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🏥 NEET PG / INICET RAPIDO REVISION NOTES

SURGERY - BREAST

From Bailey & Love, Sabiston, S Das, Robbins

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📌 QUICK ORIENTATION - WHAT EXAMS ASK MOST

"Breast is a HIGH-YIELD topic - expect 4-6 questions per NEET PG. Focus on: ANDI concept, risk factors, TNM staging, DCIS vs LCIS, surgical options, sentinel node, hormone receptors, and Paget's disease."

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SECTION 1: SURGICAL ANATOMY (Bailey & Love, Sabiston)

🔑 Key Points

🧠 MNEMONIC: "BREAST"

B - Blood supply: Internal mammary (medial 2/3) + Lateral thoracic (lateral 1/3) R - Retromammary space (between breast and fascia - rich in lymphatics) E - Extension = Axillary tail of Spence (extends into axilla through foramen in deep fascia) A - ANDI concept (Aberrations of Normal Development and Involution) S - Suspensory ligaments of Cooper T - TDLU = Terminal Duct Lobular Unit (origin of most cancers)

Lymphatic Drainage (HIGH YIELD!)

┌─────────────────────────────────────────────┐
│           BREAST LYMPH DRAINAGE             │
│                                             │
│  Lateral 75% ──→ Axillary nodes (Level I,  │
│                   II, III)                  │
│  Medial 25%  ──→ Internal mammary nodes    │
│                                             │
│  AXILLARY NODE LEVELS:                      │
│  Level I  = Lateral to pectoralis minor     │
│  Level II = Behind pectoralis minor         │
│  Level III= Medial to pectoralis minor      │
│             (infraclavicular/subclavian)     │
│                                             │
│  Rotter's nodes = between pec major & minor │
│  (Interpectoral nodes)                      │
└─────────────────────────────────────────────┘

⭐ PYQ (NEET PG 2019): Level III axillary lymph nodes are located? → Medial to pectoralis minor

⭐ PYQ: Rotter's nodes are located between? → Pectoralis major and pectoralis minor

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SECTION 2: BENIGN BREAST DISEASE - ANDI CONCEPT

ANDI Framework (Bailey & Love, Cardiff Breast Clinic)

┌──────────────────────────────────────────────────────────────┐
│                     ANDI TABLE                               │
│                                                              │
│  Phase          │  Normal Process    │  Aberration          │
│─────────────────┼────────────────────┼──────────────────────│
│  Development    │  Lobule formation  │  Fibroadenoma        │
│  (15–25 yrs)    │  (15-25 yrs)       │                      │
│─────────────────┼────────────────────┼──────────────────────│
│  Cyclical       │  Hormone-driven    │  Cyclical mastalgia   │
│  change         │  epithelial        │  Nodularity          │
│  (15–50 yrs)    │  proliferation     │                      │
│─────────────────┼────────────────────┼──────────────────────│
│  Involution     │  Stromal           │  Macrocysts          │
│  (35–55 yrs)    │  involution,       │  Sclerosing adenosis │
│                 │  lobular           │  Duct ectasia        │
│                 │  involution        │  Periductal mastitis  │
└──────────────────────────────────────────────────────────────┘

⭐ PYQ (INICET): ANDI concept was given by? → Cardiff Breast Clinic (Baum & Hughes)

A. Fibroadenoma

⭐ PYQ (NEET PG 2018): Most common benign tumor of breast in young women? → Fibroadenoma

⭐ PYQ: "Breast mouse" is? → Fibroadenoma (because it slips away from palpating fingers)

B. Breast Cysts (Bailey & Love)

• Peak incidence: 40-50 years, perimenopausal
• Involutional phase of ANDI
• Blue-domed cysts (Bloodgood's cysts) - tensely filled, translucent
• Aspirate: clear to green/brown fluid
• If bloody aspirate or no fluid - must excise

⭐ PYQ: Blue-domed cyst of breast is also called? → Bloodgood's cyst

C. Sclerosing Adenosis

• Proliferative phase; mimics carcinoma clinically AND radiologically
• No increased cancer risk by itself
• Can look like carcinoma on mammogram (microcalcifications)

D. Duct Ectasia / Periductal Mastitis

E. Breast Abscess

• Acute lactational: S. aureus (MC organism); Streptococcus
• Management: Incision & drainage OR needle aspiration + antibiotics
• Non-lactational: periareolar (young women + smokers); peripheral abscess

ABSCESS DRAINAGE FLOWCHART:
┌──────────────────────────────────────────┐
│           BREAST ABSCESS                 │
│                                          │
│  Fluctuant? YES ──→ Aspirate (needle)   │
│                   ──→ If fails → I&D     │
│                                          │
│  Location:                               │
│  - Lactational → I&D (radial incision)  │
│  - Periareolar → Periareolar incision   │
│  - Retromammary → Inframammary incision │
└──────────────────────────────────────────┘

F. Risk of Malignancy with Benign Conditions (HIGH YIELD!)

┌──────────────────────────────────────────────────────┐
│         CANCER RISK WITH BENIGN LESIONS              │
│                                                      │
│  No increased risk  (RR ~1):                        │
│    Cysts, fibroadenoma, mild hyperplasia,           │
│    adenosis, apocrine metaplasia                    │
│                                                      │
│  Slightly increased (RR 1.5–2x):                   │
│    Solitary papilloma, moderate hyperplasia         │
│                                                      │
│  Moderately increased (RR ~3x):                     │
│    Papillomatosis (≥5 papillomas)                   │
│    Sclerosing adenosis with hyperplasia             │
│                                                      │
│  Significantly increased (RR 4–5x):                 │
│    ADH (Atypical Ductal Hyperplasia)                │
│    ALH (Atypical Lobular Hyperplasia)               │
│                                                      │
│  High risk (RR ~7-10x):                             │
│    LCIS (Classic)                                   │
│    BRCA1/2 mutation                                 │
└──────────────────────────────────────────────────────┘

⭐ PYQ (NEET PG 2022): Lesion with highest risk of malignant transformation? → Atypical ductal hyperplasia (ADH)

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SECTION 3: BREAST CARCINOMA - EPIDEMIOLOGY & RISK FACTORS

Epidemiology

• Most common cancer in women worldwide (25% of all female cancers)
• 2.3 million new cases worldwide in 2020
• In India: median age ~48 years (younger than West ~60 years)
• In India: 1 in 28 women; West: 1 in 9 women

Risk Factors (Bailey & Love, Table 58.3)

🧠 MNEMONIC: "HAMLINE PORE"

H - Hormone (HRT >10 yrs, OCP use) A - Age (increasing age) M - Menarche early (<12 yrs) L - Late menopause (>55 yrs) I - Ionizing radiation (RR = 6!) N - Nulliparity / late first pregnancy (>35 yrs) E - Ethnicity (Ashkenazi Jew, American white, Parsi in India) P - Prior breast cancer / ADH/ALH O - Obesity (BMI >30, postmenopausal) R - BRCA1/BRCA2 (hereditary) E - Excess alcohol (>4 drinks/day RR 1.46)

Non-modifiable Risk Factors

⭐ PYQ (NEET PG 2021): Gene associated with hereditary breast cancer? → BRCA1 (Chr 17) and BRCA2 (Chr 13)

⭐ PYQ: Male breast cancer is associated with? → BRCA2 mutation

Protective Factors (remember: opposite of risk factors)

• Early first pregnancy (<20 years)
• Breastfeeding (>12 months)
• Exercise
• Oophorectomy before age 40
• Tamoxifen / Raloxifene chemoprevention

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SECTION 4: DCIS vs LCIS (HIGH YIELD COMPARISON!)

┌────────────────────────────────────────────────────────────────┐
│              DCIS vs LCIS COMPARISON TABLE                     │
│                                                                │
│  Feature         │ DCIS                  │ LCIS               │
│──────────────────┼───────────────────────┼────────────────────│
│  Origin          │ Ductal epithelium     │ Lobular acini      │
│  Age             │ Perimenopausal        │ Premenopausal 40s  │
│  Detection       │ Mammography (calcif.) │ Incidental biopsy  │
│  Palpable        │ May be palpable       │ NOT palpable       │
│  Bilateral       │ Usually unilateral    │ Often bilateral    │
│  Cancer risk     │ Ipsilateral risk      │ Both breasts (50%) │
│  Risk level      │ High (precursor)      │ Marker (RR ~7-10x) │
│  Treatment       │ Excision ± RT ±       │ Observation /      │
│                  │ Tamoxifen             │ Chemoprevention    │
│  Types           │ Comedo (high grade)   │ Classic (benign)   │
│                  │ Cribriform, papillary │ Pleomorphic        │
│                  │ Solid (lower grade)   │ (aggressive)       │
└────────────────────────────────────────────────────────────────┘

⭐ PYQ (NEET PG 2023): DCIS is detected on mammography by? → Microcalcifications (pleomorphic, linear)

⭐ PYQ: LCIS is a ___ for cancer? → Marker (risk factor), NOT a precursor

⭐ PYQ: Comedo type DCIS has? → Central necrosis with calcifications; HIGH grade; worse prognosis

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SECTION 5: INVASIVE BREAST CANCER - PATHOLOGY

Histological Types (Sabiston)

🧠 MNEMONIC: "My Mum Takes Pills" (Types with GOOD prognosis)

M - Mucinous (Colloid) M - Medullary T - Tubular P - Papillary (All have better prognosis than IDC)

⭐ PYQ (NEET PG 2020): Single-file pattern of breast carcinoma is seen in? → Infiltrating Lobular Carcinoma

⭐ PYQ: Which type of breast cancer has best prognosis? → Mucinous/Colloid or Tubular carcinoma

⭐ PYQ: ILC is characterized by loss of? → E-cadherin (CDH1 gene mutation)

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SECTION 6: TNM STAGING (UICC-AJCC 8th Edition) (Bailey & Love)

T - Tumor

🔑 Peau d'orange = edema of skin due to obstruction of dermal lymphatics by tumor emboli → T4b

N - Nodes (Clinical)

Stage Grouping (Memorize!)

┌─────────────────────────────────────────┐
│          STAGE GROUPING                 │
│                                         │
│  Stage 0    = Tis, N0, M0             │
│  Stage IA   = T1, N0, M0             │
│  Stage IB   = T0-1, N1mi, M0         │
│  Stage IIA  = T0-1 N1 or T2 N0       │
│  Stage IIB  = T2 N1 or T3 N0         │
│  Stage IIIA = T0-3 N2 or T3 N1       │
│  Stage IIIB = T4 any N               │
│  Stage IIIC = any T N3               │
│  Stage IV   = any T any N M1         │
└─────────────────────────────────────────┘

⭐ PYQ (NEET PG 2022): Inflammatory carcinoma of breast is staged as? → T4d (Stage IIIB)

⭐ PYQ: Supraclavicular LN involvement = which N stage? → N3c (Stage IIIC)

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SECTION 7: CLINICAL FEATURES & DIAGNOSIS

Clinical Presentation

Typical Features of Breast Ca

• Painless, hard lump (most common presentation)
• UOQ (upper outer quadrant) - MC site (50% of tumors)
• Skin dimpling / tethering (Cooper's ligament involvement)
• Peau d'orange (dermal lymphatic obstruction)
• Nipple retraction (transverse slit-like)
• Nipple discharge (blood-stained)
• Paget's disease of nipple

Clinical Examination Features (S Das)

Triple Assessment (ESSENTIAL!)

┌──────────────────────────────────────────────────────┐
│              TRIPLE ASSESSMENT                       │
│                                                      │
│  1. CLINICAL EXAMINATION (C1-5 scoring)             │
│  2. IMAGING                                         │
│     - Age <35: Ultrasound (dense breast)            │
│     - Age ≥35: Mammography ± Ultrasound             │
│     - MRI: for BRCA, implants, lobular Ca           │
│  3. PATHOLOGY (Cytology / Biopsy)                  │
│     - FNAC: C1 (inadequate) to C5 (definite malig) │
│     - Core needle biopsy (gold standard)            │
│     - Excision biopsy (if above inconclusive)       │
└──────────────────────────────────────────────────────┘

⭐ PYQ (NEET PG): Triple assessment does NOT include? → Tumor markers (CEA, CA 15-3 are NOT part of triple assessment)

⭐ PYQ: Gold standard for diagnosis of breast lump? → Core needle biopsy (Tru-cut biopsy)

Mammographic Signs of Malignancy

• Spiculated mass with irregular margins
• Pleomorphic microcalcifications (casting type)
• Asymmetric density
• Skin thickening / nipple retraction on mammogram

BI-RADS Classification

⭐ PYQ: BI-RADS 4 requires? → Tissue biopsy (core needle)

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SECTION 8: HORMONE RECEPTORS & MOLECULAR SUBTYPES (VERY HIGH YIELD!)

Receptor Status

Molecular Subtypes (MUST KNOW!)

┌────────────────────────────────────────────────────────────────────┐
│               MOLECULAR SUBTYPES OF BREAST CANCER                 │
│                                                                    │
│  Subtype      │ER│PR│HER2│ Features           │ Prognosis         │
│───────────────┼──┼──┼────┼────────────────────┼───────────────────│
│  Luminal A    │+ │+ │ -  │ Low Ki67; MOST     │ BEST              │
│               │  │  │    │ common; endocrine  │                   │
│               │  │  │    │ therapy only       │                   │
│───────────────┼──┼──┼────┼────────────────────┼───────────────────│
│  Luminal B    │+ │± │ +  │ Higher Ki67; chemo │ Intermediate      │
│               │  │  │    │ + endocrine + anti-│                   │
│               │  │  │    │ HER2 therapy       │                   │
│───────────────┼──┼──┼────┼────────────────────┼───────────────────│
│  HER2-        │- │- │ +  │ Aggressive; anti-  │ Poor (improved    │
│  enriched     │  │  │    │ HER2 therapy       │ with trastuzumab) │
│               │  │  │    │                    │                   │
│───────────────┼──┼──┼────┼────────────────────┼───────────────────│
│  Triple       │- │- │ -  │ BRCA1-related;     │ WORST             │
│  Negative     │  │  │    │ TNBC; chemo only;  │                   │
│               │  │  │    │ Medullary type     │                   │
└────────────────────────────────────────────────────────────────────┘

🧠 MNEMONIC: "TNBC = TERRIBLE No BCG vaccine" (Triple Negative = Worst prognosis, no targeted therapy)

⭐ PYQ (NEET PG 2023): HER2-enriched breast cancer is treated with? → Trastuzumab (Herceptin)

⭐ PYQ: Triple-negative breast cancer is associated with? → BRCA1 mutation, worse prognosis, chemo only

⭐ PYQ: Which breast cancer has best prognosis? → Luminal A (ER+, PR+, HER2-, low Ki67)

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SECTION 9: SURGICAL MANAGEMENT

Breast Conserving Surgery (BCS) vs Mastectomy

SURGICAL DECISION FLOWCHART:
┌─────────────────────────────────────────────────────────┐
│        EARLY BREAST CANCER (Stage I, II)                │
│                                                         │
│    ┌────────────────────────────────────┐               │
│    │  BCS (Lumpectomy/Wide local        │               │
│    │  excision) + Radiotherapy          │               │
│    │  = EQUIVALENT to mastectomy        │               │
│    │  in local recurrence & survival    │               │
│    └───────────────┬────────────────────┘               │
│                    │                                    │
│              Contraindications to BCS?                  │
│    ┌───────────────▼───────────────────┐               │
│    │  YES → MASTECTOMY                 │               │
│    │  - Multicentric disease           │               │
│    │  - Large tumor: breast ratio      │               │
│    │  - Previous chest RT              │               │
│    │  - Unable to clear margins        │               │
│    │  - Inflammatory Ca                │               │
│    │  - Patient preference             │               │
│    └───────────────────────────────────┘               │
└─────────────────────────────────────────────────────────┘

Mastectomy Types (MUST KNOW!)

🧠 MNEMONIC: "MRM = Mastectomy, Removes Muscle? NO!" (MRM preserves pectoralis major)

⭐ PYQ (NEET PG 2018): Standard operation for breast carcinoma? → Modified Radical Mastectomy (MRM)

⭐ PYQ: In Halsted's radical mastectomy, which muscle is removed? → Both pectoralis major and minor

⭐ PYQ: MRM preserves? → Pectoralis major (Patey's - preserves pec major; Scanlon's - preserves both)

Axillary Management

AXILLARY FLOWCHART:
┌──────────────────────────────────────────────────────┐
│             AXILLARY MANAGEMENT                      │
│                                                      │
│  Clinically N0? ──→ Sentinel Lymph Node Biopsy      │
│                      (SLNB)                          │
│       │                                              │
│       ▼                                              │
│  Sentinel node positive?                             │
│       │                                              │
│  YES ──→ Axillary Lymph Node Dissection (ALND)     │
│           Level I + II (or I + II + III if N2-3)   │
│  NO  ──→ No further axillary surgery                │
│                                                      │
│  Clinically N+ → ALND directly                     │
└──────────────────────────────────────────────────────┘

• Dye: Blue dye (Patent Blue V / Isosulfan blue) OR Technetium-99m sulfur colloid (radio-isotope)
• First echelon lymph node that drains the tumor
• Identifies which patients need ALND
• Avoids lymphedema in node-negative patients

⭐ PYQ (NEET PG 2021): Sentinel lymph node biopsy in breast - which dye used? → Patent blue dye / Isosulfan blue (OR Tc-99m radioactive isotope)

⭐ PYQ: SLNB identifies the first draining lymph node from? → The primary tumor site

Nerve at Risk During Mastectomy / ALND

🧠 MNEMONIC: "Long Thoracic = Wings to fly away (winged scapula)"

⭐ PYQ (NEET PG): Winged scapula after mastectomy is due to injury to? → Long thoracic nerve (of Bell)

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SECTION 10: SYSTEMIC TREATMENT

Adjuvant Chemotherapy

• Standard regimen: AC-T (Anthracycline + Cyclophosphamide → Taxane)
• AC-T + Trastuzumab for HER2+ tumors
• TNBC: AC-T ± Capecitabine, Pembrolizumab

Hormonal Therapy

⭐ PYQ (NEET PG): Drug of choice for hormonal treatment in premenopausal breast cancer? → Tamoxifen

⭐ PYQ: Tamoxifen side effects include? → Endometrial cancer, DVT, menopausal symptoms, bone protection

⭐ PYQ: Aromatase inhibitors used in? → Postmenopausal ER+ breast cancer

Targeted Therapy

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SECTION 11: SPECIAL TOPICS (PYQ FAVORITES!)

A. Paget's Disease of Nipple (HIGH YIELD!)

┌────────────────────────────────────────────────────────┐
│              PAGET'S DISEASE OF NIPPLE                 │
│                                                        │
│  WHAT IT IS: Intraepidermal spread of ductal           │
│  carcinoma cells into nipple epidermis                 │
│                                                        │
│  APPEARANCE: Eczema-like, erythematous, scaly,        │
│              nipple destruction                        │
│                                                        │
│  KEY CELLS: Paget cells (large cells with pale         │
│             cytoplasm and prominent nucleoli)          │
│                                                        │
│  ASSOCIATED WITH:                                      │
│  - Underlying DCIS (50-60% cases)                     │
│  - Underlying invasive Ca (30-40% cases)              │
│  - Only Paget's without Ca (very rare)                │
│                                                        │
│  DIFF FROM: Eczema of nipple - Eczema starts at       │
│  areola and spreads to nipple; Paget's starts at      │
│  NIPPLE and spreads to areola                         │
│                                                        │
│  BIOPSY: Wedge biopsy of nipple                       │
│  TREATMENT: Mastectomy (or BCS + RT if small)        │
└────────────────────────────────────────────────────────┘

⭐ PYQ (NEET PG 2019): Paget cells are large cells with? → Pale/clear cytoplasm, prominent nucleoli, in nipple epidermis

⭐ PYQ: Paget's disease of nipple starts at? → Nipple (spreads outward to areola)

⭐ PYQ: Paget's disease is always associated with? → Underlying carcinoma (DCIS or invasive)

B. Inflammatory Carcinoma of Breast

• Peau d'orange + erythema involving >1/3 of breast skin
• Rapidly progressive; very aggressive
• Dermal lymphatic invasion by tumor emboli (NOT an acute infection)
• Skin punch biopsy confirms diagnosis
• TNM Stage: T4d = Stage IIIB
• Treatment: Neoadjuvant chemotherapy FIRST → then surgery + RT

⭐ PYQ: Inflammatory carcinoma - which staging? → T4d, Stage IIIB

⭐ PYQ: Treatment of inflammatory carcinoma? → Neoadjuvant chemo first, then surgery

C. Male Breast Cancer

• Accounts for 0.5-1% of all breast cancers
• Associated with: BRCA2, Klinefelter syndrome (XXY), hyperestrogenic states, gynecomastia is NOT directly causative
• Most common type: IDC
• Treatment: same as female (MRM + adjuvant)

⭐ PYQ: Male breast cancer is associated with? → BRCA2 and Klinefelter syndrome

D. Breast Cancer in Pregnancy

• MC cancer in pregnancy (after cervical ca)
• Diagnosis often delayed (normal breast changes mask lump)
• FNA/Core biopsy safe in pregnancy
• Mammography: safe with shielding
• Surgery: safe in all trimesters
• Chemo: AC regimen safe in 2nd/3rd trimester
• RT: deferred until after delivery
• Trastuzumab: CONTRAINDICATED (oligohydramnios, renal anomaly in fetus)

⭐ PYQ: Which drug is contraindicated in breast Ca during pregnancy? → Trastuzumab

E. Gynecomastia

🧠 MNEMONIC for Drugs causing Gynecomastia: "DESK CA"

D - Digoxin E - Estrogens / spironolaEctone S - Spironolactone K - Ketoconazole C - Cimetidine (H2 blocker) A - Anabolic steroids / Antipsychotics

⭐ PYQ (NEET PG): Most common cause of gynecomastia in adults? → Idiopathic (25%) or drug-induced (Spironolactone, Digoxin)

F. Phyllodes Tumor

⭐ PYQ (NEET PG 2022): Phyllodes tumor metastasizes by? → Hematogenous spread (to lungs), NOT lymph nodes

⭐ PYQ: Phyllodes tumor is composed of? → Both epithelial and hypercellular stromal elements

G. Mondor's Disease

• Thrombophlebitis of superficial veins of breast and chest wall
• Presents as tender cord-like structure
• Self-limiting; treated with NSAIDs

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SECTION 12: BREAST RECONSTRUCTION

⭐ PYQ: Most common flap used for breast reconstruction? → Latissimus dorsi (LD) flap (simple, reliable pedicled flap)

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🔥 RAPID-FIRE LAST MINUTE HIGH YIELD POINTS

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🧠 MASTER MNEMONICS SUMMARY

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FLOWCHART: APPROACH TO BREAST LUMP

                    BREAST LUMP
                        │
          ┌─────────────┼────────────────┐
          ▼             ▼                ▼
    Young (<35)     Middle-aged       Elderly
    Fibroadenoma    (35-50)          (>50)
    likely          Fibrocystic /    Carcinoma
                    Cyst likely      till proved
                        │            otherwise
                        │
                  TRIPLE ASSESSMENT
                        │
           ┌────────────┼────────────┐
           ▼            ▼            ▼
     Clinical        Imaging      Biopsy
     C1-C5           (USG/Mammo)   (FNAC/Core)
                     U1-U5         B1-B5
                        │
              All 3 benign? → Reassure & follow up
              Any malignant? → MDT - Surgery ± chemo ± RT

---

FLOWCHART: MANAGEMENT OF BREAST CANCER

         BREAST CANCER DIAGNOSED
                  │
     ┌────────────┴────────────────┐
     ▼                             ▼
  EARLY (Stage I-II)          LOCALLY ADVANCED
  T1-2, N0-1                  (Stage III) or
                               Inflammatory Ca
     │                              │
     ▼                              ▼
BCS + SLNB + RT              Neoadjuvant
  OR MRM + ALND               Chemotherapy
     │                              │
     ▼                              ▼
ADJUVANT THERAPY              Then: Surgery
 ER+ → Tamoxifen (pre)              │
       AI (post)               Then: RT + 
 HER2+ → Trastuzumab            Adjuvant Rx
 TNBC → Chemo alone
     │
     ▼
  SURVEILLANCE
(Mammogram yearly,
 Clinical exam 6 monthly)

---

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📋 What's Inside (12 Sections)

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⭐ Top PYQ Themes You Must Lock In

1. BRCA1 (Chr 17) vs BRCA2 (Chr 13) - asked almost every year
2. LCIS = Marker, not precursor (bilateral risk)
3. MRM preserves pectoralis major (Halsted removes both)
4. Long thoracic nerve → Winged scapula after ALND
5. T4d = Inflammatory Ca = Stage IIIB
6. Sentinel node dye = Patent Blue / Tc-99m
7. Trastuzumab contraindicated in pregnancy
8. Phyllodes = hematogenous spread to lungs
9. TNBC = BRCA1, worst prognosis
10. Triple assessment does NOT include tumor markers