WEBVTT 1 00:00:10.000 --> 00:00:15.700 So thank you so much for inviting me to share 2 00:00:15.900 --> 00:00:21.500 my knowledge on this topic of fluorescence guided breast surgery. So 3 00:00:22.200 --> 00:00:25.800 let me give a brief introduction about myself then the topic and 4 00:00:25.800 --> 00:00:31.400 then we'll speak about the topic itself. So I 5 00:00:31.400 --> 00:00:36.600 am from a new generation of breast surgeons who are oncoplastic 6 00:00:36.600 --> 00:00:41.800 breast surgeons because now any breast surgery has become synonymous 7 00:00:41.800 --> 00:00:47.300 with oncoplastic breast surgery where we are not only aiming for oncological 8 00:00:47.300 --> 00:00:52.400 cure but we are also doing some adopted plastic 9 00:00:52.400 --> 00:00:57.900 surgery techniques to immediately restore the cosmesis of the breast thereby 10 00:00:57.900 --> 00:01:02.700 improving the quality as well as quantity of life for a woman. 11 00:01:03.500 --> 00:01:08.600 So after my breast after my general 12 00:01:08.600 --> 00:01:13.800 surgery and cancer surgery training I trained in specifically 13 00:01:13.800 --> 00:01:18.800 oncoplastic breast surgery from world-renowned mentors and now 14 00:01:18.800 --> 00:01:23.900 I am trying to provide one-stop clinic for all kinds of 15 00:01:23.900 --> 00:01:29.800 breast diseases where oncoplasty breast surgery is the 16 00:01:29.800 --> 00:01:34.900 focus of my practice. So as you know that breast surgery 17 00:01:34.900 --> 00:01:40.100 has undergone a paradigm shift. Rather oncology has undergone a paradigm 18 00:01:40.100 --> 00:01:45.600 shift and now we are in the era of organ-based oncology where 19 00:01:46.000 --> 00:01:51.500 each oncologist is devoted to a particular organ system 20 00:01:51.800 --> 00:01:58.800 and we do that to achieve excellence in our outcomes. We 21 00:01:58.800 --> 00:02:03.800 are in a litigious society as well. So our anything which 22 00:02:03.800 --> 00:02:08.900 improves our outcomes is has become the norm. Second most important 23 00:02:08.900 --> 00:02:13.700 paradigm shift in breast oncology is that now it is very well 24 00:02:13.700 --> 00:02:19.000 established breast conservation therapy which means breast conservation surgery 25 00:02:19.000 --> 00:02:24.100 plus radiotherapy to whole breast. BCT has 26 00:02:24.100 --> 00:02:29.800 superior survival in early breast cancer and an equal equivalent 27 00:02:29.800 --> 00:02:34.800 survival in advanced breast cancer as well barring a few exceptions 28 00:02:34.800 --> 00:02:39.800 like inflammatory breast cancer or some advanced breast cancers going into skin 29 00:02:39.800 --> 00:02:44.600 or involving a large area of the breast. So for Hollywood almost 30 00:02:44.600 --> 00:02:49.600 two-thirds of our cases breast we are able to do 31 00:02:49.600 --> 00:02:54.900 breast conservation and all over the world in 32 00:02:54.900 --> 00:03:00.300 centers of excellence they are able to achieve at least 50% 33 00:03:00.900 --> 00:03:06.400 breast conservation rate. In India however because almost 34 00:03:06.400 --> 00:03:11.800 two-thirds of our patients present in advanced stages so our national mastectomy 35 00:03:11.800 --> 00:03:16.000 rate is still 80%. We as a nation we only are able 36 00:03:16.000 --> 00:03:18.900 to conserve breast in 20% cases and we have a lot of 37 00:03:19.600 --> 00:03:23.300 other factors also which play into this but we are in the 38 00:03:23.300 --> 00:03:27.600 process of catching up and oncoplastic breast surgery is helping us do 39 00:03:27.600 --> 00:03:33.000 that by expanding the indications and feasibility 40 00:03:33.000 --> 00:03:38.400 of breast conservation. Another important paradigm shift is that 41 00:03:38.500 --> 00:03:44.000 we now know that breast cancer treatment is now a multimodality 42 00:03:44.000 --> 00:03:49.200 treatment. We are seeing innovations 43 00:03:49.300 --> 00:03:54.300 and newer targeted treatments in every subtype 44 00:03:54.300 --> 00:03:59.600 of breast cancer and now we have advanced systemic 45 00:03:59.600 --> 00:04:04.700 and target targeted treatments for hormone positive or to 46 00:04:04.700 --> 00:04:09.900 end range triple negative and triple positive breast cancer 47 00:04:09.900 --> 00:04:15.000 as well. So in this in today's era all breast cancer patients 48 00:04:15.500 --> 00:04:20.800 undergo surgery, some kind of systemic therapy or targeted therapy 49 00:04:21.300 --> 00:04:26.700 and radiotherapy. So all three treatments are needed. The sequencing depends on 50 00:04:27.000 --> 00:04:32.500 what is the stage of breast cancer and stage now includes 51 00:04:33.300 --> 00:04:37.800 not only the area which is involved by cancer but also the 52 00:04:37.800 --> 00:04:42.200 biology of breast cancer, what subtype it is. It's part of staging. 53 00:04:43.100 --> 00:04:48.800 And genomics and genetics has come up in a big way. Genomics 54 00:04:48.800 --> 00:04:53.800 scores are used to determine that what is the risk of local 55 00:04:53.800 --> 00:04:58.900 or distance distant recurrence in a particular breast cancer and that 56 00:04:58.900 --> 00:05:03.900 can help us you know stratifying which patients need more 57 00:05:04.000 --> 00:05:09.700 extensive treatment and in which patients we can de-escalate the treatment. Genetics, 58 00:05:10.000 --> 00:05:15.100 germline testing, somatic testing, germline is via blood, somatic 59 00:05:15.100 --> 00:05:20.200 is on the tissue for various targets for 60 00:05:20.200 --> 00:05:25.500 treatment and germline mutations, the risk that 61 00:05:25.500 --> 00:05:30.600 they impose on a particular patient. For example, BRCA mutations lead to 62 00:05:30.600 --> 00:05:34.800 hereditary breast and ovarian cancer syndrome and knowing that somebody has such 63 00:05:34.800 --> 00:05:40.800 kind of mutation can actually help us in formulating 64 00:05:41.000 --> 00:05:46.100 preventive risk reducing strategies for 65 00:05:46.100 --> 00:05:51.100 such patients including some surgical treatment options and some 66 00:05:51.100 --> 00:05:56.800 medical treatment options for reducing their risk, managing that risk. and 67 00:05:56.800 --> 00:06:00.400 the last and important paradigm is that as I said before that 68 00:06:00.400 --> 00:06:03.100 we are not only aiming for cure but we are also aiming 69 00:06:03.100 --> 00:06:08.300 for cosmesis and quality of life. So when we talk about 70 00:06:08.300 --> 00:06:14.300 breast cancer surgery, one important aspect is the breast 71 00:06:14.600 --> 00:06:19.800 reconstruction either partial or whole. And when we talk about axillary surgery, 72 00:06:19.800 --> 00:06:24.900 then preventing early identifying and treating 73 00:06:24.900 --> 00:06:30.000 lymphedema. So these are some of the aspects and here 74 00:06:31.000 --> 00:06:36.500 fluorescence guided breast surgery has really changed the landscape and 75 00:06:36.500 --> 00:06:41.900 helps us in achieving these targets. So 76 00:06:41.900 --> 00:06:45.600 what are the different game changers in breast surgery? So one is 77 00:06:45.600 --> 00:06:50.600 that we have seen evolution of advanced mammography techniques especially 3D 78 00:06:50.600 --> 00:06:55.700 mammography, auto more synthesis, contrast enhanced mammography CESM 79 00:06:56.800 --> 00:07:02.100 as well as MRI of the breast, dynamic contrast enhanced MRIs. 80 00:07:02.500 --> 00:07:07.900 So MR mammography. Now we have advanced biopsy techniques like 81 00:07:07.900 --> 00:07:13.000 stereotactic biopsies and also vacuum-assisted biopsies, 82 00:07:13.000 --> 00:07:18.000 MR guided biopsies. So contrast enhanced memo guided biopsies. 83 00:07:18.000 --> 00:07:23.000 So biopsy techniques have also evolved. We have scarless surgeries 84 00:07:23.000 --> 00:07:28.200 now. We have vacuum-assisted excisions for fibroadenomas or some papillary lesions 85 00:07:28.200 --> 00:07:33.300 or indeterminate lesions. ICG or 86 00:07:34.000 --> 00:07:38.800 fluorescence guided breast surgery. We're going to talk about this in more 87 00:07:38.800 --> 00:07:43.900 detail. And of course oncoplastic breast surgery team 88 00:07:44.400 --> 00:07:48.100 not only surgeon but you need a whole team to change the 89 00:07:48.100 --> 00:07:53.500 landscape of breast surgery that you're offering. So 90 00:07:53.600 --> 00:07:58.500 why fluorescence guided breast surgery? So if you look at the screen 91 00:08:00.100 --> 00:08:01.500 I saw this very interesting slide in one of the presentations in 92 00:08:04.200 --> 00:08:06.000 a conference that was I was attending Bristol and apparently 93 00:08:09.300 --> 00:08:10.900 this was a full-fledged profession being a knocker upper waking up people 94 00:08:13.400 --> 00:08:15.800 and now this profession is extinct. So you know Darwin 95 00:08:19.900 --> 00:08:25.000 and so unless we evolve we are responsive to change that 96 00:08:25.000 --> 00:08:30.100 profession becomes extinct. So fluorescence guided breast surgery 97 00:08:31.300 --> 00:08:36.400 came up I would say 5 10 years ago and now it 98 00:08:36.400 --> 00:08:41.400 has become the new normal in breast surgery. So let us talk 99 00:08:41.400 --> 00:08:47.200 a little bit about what is fluorescence guided breast surgery. So the 100 00:08:47.200 --> 00:08:52.300 commonest fluorescent dye that we use is indocyanine green. There 101 00:08:52.300 --> 00:08:57.000 are some other fluorescent dyes also. For example, fluorescein dye can be 102 00:08:57.000 --> 00:09:02.700 seen under a blue light and it has been researched by some 103 00:09:02.800 --> 00:09:07.800 Indian breast units because it is way more cost-effective. 104 00:09:08.000 --> 00:09:13.100 It has a learning curve but fluorescein dye also can 105 00:09:13.100 --> 00:09:18.200 be used for fluorescence guided breast surgery. What is more common is 106 00:09:18.200 --> 00:09:24.200 using indocyanine green dye. Indocyanine green lymphangiography 107 00:09:24.800 --> 00:09:29.400 is an imaging technique where we use this fluorescent dye to visualize 108 00:09:30.000 --> 00:09:35.000 a lymphatic system. B we can also do 109 00:09:35.000 --> 00:09:40.300 the angiography part where we can assess the vascularity. So this fluorescent 110 00:09:40.300 --> 00:09:45.400 dye for lymphangiography is injected into skin 111 00:09:45.700 --> 00:09:49.900 which can be skin of upper limb or it can be skin 112 00:09:49.900 --> 00:09:55.100 of breast and a specialized camera is used to visualize this 113 00:09:55.200 --> 00:10:00.400 dye, its flow and its distribution. And this is to 114 00:10:00.400 --> 00:10:05.500 see the lymphatics. Lymphatics travel to sentinel 115 00:10:05.500 --> 00:10:11.100 lymph nodes which are the you know which are the guardians 116 00:10:11.100 --> 00:10:16.100 of that lymph node basin and the rational behind 117 00:10:16.100 --> 00:10:21.000 sentinel lymph node biopsy is that if these sentinel lymph nodes are 118 00:10:21.000 --> 00:10:26.900 negative then this lymph node basin stage 119 00:10:28.100 --> 00:10:32.800 staging is also negative which means that that cancer has not reached 120 00:10:32.800 --> 00:10:36.900 this lymph node basin and when we talk about breast cancer we 121 00:10:36.900 --> 00:10:42.300 are talking about axillary lymph nodes. If you remember my last lecture 122 00:10:42.300 --> 00:10:46.900 we had discussed that axillary lymph nodes at our at various levels, 123 00:10:46.900 --> 00:10:51.000 level one, two, three and four and they are the next station 124 00:10:51.200 --> 00:10:57.100 for breast cancer metastasis. 125 00:10:57.100 --> 00:11:02.200 So breast cancer can be travel from breast to these axillary 126 00:11:02.200 --> 00:11:06.600 lymph nodes and 80% of breast lymphatics drain into axillary lymph nodes, 127 00:11:06.600 --> 00:11:11.700 20% drain into internal mammary. And there is a lot of variation 128 00:11:11.700 --> 00:11:18.300 also but generally axillary lymph nodes are 129 00:11:18.300 --> 00:11:23.400 staged via a surgery and clinically. So if 130 00:11:23.400 --> 00:11:30.200 the clinically clinical examination and on imaging like ultrasound also 131 00:11:31.000 --> 00:11:36.300 nowadays we do along with ultrasound and mammography we do. 132 00:11:36.300 --> 00:11:39.900 Sometimes we are doing MR mammography or we are also seeing lymph 133 00:11:39.900 --> 00:11:45.400 nodes on pet scan. So the most accurate clinical staging modality 134 00:11:45.600 --> 00:11:51.000 is ultrasound and ultrasound guided FNAC. So when this clinical staging 135 00:11:51.000 --> 00:11:56.000 is negative we designate that axillary lymph node basin as clinically 136 00:11:56.000 --> 00:12:01.300 node negative or CN0 as per TNM staging and in CN0 137 00:12:01.300 --> 00:12:06.100 cases doing sentinel lymph node biopsy which means we remove limited amount 138 00:12:06.100 --> 00:12:11.200 of lymph nodes. And if those lymph nodes are negative either 139 00:12:11.200 --> 00:12:15.400 on frozen section which is a common practice in India or in 140 00:12:15.500 --> 00:12:20.500 a western countries where frozen section is not so freely available. 141 00:12:20.900 --> 00:12:26.200 They sometimes look at the final report to designate 142 00:12:26.400 --> 00:12:31.700 a pathological stage. So if if the sentinel lymph nodes are 143 00:12:32.600 --> 00:12:37.600 negative then then then we stop at sentinel 144 00:12:37.600 --> 00:12:41.800 lymph node biopsy and we didn't need not do further axillary dissection. 145 00:12:42.300 --> 00:12:47.900 Now axillary staging and management of axilla is a separate 146 00:12:47.900 --> 00:12:53.700 topic. There are many changes. There is a trend towards de-escalation. 147 00:12:54.300 --> 00:12:59.000 I'll just give an example. So these days even if one or 148 00:12:59.000 --> 00:13:04.200 two sentinel lymph nodes are positive but the patient meets some specific 149 00:13:04.200 --> 00:13:09.900 criteria as per research then we can also not 150 00:13:09.900 --> 00:13:15.200 do a further axillary surgery or give axillary radiotherapy. So 151 00:13:15.200 --> 00:13:19.200 overall if I had to sum it up the management of axilla 152 00:13:19.200 --> 00:13:24.300 in breast cancer is currently 153 00:13:24.400 --> 00:13:29.800 undergoing de-escalation. So less is more. We want to do axillary 154 00:13:29.800 --> 00:13:35.200 surgery is necessary and which is accurate. 155 00:13:35.300 --> 00:13:40.500 So currently for sentinel lymph node biopsy which is removing limited number 156 00:13:40.500 --> 00:13:43.800 of lymph nodes which are sentinel lymph nodes and how do we 157 00:13:43.800 --> 00:13:48.800 identify this sentinel lymph nodes? We inject dye in the 158 00:13:48.900 --> 00:13:54.100 skin of the breast either intradermal or subcutaneous and 159 00:13:54.100 --> 00:13:59.300 then we visualize these lymphatics. Here's where fluorescence helps and 160 00:13:59.300 --> 00:14:03.100 these lymphatics travel to these sentinel lymph nodes which are then identified 161 00:14:03.100 --> 00:14:08.100 during surgery removed and there is a pathological assessment of 162 00:14:08.100 --> 00:14:13.600 these lymph nodes. So so ICG 163 00:14:13.700 --> 00:14:18.700 dye is given and there is a camera which did which detects 164 00:14:19.600 --> 00:14:24.800 ICG fluorescence. The other thing is that ICG 165 00:14:25.800 --> 00:14:31.300 it has low molecular weight. So it travels faster via lymphatics. 166 00:14:31.900 --> 00:14:36.000 So usually what we do is that we use two dyes a 167 00:14:36.000 --> 00:14:41.600 combination of methylene blue and ICG and we inject this dye either 168 00:14:42.000 --> 00:14:47.300 in periareolar location or peritumoral location. Periareolar 169 00:14:47.300 --> 00:14:52.300 is standard. You have to give 0.05 ml of 170 00:14:52.300 --> 00:14:57.000 indocyanine green intradermally at two places. If we have to give methylene 171 00:14:57.000 --> 00:15:02.200 blue it is can be given subcutaneously. Sometimes in some units 172 00:15:02.500 --> 00:15:07.200 methylene blue is also given intradermally in a smaller amount and lymphatics 173 00:15:07.200 --> 00:15:11.900 are visualized with the help of a camera which is a dedicated 174 00:15:11.900 --> 00:15:18.000 camera to detect this near infrared rays light. And 175 00:15:19.000 --> 00:15:24.200 the one of the limitations is that the near infrared rays usually 176 00:15:25.400 --> 00:15:30.600 can go up to only about 3 cm from skin surface. So 177 00:15:30.800 --> 00:15:33.000 you have there is a learning curve to this. You have to 178 00:15:33.000 --> 00:15:38.100 be really well versed with the technique and sometimes in obese patients 179 00:15:38.100 --> 00:15:43.200 it can be difficult to visualize lymphatics. So 180 00:15:43.200 --> 00:15:48.300 what are the different uses of this ICG lymphangiography or fluorescence 181 00:15:48.300 --> 00:15:53.700 in breast surgery? So one is as I said sentinel 182 00:15:53.700 --> 00:15:58.900 lymph node biopsy. Another use is that you can inject these 183 00:15:58.900 --> 00:16:03.100 dye in the web space of arm and you can actually do 184 00:16:03.100 --> 00:16:07.200 reverse axillary mapping. So you look at arm lymphatics and the flow 185 00:16:07.200 --> 00:16:12.800 of lymph in these arm lymphatics. You identify these lymphatics and safeguard 186 00:16:12.900 --> 00:16:19.000 these lymphatics while you are doing axillary lymph node dissection. Because 187 00:16:19.400 --> 00:16:24.000 when you do level three axillary lymph node dissection which is not 188 00:16:24.000 --> 00:16:29.000 done routinely there the lymphatics from axilla 189 00:16:30.100 --> 00:16:36.400 and lymphatics from arm can have some overlap. usually 190 00:16:36.500 --> 00:16:41.500 we do not go superior to axillary vein to avoid arm 191 00:16:41.500 --> 00:16:46.600 lymphatics but sometimes they have a variable course and when 192 00:16:46.600 --> 00:16:47.600 you do reverse axillary mapping you can actually avoid damaging these lymphatics 193 00:16:53.100 --> 00:16:58.100 from arm. If we damage the lymphatics then it 194 00:16:58.100 --> 00:17:03.200 can lead to lymphedema. This damage can be 195 00:17:03.200 --> 00:17:07.700 because of surgery. This damage can be because of radiation. So when 196 00:17:07.700 --> 00:17:12.000 we do axillary lymph node dissection routinely we do level one and 197 00:17:12.000 --> 00:17:15.300 one level two axillary lymph node dissection. Sometimes if we have gross 198 00:17:15.300 --> 00:17:19.200 nodes at level two then we also need to clear level three. 199 00:17:20.700 --> 00:17:26.100 Three and four are usually also treated with regional nodal irradiation 200 00:17:26.200 --> 00:17:31.100 radiotherapy. So routinely when we do level one and level two axillary 201 00:17:31.100 --> 00:17:36.300 lymph node dissection the incidence of lymphedema has come comes 202 00:17:36.300 --> 00:17:39.600 down but still it is in the literature it is quoted to 203 00:17:39.600 --> 00:17:44.500 be about 20%. So when we do sentinel lymph node biopsy this 204 00:17:44.500 --> 00:17:49.600 lymphedema rates come down to almost 5% or less than 205 00:17:49.600 --> 00:17:55.900 that. So that is why wherever possible 206 00:17:56.400 --> 00:18:01.100 if clinically if the axilla is negative then we try to do 207 00:18:01.200 --> 00:18:05.900 sentinel lymph node biopsy. And to do sentinel lymph node biopsy accurately 208 00:18:06.100 --> 00:18:11.200 we take help of these both dyes methylene blue and fluorescent 209 00:18:11.200 --> 00:18:16.800 dye which is ICG. Third use of ICG 210 00:18:16.800 --> 00:18:22.100 in axillary surgery is to do lymphovenous 211 00:18:22.200 --> 00:18:27.500 bypass. So in cases where we are doing axillary lymph node dissection 212 00:18:27.600 --> 00:18:32.900 especially level three where we know that we may be damaging 213 00:18:32.900 --> 00:18:37.500 the lymphatics via surgery and the patient is also going to need 214 00:18:38.000 --> 00:18:43.300 radiation. Then we do a preventive lymphovenous 215 00:18:43.300 --> 00:18:48.500 bypass which is called lympha. It's a micro vascular or or 216 00:18:48.500 --> 00:18:53.600 super micro surgery. And there to visualize the lymphatics we can use 217 00:18:53.900 --> 00:18:58.500 ICG dye. Again the way we do reverse axillary mapping we can 218 00:18:58.500 --> 00:19:02.600 give in ICG injection in the upper limb and we can visualize 219 00:19:02.600 --> 00:19:07.700 the lymphatics. And then the lymphatics can be 220 00:19:08.700 --> 00:19:12.800 we choose the appropriate lymphatic and then we connect it to a 221 00:19:12.800 --> 00:19:17.900 vein so that it has a the the cut or 222 00:19:17.900 --> 00:19:23.200 the damaged lymphatics are bypassed into venous circulation and lymphedema 223 00:19:23.200 --> 00:19:28.200 can be prevented. Secondary lymphedema surgery is when somebody has 224 00:19:28.200 --> 00:19:33.200 developed lymphedema as a sequelae of axillary surgery 225 00:19:33.200 --> 00:19:38.500 and now we want to treat this lymphedema. And we can also 226 00:19:38.500 --> 00:19:43.600 use ICG dye in our clinic to screen patients for 227 00:19:43.600 --> 00:19:48.300 lymphedema. So patients who have completed their treatment are and are on 228 00:19:48.300 --> 00:19:53.400 surveillance. They can be screened via ICG to check whether they have 229 00:19:53.400 --> 00:19:59.200 developed lymphedema when there is a clinical suspicion and the 230 00:20:00.400 --> 00:20:04.600 visualization of lymphatics on ICG also gives us an idea that how 231 00:20:05.000 --> 00:20:10.300 severe is lymphedema. And how what 232 00:20:10.300 --> 00:20:16.000 are what is the pattern of lymphatics. Now 233 00:20:16.000 --> 00:20:21.000 coming to the vascularity part when we give ICG intravenous 234 00:20:22.000 --> 00:20:27.800 3 ml then we are able to see the 235 00:20:27.800 --> 00:20:33.100 vascularity all over the body 236 00:20:33.200 --> 00:20:38.200 and when we focus on breast or wherever you we 237 00:20:38.200 --> 00:20:42.000 are doing reconstruction we are able to see the vascularity of that 238 00:20:42.100 --> 00:20:47.100 area and not only qualitatively but also. These 239 00:20:47.100 --> 00:20:51.900 days the ICG camera has quantitative function where it can show us 240 00:20:52.300 --> 00:20:57.400 the quantitative perfusion when we compare it with the 241 00:20:57.400 --> 00:21:02.300 normal tissue. So this assessment is helpful when we are trying to 242 00:21:02.300 --> 00:21:07.700 see the skin vascularity or nipple areola complex vascularity or 243 00:21:07.800 --> 00:21:13.300 if we have taken a pedicled flap or then we are able 244 00:21:13.300 --> 00:21:17.400 to visualize how vascular the flap is and what are the areas 245 00:21:17.400 --> 00:21:20.400 which are not well vascularized and we are able to see this 246 00:21:20.400 --> 00:21:25.100 in real time and suppose if we are we are doing a 247 00:21:25.100 --> 00:21:29.600 perforator flap surgery and we see that some area of that flap 248 00:21:29.600 --> 00:21:33.600 is not well vascularized then we can actually trim that area and 249 00:21:33.600 --> 00:21:38.800 save the patient from complications like fat necrosis or infection 250 00:21:40.400 --> 00:21:45.500 developing because of such flap necrosis. And in 251 00:21:45.500 --> 00:21:51.300 this way fluorescence guided guidance is able to enable 252 00:21:51.700 --> 00:21:56.600 a variety of oncoplastic breast surgery procedures. So now we just going 253 00:21:56.600 --> 00:22:01.700 to see some examples. So here is an an example. 254 00:22:01.900 --> 00:22:06.900 So this particular case was challenging because 255 00:22:07.400 --> 00:22:12.700 this patient had already undergone biopsy. 256 00:22:13.600 --> 00:22:19.000 And somebody did a biopsy surgically thinking that it's 257 00:22:19.000 --> 00:22:23.400 a fibroadenoma and it was in fact a triple negative breast cancer 258 00:22:23.400 --> 00:22:28.200 which was mimicking the fibroadenoma. And I would like to highlight that 259 00:22:28.600 --> 00:22:34.000 they had also done a core needle biopsy. The biopsy was 260 00:22:34.700 --> 00:22:39.900 actually inconclusive and it was a case of radiopathological discordance 261 00:22:39.900 --> 00:22:44.900 where on radiologically there was some suspicion that whether is this 262 00:22:44.900 --> 00:22:50.700 really fibroadenoma but the biopsy was not you 263 00:22:50.700 --> 00:22:55.800 know in in agreement. So in such cases nowadays ideally we do 264 00:22:55.800 --> 00:22:59.900 a repeat core needle biopsy or we do vacuum-assisted biopsy at times 265 00:23:00.000 --> 00:23:04.100 but somehow I mean this this patient then landed up to our 266 00:23:04.100 --> 00:23:09.800 center and we planned breast conservation 267 00:23:09.800 --> 00:23:15.800 surgery for her where we had revised the margins and because 268 00:23:15.800 --> 00:23:20.500 she was clinically node negative we wanted to do a sentinel lymph 269 00:23:20.500 --> 00:23:26.100 node biopsy. Now normally it is challenging because a 270 00:23:26.100 --> 00:23:29.400 scar in the upper outer quadrant can really disrupt the flow of 271 00:23:29.400 --> 00:23:33.900 lymphatics but it as you can see that snail which is sentinel 272 00:23:33.900 --> 00:23:38.800 lymph node biopsy after initial axillary surgery is quite feasible. There are 273 00:23:38.800 --> 00:23:44.100 many centers from India which have reported such kind of surgeries. And 274 00:23:44.100 --> 00:23:48.900 it's feasible, it's accurate and with ICG this kind of surgery can 275 00:23:48.900 --> 00:23:53.000 be done. So on the bottom of the screen you can see 276 00:23:53.200 --> 00:23:58.500 sentinel lymph nodes. And this is color segmented mode of ICG 277 00:23:58.500 --> 00:24:04.400 camera where you know you can differentiate between fat 278 00:24:04.400 --> 00:24:09.400 and lymph node where the lymph node is shown 279 00:24:09.400 --> 00:24:15.100 the is there is a red dot. And lymphatics or fat 280 00:24:15.100 --> 00:24:20.300 are in a different color. As 281 00:24:20.300 --> 00:24:24.300 I said the principle of axillary surgery these days is less is 282 00:24:24.300 --> 00:24:29.400 more. We do aggressive axillary surgery only leads 283 00:24:29.400 --> 00:24:35.200 to morbidity. You can see this clinical picture. This patient had 284 00:24:35.200 --> 00:24:37.200 undergone breast cancer breast cancer surgery in some other center and later 285 00:08:01.500 --> 00:08:04.200 on she developed distant metastasis and now she reported to our center 286 00:08:06.000 --> 00:08:09.300 for palliation but you can see that this aggressive axillary surgery has 287 00:08:10.900 --> 00:08:13.400 not really helped her survival or in her cure but was only 288 00:08:15.800 --> 00:08:19.900 given her morbidity in terms 289 00:41:37.900 --> 00:41:39.900 of right arm lymphedema and her quality of life was affected by 290 00:25:04.100 --> 00:25:09.400 this. So we need to do axillary surgery which 291 00:25:09.400 --> 00:25:14.400 is necessary and accurate enough. Less is more. 292 00:25:14.800 --> 00:25:20.200 So this is how a sentinel lymph node looks through 293 00:25:20.200 --> 00:25:25.200 ICG camera. You see bright a spot that is 294 00:25:25.200 --> 00:25:31.600 the fluorescent lymph node. And below there is a 295 00:25:31.600 --> 00:25:36.600 blue node courtesy methylene 296 00:25:36.600 --> 00:25:40.300 blue. So this is how we do dual dye sentinel lymph node 297 00:25:40.300 --> 00:25:44.300 biopsy. We pick up nodes which are blue and which are fluorescent. 298 00:25:44.700 --> 00:25:49.900 Apart from this if you find any grossly enlarged or indurated 299 00:25:49.900 --> 00:25:55.300 lymph nodes so that that is also taken out but usually 300 00:25:55.300 --> 00:26:00.800 dual dye method is accurate and false 301 00:26:00.800 --> 00:26:06.200 negative rate of dual dye method is below 10% which is acceptable. 302 00:26:08.200 --> 00:26:13.000 This is how you inject methylene blue when you are trying to 303 00:26:13.000 --> 00:26:18.000 visualize arm lymphatics. And on the bottom of the screen there 304 00:26:18.000 --> 00:26:23.000 is a picture of our reconstructive surgeon who is doing 305 00:26:23.900 --> 00:26:29.300 super microsurgery. It's a lymphovenous bypass on on his microscope 306 00:26:29.300 --> 00:26:33.900 screen. You can see that the a lymph lymphatic is connected to 307 00:26:33.900 --> 00:26:38.900 a vein. The result is that we are able 308 00:26:38.900 --> 00:26:44.000 to do aggressive axillary surgery in some 309 00:26:44.000 --> 00:26:48.100 situations where we are cornered like this one case which had high 310 00:26:48.100 --> 00:26:53.100 nodal burden in axilla and she was not responding very well to 311 00:26:53.100 --> 00:26:56.800 chemotherapy. You see we were forced to do an aggressive axillary surgery 312 00:26:56.800 --> 00:27:02.200 but with lympha which was guided by ICG 313 00:27:02.200 --> 00:27:08.500 dye. We are able to avoid lymphedema. This 314 00:27:08.500 --> 00:27:13.800 is these are cases where we have done vascularity assessment. So upper 315 00:27:13.800 --> 00:27:19.300 picture is a normal MRM or mastectomy 316 00:27:19.300 --> 00:27:22.900 flap and you can see how you can see the blood vessels 317 00:27:23.000 --> 00:27:28.800 in the flap, MRM flap and chest wall and abdominal wall. And 318 00:27:28.900 --> 00:27:34.200 below this is a perforator flap skin paddle. 319 00:27:35.200 --> 00:27:40.400 And you can see that the quantitative perfusion. 320 00:27:40.600 --> 00:27:46.100 So quantitative perfusion you also get a number. Anything more than 40% 321 00:27:46.100 --> 00:27:50.300 will survive and there is also color segmented mode where everything which 322 00:27:50.300 --> 00:27:53.700 is red, green and blue will survive. If there is something which 323 00:27:53.700 --> 00:27:59.200 is gray then you have to trim it off. And with that 324 00:27:59.200 --> 00:28:04.200 we are able to do partial and whole breast reconstruction. So these 325 00:28:04.200 --> 00:28:09.200 are two cases. So this is one case where we 326 00:28:09.200 --> 00:28:15.000 have done skin sparing mastectomy and LD and implant-based 327 00:28:15.000 --> 00:28:20.100 reconstruction. She developed marginal flap necrosis which 328 00:28:20.100 --> 00:28:26.400 gave a ragged scar but overall the symmetry 329 00:28:26.600 --> 00:28:31.600 and the contour of the breast was acceptable. And 330 00:28:31.600 --> 00:28:36.000 on the other side there is a case. Again somebody did an 331 00:28:36.000 --> 00:28:41.200 incision and drainage in fact in this young patient thinking that the 332 00:28:41.200 --> 00:28:43.800 lump that she has is a breast abscess but it was again 333 00:28:43.800 --> 00:28:48.300 a triple negative breast cancer. So in because she was node positive 334 00:28:48.500 --> 00:28:54.100 we gave her chemotherapy first. And these days remember 335 00:28:54.100 --> 00:28:59.900 that triple negative breast cancer and her to enrich breast cancer. We 336 00:29:00.000 --> 00:29:05.100 tend to give chemotherapy first even in node negative small tumors because 337 00:29:05.500 --> 00:29:11.200 the biologically they are very well responsive to chemotherapy 338 00:29:11.200 --> 00:29:15.400 and the outcomes are better if we give chemo first. So this 339 00:29:15.400 --> 00:29:20.500 was triple negative breast cancer. Somebody had done incision and drainage on 340 00:29:20.500 --> 00:29:26.000 her. Then we gave some chemotherapy. And then we did nipple 341 00:29:26.000 --> 00:29:32.200 sparing mastectomy for her. You can see the specimen from 342 00:29:32.200 --> 00:29:40.700 a previous surgery where of a skin sparing mastectomy. And 343 00:29:43.300 --> 00:29:46.900 I don't have the photo of specimen for nipple sparing mastectomy but 344 00:29:47.000 --> 00:29:52.400 this is her final result. So again we did LD 345 00:29:52.400 --> 00:29:57.500 flap and implant-based reconstruction for her. And our goal here to was 346 00:29:57.500 --> 00:30:02.500 to achieve in bra symmetry. And this is the 347 00:30:03.600 --> 00:30:08.600 ICG vascularity assessment in this case. We had done 348 00:30:08.600 --> 00:30:13.900 a map. So this is via one other machine 349 00:30:14.500 --> 00:30:19.700 and other camera, other technology for ICG assessment. So they 350 00:30:19.800 --> 00:30:24.200 they give a map of vascularity and you can see that her 351 00:30:24.200 --> 00:30:29.400 flap is well perfused. So 352 00:30:29.400 --> 00:30:33.400 this is the other case where we did sentinel lymph node biopsy 353 00:30:33.500 --> 00:30:38.600 after an initial surgery and we also did correct 354 00:30:38.600 --> 00:30:44.000 her cosmetic defect from first biopsy by doing a perforator flap 355 00:30:44.100 --> 00:30:49.800 for her. And you can see where I've injected ICG dye and 356 00:30:49.800 --> 00:30:55.100 her perforator flap vascularity was assessed via giving intravenous 357 00:30:55.100 --> 00:31:00.100 ICG as well. So last part is about how ICG 358 00:31:00.100 --> 00:31:03.400 enables oncoplastic breast surgery. So I'm just going to show you some 359 00:31:04.400 --> 00:31:09.400 results of oncoplastic breast surgery. So no more 360 00:31:09.400 --> 00:31:14.300 traditional breast surgery and traditional surgeons. So we should not be seeing 361 00:31:14.300 --> 00:31:19.400 cases like this where breast conservation was done with traditional 362 00:31:19.500 --> 00:31:25.200 breast conservation surgery. Traditional breast conservation surgery leaves seromas 363 00:31:26.000 --> 00:31:31.000 and seromas get fried with radiotherapy and you have this poor cosmesis. 364 00:31:31.400 --> 00:31:35.800 And such kind of breast conservations are actually I mean it's better 365 00:31:35.800 --> 00:31:39.700 to do a mastectomy than to do breast conservation like this but 366 00:31:39.800 --> 00:31:44.900 these cases used to happen unfortunately still happen. 367 00:31:45.200 --> 00:31:48.300 On the left side you can see a big seroma under a 368 00:31:48.300 --> 00:31:53.300 mastectomy flap and you know these these are the 369 00:31:53.300 --> 00:31:58.900 kind of surgeries which should not be done now. So 370 00:32:00.700 --> 00:32:05.300 all breast surgeries need to be oncoplastic breast surgeries. Even when you 371 00:32:05.300 --> 00:32:10.000 are removing a small portion less than 20% volume of breast you 372 00:32:10.000 --> 00:32:15.000 should not be leaving behind seromas. You should be taking lipoglandular 373 00:32:15.000 --> 00:32:19.700 flaps and you should be closing that cavity so that your cosmesis 374 00:32:20.100 --> 00:32:23.600 is excellent on the day of surgery as well as one year 375 00:32:23.600 --> 00:32:28.600 after surgery when they're done with radiotherapy. So current standard is 376 00:32:28.600 --> 00:32:34.300 doing oncoplastic breast conservation surgery where you have minor 377 00:32:34.400 --> 00:32:40.200 cosmetic problems but overall you should have you 378 00:32:40.200 --> 00:32:45.900 should have symmetry and the contour of the breast should match. So 379 00:32:45.900 --> 00:32:51.900 no more seroma cavities. Again you can see the ICG staining where 380 00:32:51.900 --> 00:32:56.300 we have you know injected ICG dye for sentinel lymph node biopsy. 381 00:32:57.200 --> 00:33:02.400 This is again a revision surgery. So a lumpectomy 382 00:33:02.400 --> 00:33:05.700 was done thinking that this is some benign breast disease and then 383 00:33:05.700 --> 00:33:09.000 it turned out to be a mucinous CA breast which is a 384 00:33:09.000 --> 00:33:15.000 good biology disease. And there was a lower central 385 00:33:15.000 --> 00:33:19.300 quadrant defect left by the first surgery which we corrected by doing 386 00:33:19.300 --> 00:33:21.300 a perforator flap based on the chest wall perforators. So such surgeries 387 00:16:47.600 --> 00:16:53.100 are possible because of taking fluorescence guidance. It 388 00:33:32.800 --> 00:33:38.100 helps it it gives more information 389 00:33:38.100 --> 00:33:43.200 over and above our clinical judgment so as to optimize our results, 390 00:33:43.200 --> 00:33:48.400 minimize the complications with some oncoplastic 391 00:33:48.400 --> 00:33:53.400 techniques like therapeutic mammaplasty which is a volume displacement technique. 392 00:33:55.700 --> 00:34:00.200 We do breast volume reduction as well as we displace the breast 393 00:34:00.200 --> 00:34:04.700 volume in such a way that we achieve better looking breasts. So 394 00:34:05.300 --> 00:34:10.300 this case she had large trotting breast on one side. There was 395 00:34:10.300 --> 00:34:15.100 breast cancer. On another side side there was a benign phyllodes tumor. 396 00:34:15.600 --> 00:34:20.600 And by doing bilateral therapeutic mammaplasty we are not only we were 397 00:34:20.600 --> 00:34:25.800 able to treat breast cancer, remove benign phyllodes but leave her with 398 00:34:25.900 --> 00:34:30.200 better looking breasts. So this is therapeutic mammaplasty is one of the 399 00:34:30.200 --> 00:34:35.900 oncoplastic breast techniques. We have adopted 400 00:34:35.900 --> 00:34:41.000 this procedure of breast reduction or mammaplasty from plastic surgeons. 401 00:34:41.500 --> 00:34:47.000 And we use it in therapeutic for 402 00:34:47.000 --> 00:34:52.500 therapeutic indication like treating breast cancer or treating breast 403 00:34:52.500 --> 00:34:57.600 disease like phyllodes. So another 404 00:34:57.800 --> 00:35:02.800 important oncoplastic technique is a volume replacement technique where you replace the 405 00:35:02.800 --> 00:35:08.100 volume. So generally this is done in small or medium 406 00:35:09.200 --> 00:35:14.200 breast which are not very trotting. So there we 407 00:35:14.200 --> 00:35:19.200 use volume replacement. And it also depends that how much volume 408 00:35:19.200 --> 00:35:24.400 you are going to remove. So anything up to 20% 409 00:35:24.400 --> 00:35:28.600 is okay but 20 to 50% you need to do type two 410 00:35:28.900 --> 00:35:34.200 oncoplastic procedures. So type two oncoplastic procedures can be either volume 411 00:35:34.500 --> 00:35:38.900 displacement or replacement and this is one of the volume replacement techniques. 412 00:35:39.300 --> 00:35:43.700 So on the left this is a my cap flap. It is 413 00:35:43.700 --> 00:35:48.100 one of the chest wall perforator flaps. My cap helps us in 414 00:35:48.100 --> 00:35:53.200 replacing the volume that we have removed from lower inner 415 00:35:53.200 --> 00:35:58.400 quadrant. And on the right side is a design for lateral chest 416 00:35:58.400 --> 00:36:03.600 wall perforator flap. So women generally have redundant skin 417 00:36:03.600 --> 00:36:09.100 and soft tissue on lateral side of their chest wall. And 418 00:36:09.100 --> 00:36:15.300 it can be used to replace volumes from almost 419 00:36:15.300 --> 00:36:20.400 all quadrants. So this is lateral chest wall perforator flap and anterior 420 00:36:20.400 --> 00:36:25.300 chest wall perforator flap. This is again a very interesting case. This 421 00:36:25.300 --> 00:36:30.600 lady had a huge huge 1.8 kg tumor 422 00:36:32.000 --> 00:36:35.800 which was very close to her skin in the upper half of 423 00:36:35.800 --> 00:36:41.000 the breast. And thankfully the it was again a mucinous tumor with 424 00:36:41.000 --> 00:36:46.200 good biology. So we have done a nipple sparing mastectomy and 425 00:36:46.200 --> 00:36:52.100 with LD flap and implant-based reconstruction. So her 426 00:36:54.400 --> 00:36:59.400 right breast is non-totic because there is 427 00:37:00.000 --> 00:37:05.000 implant-based reconstruction there. We had tried to counsel her about opposite breast 428 00:37:05.000 --> 00:37:10.700 reduction but it it's difficult in some women. So she 429 00:37:10.800 --> 00:37:16.800 still has very good infra symmetry. And we were able to save 430 00:37:18.200 --> 00:37:23.100 her nipple and her skin envelope and replace some skin and volume 431 00:37:23.100 --> 00:37:27.500 with the help of LD flap and an implant. So when we 432 00:37:27.500 --> 00:37:32.500 are doing such complex reconstructions there we need fluorescence 433 00:37:32.500 --> 00:37:37.700 guidance to be sure that the to make sure that the vascularity 434 00:37:37.700 --> 00:37:42.800 of our flap, the nipple, the the 435 00:37:42.900 --> 00:37:49.600 skin of breast it is all intact. So 436 00:37:51.700 --> 00:37:55.900 it is not a one-person job. And you need the whole team 437 00:37:55.900 --> 00:38:01.100 with you radiologist, oncopathologist, anesthetist. 438 00:38:01.800 --> 00:38:06.800 You need plastic and reconstructive surgeons with you. Your oncology team, 439 00:38:06.800 --> 00:38:11.900 medical and radiation oncologists. So just having 440 00:38:11.900 --> 00:38:17.200 one technology is not going to change anything 441 00:38:17.300 --> 00:38:23.200 but having multiple technologies can lead to this 442 00:38:23.200 --> 00:38:26.400 this kind of paradigm shift where you're able to do these advanced 443 00:38:26.400 --> 00:38:31.400 procedures. So only ICG is not enough. You also need so many 444 00:38:31.400 --> 00:38:36.400 other things. You need intraoperative radpath margin guidance. You need 445 00:38:37.700 --> 00:38:42.800 radiologist to do intraoperative ultrasound, specimen mammography. You need 446 00:38:42.800 --> 00:38:48.400 a PACS system. You need onco anesthetics and to protect 447 00:38:49.000 --> 00:38:54.000 and your oncological and your cosmetic outcomes. You 448 00:38:54.000 --> 00:38:59.800 need a radiation oncologist which is oriented in oncoplastic breast surgery. So 449 00:39:01.600 --> 00:39:05.500 so this was all about this game changer which is fluorescence breast 450 00:39:05.500 --> 00:39:10.700 surgery and thanks to ICG lymphangiography and ICG cameras which have come. 451 00:39:11.100 --> 00:39:16.600 There are at least two companies who 452 00:39:16.600 --> 00:39:21.100 in India which make you know one is a made in India 453 00:39:21.100 --> 00:39:26.100 company. And another is foreign company but both both 454 00:39:26.100 --> 00:39:31.000 machines are available in India and all the breast centers have adopted 455 00:39:31.600 --> 00:39:36.900 ICG lymphangiography to do these kind of advanced breast cancer surgeries. And 456 00:39:36.900 --> 00:39:41.200 what is the next game changer? It is robotic or minimally invasive 457 00:39:41.200 --> 00:39:45.600 breast surgery. So maybe in next lecture we will talk about that. 458 00:39:46.600 --> 00:39:52.300 So you all know my oncoplastic journey. So 459 00:39:53.800 --> 00:39:58.000 I'm just going to skip right through. It is mainly because find 460 00:39:58.000 --> 00:40:03.100 find your organ, find your mentors, find your team, find yourself, 461 00:40:03.200 --> 00:40:08.200 find your tribe. And find what you represent. So thank 462 00:40:08.200 --> 00:40:12.400 you so much. You know where to reach me. I am available 463 00:40:12.400 --> 00:40:17.900 on being breast aware which is a Instagram campaign for breast 464 00:40:17.900 --> 00:40:23.300 health awareness and I look forward to your questions. Thank you. So 465 00:40:23.300 --> 00:40:27.700 mam to begin with the first question is how is fluorescence guided 466 00:40:27.700 --> 00:40:32.800 breast surgery? The process the procedure different from 467 00:40:32.800 --> 00:40:37.800 the traditional method of breast surgery. Okay. Yeah 468 00:40:37.800 --> 00:40:42.700 mam. So how is it different from the traditional techniques and what 469 00:40:42.700 --> 00:40:47.700 is your take on like whether to opt for it or what 470 00:40:47.700 --> 00:40:52.700 is your take on that? So when we I mean when this 471 00:40:52.700 --> 00:40:58.100 surgery started so initially this technology was not available 472 00:40:58.600 --> 00:41:03.600 everywhere. So clinical judgment for example, 473 00:41:03.600 --> 00:41:08.800 when you're doing a flap then you you know as when 474 00:41:08.800 --> 00:41:12.600 I was doing my residency you would check for thermal bleeding points. 475 00:41:12.800 --> 00:41:18.100 So there are various methods to assess flap vascularity. And with respect 476 00:41:18.100 --> 00:41:21.200 to so when we talk about fluorescence we have to talk about 477 00:41:21.300 --> 00:41:26.300 one is lymphatic surgery which is the axillary surgery and the 478 00:41:26.300 --> 00:41:31.300 other part is assessing vascularity, the breast or the flap vascularity. 479 00:41:31.800 --> 00:41:36.700 So the traditional methods of assessing flap vascularity like you know looking 480 00:41:36.700 --> 00:41:37.900 for the edge bleeding or you know scratching the flap and seeing 481 00:41:41.400 --> 00:41:45.500 what is the how it bleeds. So those were the traditional methods. 482 00:41:45.800 --> 00:41:49.900 Those still hold true because you know this kind of technology is 483 00:41:49.900 --> 00:41:56.500 only available in you know tier one cities. And 484 00:41:57.500 --> 00:42:02.000 few breast centers they're not available everywhere. So I would I would 485 00:42:02.000 --> 00:42:06.800 say that clinical judgment is important. And it it is here to 486 00:42:06.800 --> 00:42:12.200 stay. These are additional methods but yes because you 487 00:42:12.200 --> 00:42:16.900 know something like quantitative perfusion is something which we can only do 488 00:42:16.900 --> 00:42:22.400 with the help of technology. Similarly in lymphatic visualization 489 00:42:22.700 --> 00:42:26.700 we there are many dyes. So for example, methylene blue is one 490 00:42:26.700 --> 00:42:30.400 dye which was used to you know the way we give ICG 491 00:42:30.400 --> 00:42:34.900 we can give methylene blue dye and visualize the lymphatics. So it 492 00:42:34.900 --> 00:42:41.400 it still has a role. But ICG 493 00:42:42.300 --> 00:42:48.300 is in in some ways ICG is better for lymphatic visualization. So 494 00:42:48.400 --> 00:42:53.500 these are supplementary or additional. This 495 00:42:53.500 --> 00:43:00.700 is an additional way to assess for lymphatics and vascularity. All 496 00:43:00.700 --> 00:43:04.300 right mam. Mam so moving on to the next question that is 497 00:43:04.300 --> 00:43:09.300 are there any emerging fluorescent agents or technologies that shows 498 00:43:09.300 --> 00:43:15.100 promise for improving FGVS outcomes in near future? So 499 00:43:15.100 --> 00:43:20.400 as I said that fluorescein is also being adopted because fluorescein to 500 00:43:20.400 --> 00:43:25.700 visualize fluorescein you just need a particular blue blue light lamp 501 00:43:26.100 --> 00:43:31.100 which is way more cost-effective and so that is also being researched 502 00:43:31.100 --> 00:43:36.200 and adopted in India. It just has a a little more 503 00:43:37.300 --> 00:43:43.800 intense learning curve. All 504 00:43:43.800 --> 00:43:47.000 right mam. Mam with this I would like to conclude today's session. 505 00:43:47.000 --> 00:43:49.600 Thank you so much for your time even in this busy and 506 00:43:49.600 --> 00:43:53.100 hectic schedule. You took out time and you have delivered such an 507 00:43:53.100 --> 00:43:56.900 insightful session. Really looking forward to hosting you again and thank you 508 00:43:56.900 --> 00:44:00.300 so much for being here on our platform mam. You're welcome. Thank 509 00:44:00.300 --> 00:44:00.500 you.