to a trauma or maybe to an infection and some authors have suggested that there might be a link with for example Corino bacteria but this has not been proven or established the pathologist who is actually the person who will confirm the diagnosis um sees granulomas usually multiple granulomas in the tissue and they are um in contrast to other forms of Gran granulomas in the breast usually locate at in the lobules sometimes there will be also an absis present but it is very important to know that the granuloma itself doesn't necessarily mean that our patient has idiopathic chonus mastitis because this disease is actually a diagnosis of exclusion uh and this is particularly important when you're dealing with a patient who might have one of these other diseases that you see here and particularly in case of patients with tuberculosis or Sarco dois granuloma is located at different uh parts of the body are not uncommon so usually the pathologist who sees granulomas in the breast tissue following a core biopsy or a surgical excision uh will uh usually asked if there might be a suspicion of other diseases in the patient and obviously in countries where TBC is very common um this is a known phenomenon for example colleagues from Turkey have published extensively on this topic and also uh about how to distinguish TBC granulomas from IGM idopathic gropus mastis IGM has first been described in the 70s so it's actually not a very young disease um and it was described as an a rare entity that might mimic a breast carcinoma so usually the patient presents with a lump and also symptoms associated with an inflammation pain redness swelling of the skin and all these symptoms might might uh mimic indeed a carcinoma and particularly an inflammatory breast cancer so it's very prent to always keep in mind that one of our diagnosis uh one of our differential diagnosis will always be inflammatory breast cancer so in the end it's crucial to uh confirm the diagnosis by histopathology what are the risk factors who is more most likely to develop IGM uh we do not know this because the level of evidence here is very very low we know that mostly women develop IG and women with of childbearing age somewhere between 20 and 40 most patients reported in case Series so far were 35 this was the median age in most Publications and um the women usually had at least one child um the IG developed mostly several months to years after end of breastfeeding however there are some cases in women who are very very old even as old as 80 and very few cases diagnosed in men or in women who are pregnant which may be challenging uh to for establishing a treatment strategy non-white ethnicity seems to be a risk factor uh in the studies that we have seen so far and there have been multiple factors discussed as potential risk factors like smoking or maybe autoimmunological disease uh in the past and also hormonal contraception but uh frankly there is not enough data to talk about risk factors uh in EV in an evidence-based manner from what we know so far there is no um there's no association between IGM and an increased risk of developing breast cancer in the future but having said that there have been some reports of patients having granatus mastitis and then being diagnosed with for example DCI dactyl carcinoma Inu following a surgical excision performed for granatus MTI uh but still for our patients who have I GM and have healed well um there is um from the literature no hint of having an increased risk of having breast cancer in the next years when we perform Imaging usually the first form of Imaging performed would be ultrasound and then we see hypoechoic and usually very heterogeneous lesions are sometimes extended in one quadrant or or in some patients even in the whole breasts so we can see see absess formations and some patients will also receive MRI uh as we've heard before our uh differential diagnosis is inflammatory carcinoma and sometimes the um patient who does not respond well to treatment will will receive MRI because we're so concerned and for the radiologist it is quite challenging to exclude malignancy upon MRI if a patient has granatus mastitis because he usually sees uh contrast enhancement it might be mass-like or non-mass-like um there is usually some uh suspicious signal intensity and there has been one very nice publication uh where colleagues from Turkey tried to find um Tred to distinguish um um between carcinoma non-mass like enhancement and gropus mastitis enhancement in MRI and it seems to be very challenging because most findings are actually overlapping so let's talk about treatment and here we do not have any evidence-based uh recommendations we do not have guidelines on this topic because the disease is very rare and as you can see uh various different strategies have been employed so far most patients reported in the case Series so far have received steroids at least once sometimes local in form of an ointment some authors recommend injecting steroid into the lesion uh and many uh recommend systemic ster steroids and on the right side in the Box you see one of the possible regiments for steroids um that is used at some sites here in Germany so this is a prednisolone uh regimen starting at a quite high doses for four weeks and then tapering it over several weeks so the total duration of therapy in case of IG usually takes at least two to three months until you can win the patient of steroids in some case series patients received uh full surgical excision uh sometimes even a mastectomy in very persistent or recurrent cases usually this is not necessary and there seem to be in the literature a trend towards um a fine needle aspiration as uh as well opposed to uh surgical evacuation so this might be a good idea but we do not have any trials on this so far and of course no randomized trials when it comes to other forms of systemic therapy there have been different agents uh that have been recommended to patients uh particularly immunosuppressive drugs like metot trite for example but also some other drugs that we know from chemotherapy and also from treatment of uh autoimmunological diseases uh bromocryptine uh anti lactation an antigen and most patients receive at least at first antibiotics um if you had patients treated for IGM you probably know that usually if you perform needle aspiration from the ab formation mostly they are sterile of course of course we send it to the lab and ask for an antibiogram but usually there are no bacteria uh in there and if we perform repeated in uh repeated aspirations repeated evacuations they usually stay sterile for the whole time uh there have been uh very uh rare studies on other forms of treatment like ozone therapy or microwave ablation but this is something that has not been uh employed in many patients so far one thing that you should definitely uh take with you is always confirm histologically the diagnosis because the clinical presentation of the patient is very very similar to the inflammatory breast cancer so we always need histological confirmation before we start treatment uh particularly because the agents we use like steroids or um immunosuppressants uh might not be a good idea if we're dealing with a case with a cancer patient and here I brought you an example of a patient who present Ed with a large breast lump and also swelling and redness and typical symptoms of inflammation and upon ultrasound she had a hypoechoic lesion that has been um um has been aspirated the legion was sterile and core biopsy confirmed the diagnosis of IGM she has no suspicion of any other disease like TBC or CCO dois and we started the course of uh storage regimen after one week the leion was small and her symptoms were better she was also put on nsid to uh to reduce her symptoms after three weeks we saw uh quite a small leion and after six months when she came for a follow-up visit there was just a small residual leion located in her lower outer quadrant and there was still some redness uh and some um skin swelling in this area but the patient did not uh require any form of surgery sometimes if you follow up patients for a long time uh they might wish for a surgical excision of the residual uh lesion particularly if they have some pain uh at this area and this is also possible but as I said before there are no guidelines on this topic the case series that have reported on a followup of their patients um have shown that the patients have actually quite a high risk of having a recurrence of IG uh somewhere between 80 somewhere between 8 and 30 asent so uh some patients we will be seeing again and when I Was preparing for this talk I searched in pet of course for new evidence and I was quite surprised that there seemed to be um a certain interest in idopathic rolat mastitis but when you look closely um most papers that have been published have been published 2021 and these were 606 public six Publications so the evidence is very very limited uh then I dig deeper and uh I saw saw that most Publications come from Turkey uh so many thanks to all Turkish researchers uh that have provided insight to this topic there have been some Publications from the USA uh from uh China and from other regions but still it remains a very rare disease and we urgently need more studies and this is why it is my great pleasure to uh present shortly the grammar study it is a registry study uh designed by the UB breast study group maybe you have heard of UB breast um this is the study group that leads theana study and in cooperation with the ianet from the UK uh the melody study this is how yzan and I met and the grammar registry study will be led by my esteemed colleague from dorf um and Natalia cfic who is about to initiate this study in the next two months so this study is a registry it is observational non Interventional um the target acal is non limited uh because obviously based on the Rarity of of disease uh we uh want to start it as an open registry and what I liked most there will be a retrospective data collection so all patients that had IGM between 2015 and the time point of activation of your study site can be included in an anonymized manner they do not have to sign anything there's no ICF for these patients and then starting uh from the activation of your study site you start recruiting for the prospective data collection and here obviously the patients have to sign the informed consent form and they will be follow uped for until uh 5 years and we want to gain more insight into this rare disease we want to know uh how the symptoms are how long the symptoms take until they resolve what kind of treatment the patients receive this is the part that I'm most interested in uh which factors contribute to a higher risk of receiving a surgery for example and how high the relapse rate is so all the things that are actually very interesting to all of us I'm sure of all patients have to have histologically confirmed granulatus mastitis this is very important because we want to focus only on uh IGM and uh we of course exclude patients having other forms of diseases that might lead to granulomas in the breast particularly TPC sarcoidosis but there are no examinations that are mandatory uh according to the protocol so uh if there is no clinical suspicion of these diseases the patient can be enrolled uh in the registry and this is the flowchart and if you're interested we're still looking for our International Partners to um conduct this study uh you can look look this up at east.org and this is uh my take- home message slide with all the important information I must say I was a little bit disappointed how little we know about this study when we started talking about the registry uh so I hope very much that this crossborder study will allow us to um to uh write uh real evidence-based guidelines in the future thank you very much great talk Maggie and it's it's it's not easy always to cover something as rare as GM titis and there's lots of questions in the Q&A section you already can see 18 or 19 many about the IGM and there's lots of on the chat function so I think we'll have lots of lots of discussion on the IGM uh the next speaker will be introduced by my co-chair by erini so erini right I'm very happy to introduce Michael Boland an oncoplastic breast surgeon from s Vincent University Hospital in Dublin um he will be talking to us about desmoid tumors of the breast you can H go Michael thank you uh arini let me just share my screen um okay um so uh good evening everybody uh my name is Michael Boland um I am a consultant oncoplastic breast surgeon working in St Vincent University Hospital uh in Dublin and it is it is an honor to be um asked to speak on uh I breast book something I've followed very closely over the last number of years so I'm delighted to to speak about this and um to to yazan and arini for asking me I think we we have previously published on this which is why i' been asked to to to talk about it so I have no disclosures so today I want to speak um really just to Define fibromatosis of the breast and speak a little bit about the current guidelines which have changed quite significantly specifically within Europe over the last decade and then to talk about our own experience in Ireland of dealing with breast fibromatosis uh and a number of other studies which have detailed analysis of of of management uh and to finish by concluding with future strategies what is this condition bre breast fibromatosis is a very rare entity and is a type of meenal meenal tumor or desmoid tumor involving connective tissue desmoid fibromatosis can be split into intraabdominal fibromatosis which is almost always associated with familial adomus polyposis syndrome or extraabdominal desmoid fibromatosis which is where we we come across it within the breast it is exceedingly rare desmo tumor are are seen on average three to four times per million people per year uh and less than 10% of these cases are seen uh within the breast and so we we see these very very rarely and certainly in terms of our own experience in Ireland this was evidence by the number of cases we had seen o over a decade the challenge with this entity is that it often mimics breast cancer both clinically and radiologically and so we rely very much on the expertise of our our Pathologists to guide us in terms of saying that this is not breast cancer that this is fibromatosis of the breast what is it well it is a monoclonal fiberblast proliferation that appears histologically as Bland spindle cell spicules it has low cellularity it has a low mitotic rate and it is actually benign so it lacks metastatic potential lacks the the potential to to metastasize to other areas of the body but it is locally aggressive and so historically has been challenging to treat surgically uh and is associated with these Stellar extensions that make margin management uh particularly challenging the key to diagnosis within breast fibromatosis um is immunohistochemistry and as stated the pathologist it really is the the key person within the MDT to guide us when we look at this these are two h& uh stains for for breast fibromatosis we see the stain on on the left which shows these Stellar extensions uh and the stain on the right showing this very Bland uh appearance with a low mitotic rate and almost acellular appearance to the slide that we see uh within this compared to say for example a breast carcinoma macroscopically this is a a fibromatosis from an extra abdominal uh wall uh tumor and you can see here I'm not sure if my my cursor is working but you can see here that the actual edges of this are very very poorly defined and this is what the pathologist will see when we send this from the breast it's very very difficult to ascertain where this actually starts and where this stops so how does this present clinically well most commonly we see this in the clinic as a mass um it often occurs in patients both with a history of breast cancer and can also occur in patients who have a history of breast surgery so if patients have high cosmetic breast surgery or if has obviously a surgery for for malignancy in the past that is something to consider we see it most commonly obviously in females and in the fourth to fifth decade and as stated you should consider a history of breast cancer previous surgery and also history of trauma as evidenced by the paper by Newman at Al um from Memorial published in 2008 the gold standard really in in ass setting for breast for bosis is cross-sectional Imaging involving usually an MRI of the breasts a lot of a lot of these are incidentally picked up on CTS but when we see these at the MDT and MRI should will certainly be performed and what we see on an MRI and I will go through a number of images later in the talk is hypointensity to muscle on T1 weighted images and hyperintensity on T2 weighted images and this area usually shows marked enhancement after galini injection standard mamogram and ultrasounds are not particularly useful ultrasound often shows an oval-shaped abnormality again which I will show but no obvious mass or or or necrosis that you may see within a breast carcinoma this is one of the the CTS this is a um a coronal view of a CT uh from a paper from leod one of the earlier papers describing breast fibromatosis and an obvious abnormality in the right breast and you can see the propensity for this to extend especially towards the chest wall which makes surgical management particularly challenging in terms of immunohistochemistry features the positive stains we see are for ventin which is a filament within the mean chimal tissue as well as beta catenin and smooth muscle active and negative stains were seen within things like for desmin cyarin and S100 breast fibromatosis or fibromatosis generally is sporadic in around 80 to 85% of cases and is usually seen with an abnormality in the uh ctnnb1 Gene which is the gene that is responsible uh for producing beta Catalin and it's usually an abnormality within this Gene that causes the um the proliferation of beta catenin driven fibromatosis cells that causes this very very dense proliferation of these cells within the breast or elsewhere in familial cases we see it in association with the APC uh Gene which is a tumor suppressor Gene uh mutation or what is known historically as Gardener syndrome so I think what we will see in in the next decade is an increase in the road of Next Generation sequencing for diagnosing this and specifically for looking at abnormalities in the ctnnb1 gene mutation um this actually be done on core biopsy um and is very very sensitive in terms of uh confirming fibromatosis in other areas of the body unfortunately it's not as sensitive within breast cases H but it is good at ruling out other spindle cell lesions the other thing that you may see with Next Generation sequencing is is looking at abnormalities within the W NT signal pathway which is also responsible for uh beta Catalin production and I think you will also see some uh some activity within this in terms of using W NT inhibitors uh for treating fibromatosis of the breast so in terms of how we manage this I think there is an increasing value of of these cases being discussed at length at the MDT um and having a dedicated both breast pathologist and and I think in time saroma pathologist who has experience in in looking at these abnormalities under the microscope historically these cases were managed with surgery but in the last decade as I stated there has been an increased focus on the use of active surveillance so all patients require discussion at the MDT and value the input of your Pathologists and certainly they will provide very very good information or should provide very good information as to whether or not this is fibromatosis based on the immunohistochemistry as stated the historical standard of care was uh surgical intervention or Surgical exision and this does remain an option but because of the locally aggressive nature of breast fibromatosis we found that patients who are having surgery for this often require mastectomies and in some other cases um radical mastectomies with with often debilitating and very poor cosmetic results and it was not clear um whether or not margins actually um affected the the longer term outcomes or recurrence um rates for breast fibromatosis certainly in recent years there has been a metanalysis published in The BJs by uh group johnsen at Al which demonstrated that clear margins did affect the risk of recurrence and what we can see here is the forest plot that demonstrates an increased risk ratio for uh positive margins um for the development of of recurrence of disease however the evidence on this is mixed um a paper publish in jco by a group from Bordeaux Salis atal back in 2011 and probably the the largest um breast fibromatosis paper by rousan at Al and the Bon Val at Al group um which basically Al has demonstrated that the uh rate of margin positivity does not improve outcomes so in the Salas paper which looked at fibromatosis extraabdominal fibromatosis throughout the body they had over 400 patients and really they found no difference in fiveyear progression free survival between those who had an or zero reection and an or one reection the Rus sandpaper published in the European Journal of Surgical Oncology in 2015 looked specifically at breast fibromatosis and had 20 patients nine of whom had clear margins and nine of whom did not and again no difference in recurrence at a median follow-up time with eight patients developing a recurrence between the two groups so the uh the question then arises is surgery really necessary for this and you know are clear margins necessary and would our our historical friend Mr Halstead be turning in his grave at the thought of not operating on uh breast fibromatosis well in the last 10 years we have seen a significant shift uh uh in terms of patients being placed under surveillance with breast fibromatosis so again the rousan group looked at 11 patients treated with as or active surveillance and found that 88% had a median followup of over 40 months and developed stability or regression without any treatment at all and this really um impresses on on surgeons the the benefit of of avoiding mutilating surgery uh in patients who require extensive resections and many who as stated will stabilize following this the uh systematic review met analysis published by Tim Bergen adal in the European Journal of cancer involving 25 articles again demonstrates a stability or regression rate of close to 80% at median follow-up time and as a result of this both the desmoid tumor working group based in France and the European Society of medical oncology now Advocate active surveillance for breast fibromatosis which is a significant shift um toward from the historical uh option of of uh operating on on all of these but who should we operate on well the switch to active treatment or surgery usually occurs in around 30% of cases and the most likely patients who would require this are those with a younger age those with uh painful tumors and most specifically those with larger tumors that are particularly aggressive and without surgical intervention are likely to cause you know very significant problems other points to note is that grossly positive margins are or two where there is clearly tumor left behind is certainly to be avoided if you are operating but or one margins are acceptable if they are um if they are going to be Associated um with a high morbidity if you're trying to achieve an or zero margin we do Advocate that patients avoid pregnancy within one year of surgery as this tends for some reason to accelerate H the rate of growth of breast fibromatosis what other treatments can we give and I think the importance of the other some other randomized trials we've seen in the last number of years have looked at systemic therapies that can be used for breast fibromatosis so specifically the um the desmas study which was published in laned oncology by tandal a number of years ago looked at the use of pazo pazopanib which is a tyin kinus inhibitor uh as well as the New England Journal of Medicine paper looking at the use of sarapin and these showed an objective response rates close to to somewhere between 25 and 40% um um which are are very very reassuring in terms of patients with breast fibromatosis and demonstrate again the ability to stabilize patients and in some patients cause significant regression of disease um the other drug that has been looked at which is a gamma secretz inhibitor Niro gasat um was looked at by Kumar in a phase two study published in jco and again showed an objective response rate of around 30% other medications that have been have had some evidence in favor of them include hormonal therapy including txin more aggressive cytotoxic or standard chemotherapy agents and as said it before there is some current investigation in terms of w NT Inhibitors as it is involved with the pathway with beta catamin so in terms of guidelines for active surveillance we would recommend that if you are placing a patients on this pathway that they would have an MRI diagnosis that that they would have an MRI at six Monon intervals for three years as well as clinical review and an annual I thereafter so I want to talk a little bit about the management of Rest by brosis in Ireland and the study that we had published I've included a picture of Dublin and a picture of St Vincent's Hospital down the lower right where I work and St James's hospital where that the stood the other Center that we included and all three of these pictures have Dublin looking um very blue skyed which is it is categorically not so I think it just tries to give a better picture to the uh listeners today we published this paper a number of years years ago and this is a paper that I wrote in conjunction with Professor um Elizabeth Connelly professor of breast surgery in james' hospital uh and with my um previous Mentor the late great Ender mcdermit um and this was a paper between two institutions in Ireland which looked at at fibromatosis of the breast over 10 years so we had 16 patients all of whom were female and a median age of diagnosis of 42 and 11 of 16 of these had presented with a lump one patient had a history of breast cancer one patient had a family history of breast cancer and one patient a known apcg mutation mamography was performed in 14 out of 16 patients and at abnormality seen in 11 and the most common abnormality we saw was a distortion I think what you can see in this mamogram which is one of the patients from our study was this very kind of significant Distortion in the Central and lateral breast on this CC view um but no obvious mass that we saw really in any of of these uh mammograms ultrasonography performed a 15 out of 16 in again a textural change and looking at this ultrasound we can see this kind of very distinct abnormality with again these obvious kind of extensions from the abnormality um uh which was very pathic for something like fibromatosis finally IDs were performed in eight of 16 and um the IDS were particularly useful with with obvious masses and you can see on this MRI um the mass and I think this MRI was very useful to demonstrate the the involvement of the pectoralis muscle within this patient and that is common something we see commonly in in fibromatosis of the breast in terms of the imunohistochemistry we saw um beta cin positivity in in up to 70% of patients acting positivity in nearly 50% but a low level of S100 and Desmond positivity and a low level of uh cd34 positivity 13 patients underwent surgery 10 of which had a wide local excision and three of which had an essentially a diagnostic Excision because in the earlier part of this study the diagnosis of fibromatosis was still very challenging um and three patients in the latter part of the study were placed under active surveillance of those that had positive margins sorry of those that were operated on eight had positive margins and six underwent re exision and of those who underwent re exision there there was absolutely no effect in terms of the numbers that developed recurrences we saw three recurrences within the 13 that it had surgery all within two years uh and all of which which because of the the changing Paradigm in terms of how we managed this all of were then treated without surgery in place on active surveillance so in terms of the three recurrences and the three patients who had initially been placed on active surveillance all stabilized and none of whom uh required surgical intervention within a median followup after the 10 years of of of roughly around five years so we saw a significant change in the in approach over the decade margins have become certainly less important and and recurrences it with within this certainly in our study were common two other very quick studies to mention I think the seminal paper published from um Memorial on fibromatosis of the breast came in 2008 they they this is a larger series 32 patients um all of whom had surgical intervention because of when um they had their diagnosis but a significant recurrence rate and they found that recurrences were more common in patients with a lower age as I alluded to earlier those are positive margins and those with larger T tumors 25% of those who had fibromatosis had a history of breast cancer and as stated for 44% of these patients that had some previous breast surgery uh and recurrences when they occurred tend to occur early similar to our experience in in Dublin the second paper probably the largest paper from the bonal group and this was a paper by uh Ludwig duazo cassen published in breast cancer research and treatment in 2019 from the French group really looked at this is the largest series we have which is 63 patients and of the these 46 patients underwent surgery uh and 17 replaced on active surveillance and of those 17 15 have have not required surgery in in in the follow-up time again of over 40 months um with two proceeding to require wide local exision in terms of those who did require surgery there was a five positive margin rate Five had what they described as radical resections with very very poor cosmetic outcomes uh and four patients which is a low uh rate compared to other series developed to recurrence so to conclude I think it is critical that you put these patients through the MDT that you have a dedicated breast pathologist and possibly a saroma pathologist uh to review the slides if possible the current guidance would state that these patients require active surveillance um with with clear guidance on the mode of surveillance that is required and clear guidance on those that may require surgery um you know depending on the factors that develop those factors include patients that are are younger have larger tumors and have particular the aggressive tumors but it is increasingly important to explore the role of non-surgical options including tirene kindness Inhibitors specifically such as sarapin um in terms of managing this thank you thank you very much Michael it was a great talk very nice overview of a rare but rather challenging diagnosis um we're going back to yazan so we can start with the questions and discussion so let's open the videos for for all the panelists and speakers we still have S we have Naim also online and Victor do you want to open your uh I'm not able to open the the the my my camera oh thank you it's fine okay you've stopped my uh camera Yen you can start it again I try is isable oh is it more but I can hear you fine I think you have stopped it yeah yes you have I've sent you and ask to start videos has that worked at all there it is yes yeah now we can see you perfect and I can see you and yeah now we have the full cohort so thanks for the four speakers for thanks for Maggie for Michael Victor and for Saleem now with the panelists we have inini the co-chair with me and we have one of the usual serial offenders and Usual Suspects Ash it's great to see Ash online today and we have also Prof Naim kadu who's one of the surgeons also in uh in London and Naim sent me an email Maggie because they've written a book on idopathic grtis mastitis so that might be uh very interesting and might be something to look for yeah because there'll be potential for collaboration in the future yes thanks so shall we start with the first talk so the first talk was the nipil adomas and uh for me location is very important for the lip adomas the base is very important because excising it is not always as straightforward as it can be and always as you've shown in your lovely video Victor sometimes going into the breast tisue if you don't do a full excision recurrence is an issue but do we need to operate on all normals any comments on that because there's lots of questions do we really need to operate on all those Adas I I I think we do I think we do because again it will keep it will keep growing and sometimes as I say it in in one of the slides it could have a it could behave in an infiltrative manner so again um if we're looking forward not to lose all all the nible for instance um we should um excise the other thing is that we if we perform a pre biopsy let's say a punch I don't know about the rest of the panel but if it's not going to be um few times that the pathologist will require the exision of the complete Legion in order to see uh the adjacent tissue and if there's definitive a an infiltrative component there so again I think for the moment we still need to operate them but I think we all do the biopsis many to confirm diagnosis because you don't want to be missing a padet so missing something else and then right so it's it's I don't think that anybody here will you operate without will anybody here operate without doing a punch if you see any Poma no no no recent experience I had a patient a few months ago where uh where she she been suffering for about a few years uh before we decided to excise the nipple so I think I agree with Vector I think the the the the way straightforward is to excise the nipple yes but I wouldn't do it without a biopsy before I I've seen one recent lady her nipp is 5 cm at least taking the whole base of the arola now and if you want to excise it you want to remove the whole nipple arola complex because you cannot excise it if you look at her and she doesn't want anything and it has been growing slowly for years and years she doesn't want anything done any comments from any panel may I tell something so I think we have no just right to operate any adenoma without any core biopsy that's my you know View and that's you know basic the practice here in UK and just I would like to tell you about my recent practice about few months ago I have seen one young lady breastfeeding in her late 50s I think she was 52 53 and she was breastfeeding presented with a nipple adenoma type picture and I was very keen to operate on her so just was very difficult you know to do I just suggested biopsy she declined biopsy and she came on the day of surgery I said no I'm not happy to do it and just I did the biopsy in theater because she declined she want to be done under general anesthetic you know and it showed basically reaction it was you know inflammatory reaction and after the you know the core biopsy I took at least through the nipple core biopsy 4 five and about a month later it disappeared that I was nearly to take it was looking real adenoma and she insist on basically to remove that error there is no evidence you know to do any basically no indication for surgery without biopsy I wouldn't proceed without I think this is you know it might cause a lot of medical legal problems you know if you do without any core biopsy if you do if you operate any nipoma so we agree we need to biopsy all Legions before we take them out so that's you know it has to be a rule but the other thing is that let's say we excise the Noma and you have clear margins on it do we need to follow them up or not any comments on that Victor anything was there in the literature about follow up we we don't tend to if there's no excise we we just tell them if there is any problem you come back actually not actually not and um the the the recurrence um um numbers are are very low the thing is that we need to have a very good um Imaging preop um scenario as the differenciation with the PES disease as I said it before and um I think that's that's much it I don't know about the rest of the panel if if they in their institution they have a a working followup with these patients and U any comments about that Ash any comments about Nomas anything from your side so I think probably we are overtreating those patience so we need I think more evidence more International collaboration more evidence you know really we don't know how to approach to those patients and there are different approaches from different part of the world so I think still we are very aggressive to treat nipple ad denoras that's my personal view we need to be really very cautious about it Ash any comments on that I think I agree unless the patient is symptomatic I wouldn't treat an abnormal and definitely won't follow her up so let's move from adenomas to the infections and and fistula so I think the key message from the the talk s is that most abscesses you can treat with aspiration and antibiotics abely many people are still taking patients to theater making big holes in breasts and that's you how you end up mainly with fistulas uh there's lots of questions loads of questions on the Q&A section what's the duration of antibiotic when do you stop the med when when do you stop the the antibiotic and aspiration and go for surger and things like that common sense is common so if the patient is septic not well need to go to theater you take them to theater if the patient is not responding with the repeated aspirations then that's when you start thinking about taking them to theater but the majority will not heal in a week or two some people need to take two three four weeks and they need to come frequently to Clinic have ultrasound scan gued as irations and take the antibiotics and they responding they're responding any comments from anybody about that absolutely I want to stress the e letter on my on the absis the educate it is crucial to reassure the patients and educate them to well they're breastfeeding they frustrated they've got this absis they need to be reassure that it is likely that they will require that more than one session and they just need to be patient patient it's much better than taking them to theater and inside the um the absis so educate the patient is is is a very crucial uh in terms of the um indications for surgery if the skin is necrotic that fine I agree that's um that's an indication but and again failure um attempts several attempts of aspiration maybe another uh indication but in my experience most of the patients will be suitable for ultrasound guided aspiration or sometimes just clinical aspiration you don't always need the SC scan guidance in all honesty Magie you have your hand up yeah I was we have a very similar problem in Germany so that too many patients receive surgical uh drainage and not an aspiration and I was wondering um is there an incentive in the health system uh in the UK so that it's easier or better for the Department to perform surgery than to aspirate because this is uh clearly the case in Germany based uh on our reimbursement system yeah sometimes the the money comes into the equation unfortunately I have Naim and I have Michael's hands up you have comments from Naim first yeah so I think just you know I would like to address the basically the UK experience there was a very good paper of Prof Dixon about breast absess you know this has been published quite a long time ago and we have published also about bre absis in the European Journal of you know just breast and what I see is you know just I feel guilty basically letting you know non breast surgeons to drain breast abscesses we see really very big incision there is no really indication for any drainage unless if there is a obious skin necrosis or very thin skin and nearly just I think probably my personal observation is not more than five or 6% of patient might need drainage 96% can be basically treated you know just conservatively with you know proper aspiration and this aspiration has to be done by radiologist with dedicated breast Radiology this also second important thing I think we need to be in all countries you know as breast surgeons we need to take over the range of these breast abscesses and because you know we will end up with a very small incision at the end it makes huge difference and for and yeah that's you know something that you know I don't know in how many countries you know our breast consultant colleagues are being on call are going for Dra of abscesses so that's something that we might consider as you say in many parts of the world the the the the classical teaching is incision drainage even when you look at the papers that saleim shared in the UK it's still about 20% are ending up in theater 21% which is a very high percentage and that that's a National Audit but from personal experiences and from experiences like in sel's their own papers is less than five about less than 10% and I know in many places that they have edicated Radiology so for example I I spent a year in guys I don't remember draining any absences in guys everything was done under local under ultrasound scan guidance nothing end up in theater am I correct in saying that Ash it's very rare for people to end up in theater with breast infections so over the last 20 years we haven't drained one drainage and and where you talk about skin necrosis if the skin necrosis is small I wouldn't iniz it I'd wait for the skin to necrose and for the absis to Auto discharge there's no point of giving the patient anesthetic taking her to theater and excising Skin So skin necrosis I don't think is an indication for for surgical intervention and Michael you have a comment yeah it's just to Echo I think what Naim has said certainly I was involved with the mama paper that Daniel left has kind of overseen from Imperial and um like the the overwhelming finding from that is the patients who who end up having an incision in trage are those who are admitted after hours those who are admitted over weekends and those who come under the care of general surgeons and and that's not a criticism of general surgeons but I think as Saleem um referred to in his talk like the the um introducing a pathway within your institution whereby the Ed team knows that there is a very specific pathway for these patients to require ultrasound guided drainages is absolutely key because if the general surgeons and the Ed guys know that then even if if it's a patient who is admitted over the weekend and there isn't a breast surgeon or radiologist around those patients almost always can be put on IV antibiotics even if they're required to stay in if they're unwell and then have an ultrasound guided drainage on uh on Monday and and we can really drive that 20% figure down to you know the kind of two or three% figure that um that that where it should be at so I think if you're in an institution where you you know you're in you know involved in a breast service actually delivering that and and getting a pathway to to avoid patients requiring an indd in theater is is critical before going from abses to fistas I think Saleem has his hand up and then irini so s first yeah I mean in terms of the um there is an issue with the patients presenting in the weekend and I always ad advise my colleagues and Junior colleagues you don't need an ultrasound really you can just stick a needle whatever how much past you can aspirate they'll give them some relief and then they can come back on Monday so you don't always need an ultrasound guided aspiration you can just do it um with the needed and name is your hand the Legacy hand or is it in your hand yeah so just yeah okay so I would like to tell something yes so when we are encouraging all our patients to best feed okay so we know that it helps also for the treatment my main question to you know saleim will be what's his suggestion about Mr positive patients so we have just rarely just you know with this kind of you know patients with MRI Mr positivity still do we need to suggest them to breastfeed or not what's the what's his suggestion so he has a lot of work done about bis and just if he can highlight his views about it I don't have a specific view view I usually follow the local protocols by the microbiologist yeah I we need to be very cautious about it I know we don't have again very clear indication but I am really very cautious about it with recurrent obsesses all the time we need to check also about the possibility of you know MRSA positivity and that's you know strong suggestion all my colleagues you know who are listening us was your question about breastfeeding whether there beeding say positive Pati what's your I don't know the answer any other comment from other you know panelist any comments Ash Maggie I don't think there's any cont indication but Ash any thoughts so if if you look at the CDC website it says that you can breastfeed with MRC positive infections I don't think there's any contraindication it's MRSA can live in throat and nose and can live anywhere so but always involve your microbiology and infection control uh Department to see what how you can clear that uh IR any comments and now I just wanted to comment on the previous discussion about the pathways and what we do with the patients that come during the weekend when there's no availability of breast surgeon um I just wanted to um say a bit about how we do in our uni um we do have some institutional documents for guidance for the on call surgeons so it's usually pretty straightforward and they just follow a pre-designed pathway for all these patients so we've kind of lost a we we're okay with this issue we don't really have huge problems and then they just refer the patient to us for followup if needed and it's it's very easy for people just to copy a protocol from somewhere that works and just use it in your emergency department if it works elsewhere it should work also in your emergency department to decrease those incisions and Braes because that's when you end up having fistulas we we rarely see them we see them mainly in smokers with periductal mesitis but like Sim showed there sometimes can be tricky to treat you you have from the simple operation to the more complex procedure but a couple of key things if people are still smoking they will have the recurrence I don't know will you operate on smokers if you have somebody with a smoker with the with a fistula will anybody operate on smokers the recurrence state is nearly 100% yeah so the stop the smoking first and if they stop smoking there still the recurrence rate is quite high and you've shown beautifully from simple procedure like incision brainage to more complex photomy and fomy to more complex enoplastic type of procedures recurrence rate is not that much different as long as the fistula is out not with a simple operation but as long as the fistula is out am I correct in saying that s or yes that's right that's right uh yeah there's not a huge difference and the and the um success rate um but I wouldn't go that extreme and do the enoplastic techniques unless it is a wide area complex fistula otherwise excision and and um excision and primary closure my experience will do exactly so the the the ones that you showed with they havez quite a bit to mobilize the nipple and do that I wouldn't Venture into doing those things this this nipple is already under lots of had lots of of problems and you can cause more and more problems with that so I think just a pereral incision excising the fistula some people lay it open some people will close it and cover with antibiotics the main you you you said it when you did the uh you showed how it works the change of the lining from CUO to squs that's the issue the squs will never close you need to to get rid of that and if you don't change the lining then it will not heal I'll be interested to know Ash's experience because I presented one of your paper I think you an advocate for a for open um opening the F year and leave it open by secondary intention and that was Atkins uh uh procedure and you've published the series and uh is this what you still practice or do you PR do you close it so this was this was the days of my mentor Professor fent so like you said it it that was what they used to do till our generation came and we now primarily close everything under antibiotics but I was also going to ask you do do any of if you take out the ducts do a total duct EX in a postmenopausal women with a per with a f the recurrence rate is lower but you have to consider whether they're planning to breastfeed or not if they're not planning then um uh then yeah I would do a total tax excision and that's what I learn I think also guys when I was with you Ash just you you you open open the Fula clean everything and if you can do a total duct exision that will decrease the local recurrence rate sometimes I put negative pressure dressing that also sometimes make a big difference on on their healing uh but the recurrence rate is still not low last point about the fulas before we moved to the grus mastitis na you have your hand your hand up yeah yeah so just yeah I would like to ask something to panelist also to my colleagues you know all you know just also just all other colleagues you know who are listening to us you know the main question you know with breast absis patients is you know how long you know after stopping you know the smoking all the problem can be sort out I think my just answer all the time is there is no real answer about it you know even after stopping it you know the uh smoking still the damage to duct is continuing you know for long term and we don't have any data really just you know to say the real the the truth to our patients I know still the risk is higher but of course less than you know definitely than the smoking period any suggestion about do you have any you know just any evidence you know to any time just about you know how long does it take you know the the the the risk is becoming minimal the recount of absess do you have any I think the risk will still be significantly High it will not be minimum of course but time yeah we Rec them I usually say that if you still smoke it's 100% recurrence State might happen soon might happen later if you stop smoking is much less than that was there any numbers in the literature that you looked at s I'm I'm not aware of any any published data on this specific topic no um okay I couldn't see any any just suggestion about it it's very difficult to to to put a timeline on that I think uh Maggie very interesting talk loads of questions online about Ed Titus uh I think you'll see that much more in the Middle East in all honesty that's name is written a book you seen lots of literatures already from Turkey I know I've seen some talks also from Egypt with loads of cases I we've seen sadf from Iran has just mentioned on the chat that they have 300 cases that they published in from Iran also you'll see that lots of in that part of the Middle East while here for example in the UK I've seen no nothing until covid hit and then after covid I've seen two or three patients in a row and then that stopped again about a mon a year after covid started so it's always uh very interesting I think irini have a couple of questions for you and she has her hand up already arini you want to say something yes but I I did have a question for Magie um we recently had a patient with granulomatoses a young lady very hard case very challenging um open wounds in her breast three or four spread around the whole um breast and uh we we excluded everything else took biopsies um excluded tuberculosis and every um vasculitis and everything so we started in a cortisone but we also used um negative pressure um systems have you tried those I mean it really helped in our case uh we have been using those in uh plastic reconstructive surgery but not for IGM cases but yes I've heard that um that um there have been reports of using these um actually when you look into the literature there are so many different strategies that have been used like ozone therapy or um or treatment with local collagen so there have been no trials on this but uh based on the data from the reconstructive setting um well if nothing else helps I would give it a go how long have you employed negative pressure therapy um she had it for three weeks and after that we we noticed a a huge huge difference and then we just continued with the cortisone until we wied her off but um yeah I think she she had a wound that was 5 six cm and it just disappeared yeah my personal view irin is just even if you will wait just it will heal spontaneously so just you know I'm not sure really about the real indication of the V dressing in these cases but what I would like to tell just you know most of the time even if you will wait this case will heal spontanously there is no that's what I would like to address you know just IGM is not surgical disease definitely there is no any place for surgery and As yazan Told initially the beginning of you know just the presentation so recently we published the first IGM book you know with my colleague professor H gel from Turkey okay Hundai has done a lot of publication about it and because of my personal in interest also I have been involved in and we end up you know writing the first IGM book published by Spring recently I'm sure it will be it will help our colleagues and just a lot and now just recently I have been invited for consensus meeting to turkey at the end of October about IGM because I feel really guilty to mention to talk about IGM because as yazan mentioned our basically experience very limited here in UK but a lot of cases in Turkey and just you will see most of the Publications are from Turkey from Iran and just I have seen we have been just in that consensus meeting about 30 45 breast surgeons and we are in the process of you know just basically writing new guidelines new classification and hopefully evidencebased you know just treatment options of IGM the my person person observation is you know we need to have to establish basically in each Hospital IGM group and just we need basically multipl team group of know breast surgeons then just you know ID team Dermatology and rlist this is the essential we need to know from the initial point we need to follow up those patients properly this is the only way to treat you know the IGM patient it's very difficult very complicated it is really very mysterious disease and it might mimic cancer my strong suggestion to our audience you know from we have colleagues from different part of the work of course they you know conditions are different in different part of the work never you know trust your surgical experience and you know to op Direct directly you know just basically operate those patient we have cases you know just I've just heard about cases operated as a Cancer and at the end the histology came back showing you know just IGM so that's why it's very we never operate in this country but that's that's the key thing from n n the main idea from this today is that it the two cases I've seen look like cancer they were bed so many times five six CM got even bigger and worse but we sat tight on them it's a medical management for those they need the treatments and that's the KE key thing don't start chopping those areas out you'll see lots of the Middle East I don't know Victor do you see IGM in South America quite a bit or not is is it something that is often actually it's not that actually it's not that often last year I think we had maybe uh two one for sure two maybe but before that I mean the last M we had was about five years ago six years ago something like that is not that common and the the key thing is consensus would be great to have a consensus but we need more data and that's what also Maggie is doing and when we get more data and I think the target audience should not be mainly in in Europe you will not get lots of patients from Europe you might get some from the Eastern part of Europe eastern part of Mediterranean also in the subcontinent in the Middle East and when you get data then you don't only give consensus you can have more data to give better guidelines so data is very important part of the equation that is missing and because you you're we're basing things mainly on case reports and case series uh Ash you had your hand up so I think Maggie you go first and then I go after you thanks thanks a lot I was overwhelmed by by the number of questions that popped up in the chat so I have tried to answer most of them um it was a very important comment um by name and I believe as well that there is a high probability of spontaneous healing of IGM and I have seen cases that where I remember one patient 15 years ago she it was a very severe case of IGM and we have tried everything immunosuppressant and steroids and there was even some talk about a mastectomy because the patient was so well disappointed that that uh it doesn't go away and then at some point she just disappeared she she opted for um very unconventional therapy um outside of of evidence-based medicine it was some form of collagen gel that she received for a longer time and then when I have seen her again uh six months later the breast looked wonderful it looked normal there was no sign of IG so maybe it just healed spontaneously maybe it was this mysterious collagen gel that she has received uh no idea but there there is um a potential of self-healing here thank you for this comment self remitting isn't it Ash you say it is it is because I don't think the gel had anything to do with it it would have healed regardless of the gel but the question about when you do a study across different countries and different practices problem is going to be harmonizing what kind of tests have been done whether they tested for cor bacterium you know all that kind of so because it's data is rabish and rabish so you have to make sure especially when you're trying to get something like a consensus with Professor Nim is trying to do is you have to standardize what tests are done whether there's a trial of antibiotics given what treatment is given and then look at the outcomes because otherwise everyone does a little bit here and there and then you have this whole heterogenous data which doesn't make sense and maybe the consensus maybe just to look at what data should be collected one last little quick comment line before we go to the fiis because we have only 10 15 minutes left yeah I would like to tell so just and we need to really consensus meeting about it you know just we will map the treatment options properly evidencebased treat options after this Turkish consensus meeting results so we will publish it and I'm aiming to write you know just to our just Association breast surgeon president and to have National Audit here in UK to collect all total number of your migm cases and you know just you know and we might be Center there is a noric part the London North University Hospital as a IGM Center I think we have all the right because already the same Mark is for the basically inflammatory bowel disease Center so it will be very it's very interesting topic basically it requires a lot of research activities and we might specifically there was very interesting you know basically just learning for me in this Turkish consensus meeting one of the Turkish colleagues you know mentioned about Le treatment in just you know with a no recurrence in if I remember well in three years time that's quite interesting topic you know just really we need to be to have proper MDT team to decide about the treatment of all those cases it's time is a great healer and many of the times that's what you need for those patients and the lovely comment from Karen Barbosa the time heals the breast surgeon and the patient so it it just needs to needs some uh because also sometimes that the surgeons are a bit impatient and they rush into do doing things that are not always needed to be done now it's time for Michael and uh it's a lovely talk uh something that we rarely see uh it's good we have one on the mvt next week so it's a it's very well time talk so if if we have done the exision when you say you talk about margins what's a negative margin for for those is it just yeah like this is something that was quite difficult to standardize which I probably why I didn't include it in the talk is that there there doesn't appear to be an definition of margins um similar to the way we would Define margins with regard to invasive or pre-invasive disease I I think the a lot of the papers use the or zero or one or two margin definition which or zero means that you know this was clear or1 means that there was microscopic disease and or2 indicates really that you've left disease behind um I think the the the aim would be to get or zero margins but I think or one margins a lot of the newer papers have deemed acceptable if it if trying to achieve an or zero margin POS you know rate is going to leave the person with herend mous um cosmetic um deformities um I I think or two margins I think if you're going to do an operation or two margins are to be avoided but certainly or one margins um are I think acceptable you know at the um at the at the expense of of a better cosmetic result I haven't seen many of those I think we just exerc only one only recently has anybody seen lots of uh fosis or desmoids uh any anybody has seen anybody any patients recently because from the images that you're showing this can be very aggressive it's going to the chest wall so people end up with the huge excisions for something that is locally Advanced and the locally aggressive but it's not malignant uh is there case reports of it just invading through the chest and causing more major problems Michael yeah I mean certainly if you look at that Newman paper from Memorial or if you look at the um the the original b v group um which I think is from the Cy in Paris they they they described the number of their patients who they had to do mcto momies on they were involving you know um PEC reections and what you know the original kind of Halstead radical momies which are horrendously debilitating for patients um and I think you know that has really driven the the you know the the question about you know is this absolutely necessary and actually can we can we place these patients on active surveillance and the answer is yes to all they you know I think if that patient is on your MDT next week I would be saying you know that unless this is particularly aggressive or that that it looks like it's growing very very aggressively that that person should be surveyed at six-month intervals with MRIs um and if they um if they demonstrate significant progression then certainly surgery is an option but a lot of them you know 80% on the basis of the systematic review by Jim Bergen at all will stabilize and I think the other thing to say is that it's important if you have a sarom MDT try and put that patient through that um get a get a pathologist you know a dedicated p theologist to look at it um and also to get your medical oncologists involved because you know the taring kindness Inhibitors definitely do work as well I think she ended up on the C MDT said just take it out and let's see if let's confirm what it is and she has relatively close margins so I'm not sure if we're get accept there was a number there was a number of questions on the Q&A I don't think a diagnostic excision is unreasonable but I think you need to be very clear with patients that a diagnostic decision does not involve completely excising this I think sometimes a diagnostic exision is reasonable to actually prove that it is fibromatosis because some of the Pathologists find the actual diagnosis um challenging to make um but I think a diagnostic decision is completely different to going in and you know formally you know doing a wide local excision or myectomy for this uh and I think they they're they're the operations I think that the newer guidelines want to try and avoid any comments from anybody else from the AR you have your hand up um yes yes I just wanted to ask Mikel something about um the treatment of brosis I I've only seen one one of them in my life so I'm not very very experienced in that but I read recently about new methods uh like cre bless or focused ultrasound have you have you read anything about those has anyone tried them no and it's interesting I I I was going to put up a graphic similar to the um the graphic that was put up during the granus mtis talk that the fact that a lot of the Publications on these are are case reports um because it is so rare the series are very very small um and some patients or some some centers have put up things where they use different techniques certainly there's no strong evidence to support that um I think the active surveillance there is strong evidence to support it because there is you know level one evidence that supports um active surveillance and that it has at least you know the same efficacy as as uh intervening um so I I I I came across loads of different case reports suggesting different things none of which have have kind of a strong evidence base um so so I suppose no is the answer to that question and um thank you is there anything on the biopsy Michael that will tell us yeah this is better to take out or this is better just to monitor or no there's one very interesting paper that I actually didn't mention because again I thought it was probably going to open up another kind of wors but there is another one and I think this comes back to the Next Generation sequencing using circulating tumor DNA um to look at CTA ctnnb levels and if you have a high ctnnb um mutation level that that can predict patients who are going to require surgery down the line and I think going forward that's something that we may use to predict predict those who might require surgery versus those who can undergo active surveillance and the main three points you mentioned about exision is Young pain and getting larger yeah and I think it's the larger that one of the studies of the French group had said that seven centimeters above that if you see it at diagnosis it's likely that they're going to require an operation at some point so the smaller areas two or three centimeters are the ones where active surveillance seems to work quite well um patients who are younger unfortunately tend to have more aggressive disease and and one of the studies had referenced the fact that those who came in with discomfort within that abnormality and I think that indicates probably that there is some Invasion into the PEC or into the chess wall um you know again indicates that those patients may have more aggressive disease are likely to require surgical intervention anybody else do you have any uh questions or comments yeah just yeah I would like to tell something about you know really for the desb tumors of PR we don't have enough evidence you know to tell the truth to our patients you know my just experience was limited for abdominal wall desmoid tumors with high Recon rate of course they were more just painful than breast that there's more tumors I we don't know really the answer and it's quite interesting at least we have the option you know to refer to saroma unit and to have also their suggestion about it that's a good support as a breast surgeon for all of us here in UK I don't know what do they do this in the rest of the world but you know really we have more just uh publication we need more publication about it and we have a lot of question marks about you know again for the treatment of desb tumors at least now just the we have the metanalysis result the most recent one as my colleague expressed you know just we might avoid a lot of unnecessary operation on those cases but the problem is most of the time patients want they want to know the real evidence and they want and really we have the difficulties to answer their questions I don't know really I found it very difficult we don't have enough evidence that's a problem with the rare humors and that's why the idea from this is just to see how much we have and how much we don't have and sometimes it's just there's lots of judgment rather than evidence-based practices unfortunately but that's that's beautifully summarized by Michael about things that we can do for example I never knew there's a medical uh alternative not only surgery is an option and I knew that you can just monitor some of those tumors so it's eye opening uh talk with lots of uh uh great papers that were quoted Any final comments by anybody yes I would like to tell something yes and so for the IGM you know just we need to have please you know separate sessions we need to involve colleagues from Turkey from Iran and just you know I will share my our experience about the consensus meeting in Turkey because they have published a lot of of cases and just also hopefully till then we might have if we can manage to range UK you know the National Audit just I'll send the letter to uh just basic bre sege and president and we might have the chance to do it but definitely it will be very helpful and very good learning point for all of us if you can manage to organize it and I'll be more than happy you know to organize all speakers you know have a great experience because myself and h k from Turkey from the University from K turkey we will just also some Turkish colleagues you know will be delighted to contribute to that meeting and to offer their you know just experience that and that's perfect will work with lots of people from Turkey Turkey is like second home for us now we've been with bahadir and uh zafer and Abu and with lots of people so hopefully that will happen uh now since there's no other comments one key message so if you want to collect data on on IGM please contact Maggie also you can email me and I can make the connection with macki and hopefully Maggie maybe work with Naim in the future and on on this we have more data and maybe get some more information the next webinar is on the third of February it will be about the exilla we're still working on the speakers and the panelists so let you know as soon as and there'll be webinars also in in March uh I cannot thank you enough for being we're going to close na we're going I would like to tell something so we will need to close it's it's nearly 7 o'clock so may I say something many thanks for all the speakers many thanks for all the panelists for giving up your time on a Saturday afternoon it's nearly 7 o'clock now we still have 400 plus people online we had more than 600 again after all those webinars it's great to have those numbers again uh I will send you the certificates in the next few days so for people in the states and for the South America have a lovely day people for Europe have a good evening and for people from the Middle East and the Far East have a good night thank you everyone thank you bye-bye thank you