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The outer slide tubes are "bronze" and with thicker stock and oversleeves. Under the prescribed conditions for toluene the detection limit is 0. A similar trend of blood alcohol was observed at the later stage with toluene given prior to ethanol. An environment that doesn't usually command a light touch can be punishing to a vulnerable instrument. The phrase "Rods from God" is also used to describe the same concept.

Toluene Introduction:

Toluene Sources, Testing, Air Purification, and Health Information

For women with confirmed BRCA1 or BRCA2 mutations, or other gene mutations predisposing to breast cancer, referral to the high risk screening program at BC Cancer and counseling about cancer prevention and screening options for breast and other associated hereditary cancers is available. Three drugs have been shown to effectively reduce the risk of developing estrogen receptor positive pre invasive ductal carcinoma in situ, DCIS and invasive breast cancer among women with elevated risk, as determined by the sum of their risk factors using a validated risk prediction tool including, but not restricted to, the Gail model or Tyrer-Cuzick IBIS model.

In the largest study, among 13, women randomized to tamoxifen or placebo, DCIS and invasive breast cancer occurred in the placebo group and in the tamoxifen group over a 5.

Other primary prevention studies have shown similar effects. There was no increase in cardiac events and there was a modest reduction in hip, wrist, and vertebral fractures in the tamoxifen group.

Raloxifene has also demonstrated reduction in both DCIS and invasive breast cancer by the same degree as tamoxifen in a large clinical trial comparing the two drugs. Long term follow up again shows an effect that lasts beyond five years of exposure. There was no increased incidence of cardiovascular events, second cancers, fractures, or self reported development of osteoporosis. Long-term follow-up is clearly warranted for more safety data and to determine the duration of the protective effect that five years of therapy provides.

Ongoing trials are exploring the effectiveness of other aromatase inhibitors in this setting. Appointments can be booked through Tamoxifen for Prevention of Breast C ancer: Journal of the National Cancer Institute, 90 18 , J Natl Cancer Inst Cancer Prev Res; 3 6 ; —, N Engl J Med Benefit of screening mammography in women aged J Natl Cancer Inst Monograph. Efficacy of screening mammography among women aged 40 to 49 years and 50 to 69 years: J Natl Cancer Inst Monogr.

Risk increases with advancing age. Women may do regular breast self-examination BSE. For premenopausal women, this is best done in the week following the menstrual period. For postmenopausal women, a specific day of the month should be chosen. If done, the examination should include inspection of the breast and palpation of the breast and axilla. To perform adequate BSE the patient needs instruction in the technique and the manner in which she is carrying this out.

This should be checked at subsequent examinations by her family physician. There is no evidence that BSE improves survival, but regular self-examination does allow a woman to know her own body and therefore recognize early changes in the breast texture or appearance. She should be encouraged to bring any concerns to her health care provider.

The combination of physical examination by a physician and mammographic screening has been shown to reduce mortality from breast cancer. The relative importance of the physical examination vis-a-vis the mammogram remains unclear. The policy of the Screening Mammography Program of BC reflects the latest evidence and our commitment to reducing breast cancer deaths by finding cancer at an early stage.

Key policy recommendations are:. If screening mammography is chosen, patients will be recalled every two years. Routine screening mammograms are recommended every two years for asymptomatic women at average risk of developing breast cancer. Patients will be recalled every two years. Health care providers are encouraged to discuss the benefits and limitations of screening mammography with asymptomatic women in this age group.

Health care providers should discuss stopping screening when there are comorbidities associated with a limited life expectancy or physical limitations for mammography that prevent proper positioning.

If screening mammography is chosen, it is available every two to three years. Routine screening mammograms are recommended every year. Patients will be recalled every year. Please discuss patient with a screening program radiologist before referral. Routine screening with breast MRI of women at average risk of developing breast cancer is not recommended.

Patients who are mutation carriers or from families with confirmed mutations are recommended to have annual screening breast MRI from age 25 to Referral to the Hereditary Cancer Program can facilitate these arrangements.

Women who have had chest radiation between 10 and 30 years of age are also recommended to have annual screening breast MRI alternating with annual mammograms, i.

More information about the utility of MRI in the screening and diagnosis in the setting of breast cancer is discussed in the Diagnosis section. There has been considerable interest in methods of detection of non-palpable abnormalities in the breast that do not use ionizing radiation. Such methods include thermography, ultrasound and diaphanography, but in the screening of asymptomatic women none of these techniques approach the sensitivity or the specificity of mammography and cannot be recommended at the present time as the sole screening method.

Ultrasound may be very useful, in conjunction with mammogram, for diagnosis of to assess breast lesions, and in that situation is part of the workup of a mass.

However, in the absence of any abnormality on physical examination or mammogram, ultrasound is not required, is not a validated screening method, and is not funded.

Women with gene mutations are candidates for programs of special surveillance. Specific criteria for referral to the Hereditary Cancer Program are listed separately.

Referral should be offered to asymptomatic women with increased risk of hereditary breast cancer, including those with the following: In all cases, it is important to combine the radiologic assessment of the entire affected breast and the contralateral breast with the general health of the woman, examination of the breast and nodal areas, and a pathological diagnosis.

The treatment of the breast cancer will depend on combining the results of these investigations. Although most breast lumps are not cancerous, the practitioner must be aware that breast cancer can appear at any age, and if there is any suspicion, a definitive diagnosis should be obtained promptly.

The diagnosis of breast complaints and breast cancer has evolved significantly over the past 20 years with advances in imaging and pathology techniques and increased interdisciplinary management of breast problems.

Core needle biopsy of breast lesions is now the standard of care and surgical biopsy should be performed only when core needle biopsy is not possible. A complete review of management of breast complaints and benign breast disease is beyond the scope of this document. In all cases there should be a concordance assessment of the physical exam, imaging, and biopsy results and if these results are not concordant, further investigation is necessary to rule out malignancy.

History and physical examination should be performed in patients with breast complaints to determine the nature of clinical presentations, such as clarify features of discharge, assess masses for suspicion for breast cancer, and determine the etiology of breast pain. Physiologic nipple discharge should be differentiated from pathologic nipple discharge. This type of discharge does not require diagnostic medical imaging.

Physical examination is the first step in the evaluation of breast pain. The location and characteristics of the pain help to differentiate breast pain from chest wall pain.

Chest wall pain is commonly located at the costochondral junctions and over the lateral chest wall, rather than in the breast itself. Physiologic breast pain is characterized as cyclical, non-focal and bilateral and is typically due to hormonal or age-related changes.

Physiologic and chest wall pain do not require diagnostic breast imaging as pain of this nature has not been shown to correlate with the presence of breast cancer. Diagnostic imaging is indicated when a breast mass, suspicious skin or nipple changes, or pathologic nipple discharge is confirmed on physical examination.

In the absence of suspicious physical examination findings, screening mammography is recommended. Diagnostic imaging should be requested for patients with pathological clinical exam findings. In general, bilateral diagnostic mammograms and targeted ultrasound are recommended for women over Tomosynthesis is becoming increasingly available and MRI is used for problem solving in particular circumstances.

Imaging assessment involves correlating findings on the different imaging modalities. Final guidance regarding further management e. Any suspicious physical exam findings require further imaging and biopsy. Core needle biopsy CNB diagnosis of breast lesions is the preferred initial invasive diagnostic procedure 3,4,13 , and imaging guidance is recommended to increase accuracy of targeting 8.

Concordance assessment is an important part of CNB. For an image guided CNB, concordance is the agreement of imaging and histopathological findings such that the histopathology satisfactorily explains the imaging findings. Discordance presents a diagnostic situation that requires further evaluation, including the options of a repeating CNB, perhaps with consideration of larger gauge or vacuum-assisted techniques, b surgical excisional biopsy, or c clinical and imaging surveillance.

Failure to resolve imaging-pathology discordance can lead to a delay in breast cancer diagnosis. Concordance assessment also involves assessing the situation for risk of under-sampling by core needle biopsy.

When the chance of this occurring is increased, the lesion is regarded as being a high risk lesion. High risk lesions found on CNB are usually recommended to have surgical excision of the area to rule out malignancy due to under-sampling. The risk of under-sampling varies by diagnosis and is affected by factors such as the number and size of CNB specimens taken, size of lesion, and institution.

Specimen imaging of fine wire guided excisions is recommended and all breast surgical specimens should be oriented for the pathologist. Concordance assessment is recommended after surgical excision of breast lesions to ensure that the lesion of interest has been accurately targeted and excised.

In rare circumstances, the lesion found by the patient was different from the lesion biopsied under imaging guidance and this is suggested by discordance between preoperative diagnosis and surgical pathology. The finding of the core needle biopsy scar in the excised tissue suggests accurate targeting, but this can also be present in adjacent tissue. If there is discordance between the surgical pathology and the preoperative diagnosis, further investigations are indicated and can include further imaging, image guided localization, or surgical re-excision.

Interdisciplinary review is recommended to guide management. Non-palpable breast lesions masses, calcifications, asymmetries, architectural distortion can be found on screening mammograms and breast imaging done for other symptoms. The BIRADS reporting system and radiology-pathology concordance statements are particularly useful in determining the need for further management and follow up due to the absence of physical examination findings to guide the treating clinician.

With the development of increased diagnostic breast imaging options and the introduction of image-guided breast biopsy, patients may need to attend a number of appointments to obtain a diagnosis. It is recommended that patients have their mammograms, breast ultrasound, and ultrasound guided core needle biopsy performed by a consistent radiology group to facilitate comparison, limit duplication, and decrease wait times.

When more specialized biopsy or imaging techniques are required such as stereotactic biopsy, MRI, or MRI guided biopsy, the patient may need to attend additional centers. The BHS has also recommended facilitation of necessary investigations and increasing navigation resources for patients to help facilitate a prompt diagnosis. The Screening Mammography Program of BC introduced Fast Track booking for evaluation of screen detected lesions in and many breast diagnostic teams in the province have introduced care pathways and clinics to decrease wait times.

Currently each community has a slightly different system with regards to how breast imaging and biopsies are arranged. Next steps are sometimes facilitated by radiology and sometimes ordered by family physicians. With these divergent approaches pitfalls can arise, particularly if patients have mammograms outside of the usual community.

Referring physicians should be aware of these differences and the role they are expected to play in arranging investigations for their patient. The utilization and impact of core needle biopsy diagnosis on breast cancer outcomes in British Columbia. Silverstein, Abram Recht, Michael D.

Blumencranz, Terri Gizienski, Steven E. Harms, Jay Harness, Roger J. State-of-the-Art Diagnosis and Treatment. Journal of the American college of Surgeons. August 20, http: Accessed Jan 9, American College of Radiology, Lynn Pelletier: Breast Health Strategy Summary Report Provincial Health Services Association.

Accessed Mar 10, Diagnosis of Breast Cancer: Although MRI has advanced some areas of oncologic imaging, as well as neurological and musculoskeletal imaging, the transformation is less complete in breast imaging where other well established and less expensive techniques can often provide necessary information. The purpose of these recommendations is three-fold, in the absence of substantial randomized controlled trial data on the usefulness and value of breast MRI:.

To provide education and awareness to ordering physicians on the potential uses and pitfalls of breast MRI. To help radiologists and ordering physicians utilize the resource effectively in the appropriate clinical settings.

To encourage collaboration in useful clinical research projects for the above. Mammography is the standard breast imaging modality against which other modalities can be judged since there is an extensive body of trial data and a long period of surveillance follow-up.

MRI has not yet met the challenge of proving that it can help to decrease mortality, recurrence or impact of treatment. Nor do we know its true positive predictive value. Specificity is variable, particularly in premenopausal women where incidental enhancing lesions are often identified. There is currently no literature of level 1 evidence to support the use of MRI for any specific indication. It is not certain which women or imaging questions will be best served by this modality and at what costs.

Breast MRI should be used in a problem-solving mode only after high quality mammography and ultrasound have been carried out. As well, it should be done by a radiologist with expertise in breast MRI, as these images require specialized knowledge for interpretation. Like all breast imaging studies, breast MRI must be correlated with other imaging findings in light of clinical findings.

Patricia Hassell and Moira Stilwell. The consensus was that as there is not level one evidence we cannot claim that these are standard Guidelines but are suggested clinical indications and are divided into those that are more established in terms of benefit, those that are not established but may be indicated for specific patients and those that should not be routinely recommended.

MRIs within the context of clinical trials should be considered outside of these indications. In patients who have tested positive for mutations of the BRCA 1 and 2 genes or who are at high risk of breast cancer due to a family history of the disease, MRI has been shown to detect cancers before mammography, ultrasound or clinical examination could detect the malignancy.

The greater incidence of high-grade invasive malignancies in this high-risk group does provide the rationale for using MRI as a screening modality in known mutation carriers including, but not restricted to, BRCA1 and BRCA2. In these women, screening is done using annual imaging with mammography and MRI concurrently or alternately.

In British Columbia, the role of breast MRI screening in high-risk women with a strong family history of breast cancer but no known gene mutation is under review. Studies have suggested that ultrasound may also have a role in following these women but recent literature does not support continued ultrasound screening in asymptomatic high-risk women. In patients with an occult primary presenting with axillary lymphadenopathy or Paget's disease, MRI has been shown to identify the primary in many patients, thus allowing for conservative surgery rather than mastectomy.

This is not indicated if mammography clearly shows a suspicious lesion. Trials are ongoing studying the impact of MRI on this group of patients. MRI can be useful in pre-operative assessment of local disease extent when this is unclear either by physical examination, mammography or ultrasound. Mammography is more accurate in determining the size and additional sites of malignancy. This may be particularly indicated in lobular carcinoma where mammography may be less sensitive and where there may be multicentric disease.

Positive margins — post segmental resection. MRI can be useful in determining the extent of residual disease when margins are positive and the mammogram is not helpful. In the majority of cases however, as further surgery is indicated, it will not necessarily impact on treatment. Post surgical scar vs. In cases in which mammography and ultrasound can not conclusively confirm suspected recurrent disease, MRI can be helpful.

Breast tissue can show enhancement for up to 18 months following radiation therapy, however. In many of these situations, a biopsy will be necessary to rule out disease and may be a preferable diagnostic test. MRI can be useful in a small number of patients when there is an equivocal mammographic finding, i. Many of these patients have heterogeneously dense breasts. MRI has been used to monitor treatment response to neoadjuvant chemotherapy in patients with locally advanced cancer.

There is controversy over the ability of MRI to determine complete or partial response to treatment. MRI tends to underestimate residual disease. At this time this should only be used in association with a clinical trial. At present there is no data to support the use of MRI as a screening tool. To date, there are no studies demonstrating decreased mortality by the use of screening MRI.

Not all cancers seen on mammography can be identified in MRI. This is especially true for DCIS. Differentiation of benign vs malignant lesions. Because of an overlap between the enhancement and morphological characteristics of benign and malignant lesions, MRI cannot be used as a substitute for biopsy. When image detected abnormality is removed, the specimen should then be radiographed to ensure that the area of concern was removed.

The specimen, together with any specimen radiograph, should then be sent directly to the Pathologist who should carefully mark the resection margins, prior to cutting the specimen, so that the relationship of the lesion to the surgical margins can be ascertained.

When possible it is preferable to submit the specimens unfixed immediately to the pathologist who can select the most appropriate technique for handling each individual specimen. Progesterone receptors are also indicated as they may provide evidence of a potentially hormone sensitive tumour. Immunocytochemical staining is the standard technique to test for estrogen receptors.

It can be performed on fresh tissue, frozen tissue, core biopsies scrapings obtained from the surface of small lesions or frozen sections, and on aspirates with reliable results. Staining may also be performed on fixed tissue blocks, but the results may not be as accurate depending upon the fixative used and on delay in fixation of the specimen. In addition, estrogen receptor staining may be a useful technique in evaluating metastases in patients with unknown primaries in whom the possibility of metastatic breast carcinoma is in the differential diagnosis.

For further information consult your hospital pathologist or regional pathologist as several hospitals, including BC Cancer, provide estrogen receptor staining. Accurate and reliable identification of HER2 overexpression is necessary. All specimens should be measured and margins inked. Ideally, all wire-guided biopsies and wide excisions short of complete mastectomy should be processed in entirety. The pathologist should mark the margins of the specimen with silver nitrate or India ink and, if this has not already been done, send a portion of tumour for receptor studies.

Label all blocks separately and designate each block as to site in the gross description e. Blocks from wire-guided biopsies and wide excisions should be taken sequentially so the size of the tumour can be assessed by calculating the number of blocks involved multiplied by the block thickness. State how the block is taken in relation to the margin. Usually blocks are taken perpendicular to the margin but if taken "en face" this must be recorded in the dictation or on a specimen diagram.

Submit all lymph nodes and state the number included in each cassette. In general the entire node should be processed. Frozen section may be considered if the Surgeon is proceeding directly to further definitive surgery after excisional biopsy. In order to assist with optimal management of patients with breast cancer, the oncologists in British Columbia have requested the following information to be included in pathology reports.

For the convenience of the reporting pathologist, the required information is presented in the form of a checklist. This information may be incorporated in the standard report format or may be listed in the form of a synoptic report. The system is applicable to all invasive carcinomas. Special subtypes of breast carcinoma lobular, tubulolobular, tubular, papillary, mucinous, cribriform, medullary, adenoid cystic, sarcomatoid metaplastic , squamous, adenosquamous should be noted separately but should also be assigned an overall grade.

Strict criteria should be used to recognise these special types of breast cancer which have prognostic significance Ellis ; Tavassoli ; Rosen Since the term "differentiation" used in the context of breast carcinoma is an ambiguous term, it is recommended that grades 1, 2 or 3 be used instead of, or at least in addition to, the terms "well, moderately, or poorly differentiated".

Grading cannot be performed adequately on material that has been frozen for the purposes of "frozen section" or "quick section".

The Nottingham modification of the Bloom and Richardson method of grading is used most widely and is recommended for BC Cancer.

The system described below incorporates modifications suggested by Elston, Contesso, and Helpap. The three separate parameters are scored independently as follows: Nuclei are small to medium-sized, relatively uniform in size and shape, and lacking clumped chromatin or prominent nucleoli.

Nuclei may have small, inconspicuous nucleoli. Uniformity of size and shape are the most important features. Nuclei are medium to large in size but exhibit only moderate variability in size, shape and intensity and pattern of staining. Nucleoli may be quite prominent as long as the nuclei are relatively monotonous in appearance. Nucleoli with irregular outlines, giant or "macronucleoli" are absent. Bizarre giant cells are absent.

There is considerable variation in the size and shape of nuclei. Typically, nucleoli are very large, often multiple and may have irregular outlines. Giant nuclei, polylobated nuclei and multinucleate tumour giant cells may be present. Karyorrhexis, karyolysis and pyknosis of nuclei are often encountered. The above descriptions are given as guidelines, which may be supplemented by study of illustrations of the different nuclear grades in the references, cited below.

Furthermore, since there is a morphological continuum in the nuclear appearance in breast carcinomas, the extremes of the spectrum are easily recognised but, in some cases, the scoring of nuclei is to some extent subjective and differences of interpretation between pathologists are to be expected.

It must be stressed that it is impossible to assign a nuclear score based on the frozen section or post-frozen paraffin embedded material. The assessment of tubular differentiation or tubule formation applies to the neoplasm overall and requires examination of several sections at scanning magnification.

A reliable tubular score cannot be assigned when only needle biopsies or small pieces of the tumour are examined. The mitosis score is assessed in the peripheral areas of the neoplasm and not the sclerotic central zone. The neoplasm is scanned at intermediate magnification to determine the area in which mitoses are most abundant usually areas of poor tubule formation where cells are arranged in sheets or large nests.

Only definite mitotic figures are counted with care to avoid including pyknotic nuclei in the count. Although the Nottingham grading system uses a scoring system based on the number of mitoses per 10HPF's, the Oncologic Standards Committee considers that a mitotic count per square millimetre is most accurate.

Mitoses are only counted in the invasive component of the lesion. Alternatively the number of mitoses in 10 high power fields HPFs is counted. Using a Nikon Labophot microscope with a 40X objective lens i. X and a field surface area of 0. In practice, Contesso's method of scoring of mitoses is quicker and easier to perform especially on small biopsies e.

At least 20HPF's of the same area as stated above are assessed and scored as follows: The scores for the three separate parameters tubules, nuclei and mitoses are summated and the overall grade of the neoplasm is determined as follows: Cribriform Micropapillary - papillary structures lack fibrovascular cores. Papillary - fibrovascular cores present within papillary structures.

The latest consensus committee abandoned the requirement for high nuclear grade in combination with necrosis. In addition to the maximal linear size of the DCIS, a rough estimate of the volume of DCIS relative to the overall tumour should be given as a percentage. This assessment is important because EIC carcinomas treated with breast conservation have a higher risk of local recurrence within the breast unless the margins are well clear.

In general, it is possible to grade lobular carcinoma. Usually, classical lobular carcinoma will attain a total score of 5 tubules 3; nuclei 1; mitoses 1 giving the tumour an overall grade 1.

Although some of the data are somewhat inconclusive, histological variants of lobular carcinoma are thought to differ in their degree of aggressiveness as follows:.

Good Prognosis Grade 1: This variant features tubular structures that are lined by very uniform small cells resembling those of classical lobular carcinoma.

Single-file strands of identical cells are also present. Some authorities would regard this variant as a ductal carcinoma tubular type. Fairly good Prognosis Grade 1: Classical pattern with Grade 2 nuclei Alveolar variant - round and oval nests of uniform small cells Large cell variant Mixed patterns of lobular carcinoma Poor prognosis patterns Grade 3: Solid variant - large sheets of uniform small cells with round nuclei Pleomorphic lobular carcinoma - pattern resembles classical lobular carcinoma but the nuclei are grade , mitoses are easily identified, apocrine change is common, and ER is often negative.

Large calibre, thick-walled blood vessels containing tumour emboli either within the tumour in the surrounding tissue are included. Neural invasion has been shown not to be of prognostic significance in most studies.

Breast markers on invasive carcinoma should be done on the core biopsy sample where relevant. Only if the results appear incongruous with the histology, should the markers be repeated on the excision specimen. No staining 0 Weak 1 Moderate 2 Strong 3. Recommended on all invasive breast cancers. Required on all invasive breast cancers. Nodes — please see official TNM publication for details of complicated classes. Cases in which clarification of specific aspects of the tumour would impact treatment decisions, e.

These reviews are typically requested as needed by a treating oncologist - radiation, medical, or surgical. Processing and evaluation of breast excision specimens.

Am J Clin Pathol ; Henson DE, et al. Practice protocol for the examination of specimens removed from patients with cancer of the breast Cancer committee; College of American Pathologists Arch Pathol Lab Med ; Nakhleh RE, et al.

Mammographically directed breast biopsies: A College of American Pathologists Q-probe study of clinical physician expectations and of specimen handling and reporting characteristics in institutions. Arch Pathol Lab Med ; Recommendations for the reporting of breast carcinoma. Pathology of the breast. Elsevier, New York, Diagnostic histopathology of the breast. New York, Churchill Livingstone, Grading of invasive carcinoma of the breast. Histological examination of breast biopsies: Pathol Annual Pt 1; ; Owings DV, et al.

How thoroughly should needle localisation breast biopsies be sampled for microscopic examination? Am J Surg Pathol ; Ellis IO, et al. Pathological prognostic factors in breast cancer. Relationship with survival in a large study with long term follow-up. Histologic grading and prognosis in breast cancer: A study of cases of which have been followed for 15 years. Br J Cancer ;2: The value of histological grade in breast cancer: Contesso G, et al. The importance of histological grade in long-term prognosis of breast cancer.

A study of patients, uniformly treated at the Gustave-Roussy. J Clin Oncol ;5: Nuclear grading of breast cancer. Virchows Arch Path Anat ; Schnitt SJ, et al. Pathologic predictors of early local recurrence in stage I and stage II breast cancer treated by primary radiation therapy. A Canadian Consensus Document. Med Assoc J ; 3 Suppl: Davis BW, et al. Prognostic significance of tumour grade in clinical trials of adjuvant therapy for breast cancer with axillary lymph node metastasis.

Dalton LW, et al. Histological grading of breast cancer; a reproducibility study. Robbins P, et al. Histological grading of breast carcinomas. A study of interobserver agreement. Frierson HF, et al.

Interobserver reproducibility of the Nottingham modificatio of Bloom and Ruchardson histologic grading scheme for infiltrating ductal carcinoma. Galea MH, et al.

The Nottingham Prognostic Index in primary breast cnacer. Breast Cancer Res Treat ;3: The Nottingham Prognostic Index in primary breast cancer. Sundquist M, et al. Applying the Nottingham Prognostic Index to a Swedish breast cancer population. Breast Cancer Res Treat ; Stal O, et al. Significance of S-phase fraction and hormone receptor content in the management of young breast cancer patients. Br J Cancer ; Do we really need prognostic factors for breast cancer?

Robertson JFR, et al. Biological factors of prognostic significance in locally advanced breast cancer. Efficacy and safety of Herceptin as a single agent in 22 women with Her2 overexpression whjo relapsed following chemotherapy for metastatic breast cancer. Proc Am Soc Clin Oncol ; Remvikos Y, et al. Correlation of proliferative activity of breast cancer with response to cytotoxic therapy.

J Nat Cancer Inst ; P53 and c-erbB-2 expression and response to preoperative chemotherapy in locally advanced breast carcinoma. Muss HB, et al. C-erbB-2 expression and response to adjuvant therapy in women with node positive breast cancer.

N Engl J Med ; Press MF, et al. Poor prognosis in node-negative breast carcinoma. J Clin Oncol ; Sjogren S, et al. Here's an Elkhart Conn 6H. It was owned by Alex Iles. There are some dents and some serious slide wear to the inner tubes. A nice player though it needs some love. Older Yamaha YEP 4 valve euphonium.

Previously owned by Alex Iles of the LA studios. This instrument has had a Minick style tuning trigger added on the main slide to help with tuning on the fly. Overall in very good used condition. Professional Jupiter Jazzer trombone, previously owned by Alex Iles. This model has a. These Jupiter trombones are becoming very popular. This one has a gold brass bell flare and plays well.

Hip Jazz trombone developed back in the s with John Fedchock. This particular instrument was owned previously by Alex Iles. It is in nice used condition and ready to play. Somewhat rare, this is a Bach model 36GO, gold brass bell flare and open wrap valve. In very nice condition with case. A great playing instrument that is a versatile size. Good for symphonic literature as well as commercial applications.

Extremely rare bass trombone made by the famous maker, Larry Minick. This one appears to be a purpose built instrument, in that it wasn't another instrument before like a modified 62H. It has a one piece Minick bell flare, the valves are dependent and also stamped. The J bend tuning slide is prominent in the design and the slide also appears to be custom made. The valves are tuned as normal in F and D.

The leadpipe is press fit, but has corroded and should be replaced. This is a killer instrument and I've only seen a handful ever. A unique opportunity to have one of the most coveted bass trombones in the world. Made in the mid s in England not a Music Group made Besson , this euphonium has the sweetest sound. I had Brad Close make and install a custom standard large shank mouthpiece receiver so it takes a normal mouthpiece. Bob Reeves did a full valve alignment.

It is very clean, a few small dings and some lacquer scratches. Comes with a nice form fitting hard case. Rare eB alto trombone made by J. Model 3, which is the large bore. I don't know why it works so well, but despite the size of this alto, it doesn't sound like a tenor trombone. Its a fabulous sounding and looking instrument, very high quality craftsmanship.

Nickel silver bell garland and nickel slide. This is a new demo model that was assembled from parts that were shown at a trade show. It looks nearly new with a few small blems in the lacquer. Really a tremendous playing shires.

This is an unusual but very special trombone. The model 45 is a special order dual bore small bass trombone. It has a 9" gold brass bell, open wrap F attachment and narrow width dual bore. This particular instrument was hand assembled from parts at the Bach factory with assistance from Joe Alessi. It has had two owners and is in good condition. I've not seen another one like this before. Custom made Edwards bass trombone with a s Corporation Bach 50 bell flare. This bass is great, lots of presence and core with a penetrating focused sound.

Tons of clarity with a big open blow and immediate response. Always something special about the Conn 78H trombones. They have wonderful sounds and offer a great amount of versatility. The 78H has a. This one is in fantastic shape and has the desirable gold brass slide tubes.

Very clean Bach 36G with convertible valve section you can take the F valve off and make this into a straight trombone, a nifty thing indeed. Additionally, the valve section has been customized to an open wrap design by Dick Akright in Oakland. Another bonus, a seamed copper Hoelle tuning slide is also included along with the original tuning slide crook. Alright folks, here's a really unique bass trombone. Pull up a chair, cause here's a story for you.

Legend has it that Jeff Reynolds once flattened a Conn Fuchs bass trombone while out jeeping and Larry Minick returned the instrument to playable condition. I have reason to believe that the slide for this trombone is from that original Fuchs instrument. Don Sawday found the bell in the attic of a music shop here in LA many years ago still wrapped in the plastic.

Don acquired the slide from Jeff. I had Don mate these two together, which is the instrument presented here. The slide has new inner tubes and a proper threaded connector now as well as threaded leadpipe receiver. This is a unique horn folks. This horn is a workhorse and has been well used. It is a great player, has a gold brass bell, thayer valve and standard weight slide. Cosmetically it has been well used but is a very solid playing Bach.

Small patch on one of the outer tubes. Talk about being a trumpet hero, this trumpet is all about that. This horn is in great shape with no signs of wear. In very good condition and particularly good looking! The F valve has had a custom ball and socket linkage upgrade done with improves it a lot. Here's a good deal for a serious trombonist on a budget. This is a Bach 42BO, fairly recent and overall in good shape with the exception of the bell flare, which was damaged and repaired. Whoever did the repair did a poor job and has scarred the flare and thinned the rim bead.

As such, this trombone is offered at a bargain price as is. A beautiful trombone we recently refinished here at the shop. From the mid s and has all the nice features of this great era of vintage Conn trombones.

The bell has the deco engraving, tuning slide has the nickel guard and the slide has both bronze outer tubes and thick slide braces. There is some minor wear on the inner tubes. A really gorgeous vintage Conn that plays amazingly well. The technical model number for this instrument is a D and Kanstul hasn't made many of them. This one is special, as it was ordered in the style of a Bach bass trombone with tuning in the slide.

Additionally it has a removable 2nd valve. More cool stuff, it has a harmonic brace installed which lets you fine tune your vibrance with harmonic pillars none included, but you can get some from Edwards in various metals and sizes.

What more can I say. Another killer custom bass trombone, this time based on a King Duo Gravis. It has a vintage DG bell flare with dependent Getzen rotary valves, original King slide with a Bach 50 slide crook.

Might be one of the best playing commercial style bass trombones I've ever had at the shop. Also has a harmonic brace installed which fits Edwards harmonic pillars. Another one of a kind single valve bass trombone with a "Bartok" 2nd valve, which lets you extend your F tuning slide on a finger paddle. The bell flare is a YBL gold brass flare. The valve section is a Shires trubore and the Bartok mechanism was fabricated by Shires. The slide is a B62 standard. In great shape and plays great.

Used Shires Axial "Thayer" valve section with open wrap. The valve casing and core have just been replaced at the Shires factory with new parts, this is a new valve with vintage tubing. Has the original paddle type thumb trigger. Dig this, this trombone was purchased new in and has been only owned by one person and has spent its life here in LA being used professionally.

It is exactly what you'd want in a sterling silver 2B, the right vintage, the right condition and the right provenance. Sure, it has some signs of use, but it is in great shape overall and the character oozing from this horn is exciting.

This one has some serious mojo! Absolutely beautiful vintage Bach 37ML trumpet in great shape, with original lacquer which has patina to a nice honey color. It is in tremendous condition. You'd be hard pressed to find a nice vintage Bach 37 around in my humble opinion. This is a nice bargain tenor sackbut with F extension, good for a player looking to get into the sackbut scene with a quality german made instrument.

Appropriate for bass sackbut parts as well because of the valve section. Beautiful vintage Conn 72H bass trombone in excellent condition. These are the vintage that is most desirable.

The outer slide tubes are "bronze" and with thicker stock and oversleeves. The bell engraving is crisp and the rotor valve seals nicely. The 72H is a bell tuning version of the famous 70H bass trombone with tuning in the slide. The handslide is longer on a 72H to facilitate a low C in tune. The Miraphone contrabass trombone in BBb, complete with giant bell and quad bore slide. This thing is a sound monster.

It isn't the easiest thing to play in the world but with some practice you will own the foundation in any brass ensemble, film score or trombone choir. In very good condition with some minor cosmetic blems. Slide action is decent for 4 slide tubes. This bell section has a newer "dual bore" rotary valve offered from Shires. It is the same valve used on their "Ralph Sauer" model. Plays great and very even on both sides of the horn. Add a slide and you've got yourself a nice trombone!

Very nice lightly used Yamaha Yeo Bass Trombone, dependent valves with removable 2nd valve to convert to a single trigger. The bell was damaged and repaired in shipping transit and has a scar. Otherwise in very good condition. Small ding on valve tubing. This is a very nice playing trombone and comes with the special order.

King 2B Plus trombone, these are a. These are really great playing trombones with a big sound, predictable response and versatile color. Great small bore trombone for players looking for an open blowing jazzer. The 32H is a dual bore. No one makes anything like the 32H anymore. I can't think of a more versatile small bore trombone out there.

Works great on mic, in the studio, in a live setting, big band or even principal in the orchestra. This one is a late s vintage and is from the most desirable period of 32H trombone production.

In very good condition, rare to find these with gold brass bell flare and standard weight slide. I've always had a soft spot for the often overlooked Conn 79H.

Most players didn't know that this trombone was available, but I think its one of the very best instruments Conn ever made. There is something special about the bell flares on these instruments and the added bonus of having an F attachment is huge.

This one is in very good condition, some minor slide wear and cosmetics from the contact points but overall very clean. This is a no frills instrument but it gets the job done. Open wrap valve in rose brass, rose brass bell, reversed tuning slide and narrow large bore slide.

Great for someone on a budget or a budding young trombonist. Lightly used Shires orchestral tenor trombone with the popular 7YLW bell flare. Shires Trubore valve section and a TW47 slide. All in excellent like new condition with some minor wear on the valve section and a small dent in the F tuning slide. Very interesting setup, similar to what Ralph Sauer is using.

This is a standard 1Y bell, new Shires rotor valve with open wrap and a lightly used T dual bore slide. The slide has a leadpipe that takes a large shank mouthpiece. This is a great playing trombone, extremely versatile. Very clean Bach 42BOG trombone. Gold brass bell, open wrap valve and lightweight nickel slide. A solid playing trombone from the early s. Very clean Schmelzer Model 1,. Made in Germany by Manfred Schmelzer, this is a top tier jazzer. This one has a gold plated bell section and nickel slide.

A really tremendous playing Conn Elkhart 8H from the late s. It's spent its life in Las Vegas playing with many of the legends of music. Overall in very nice vintage condition and one of the better playing 8Hs I've had come in. This is the famous "Burkle" model 32H trombone, named after its designer Jake Burkle. These are incredibly versatile jazzer trombones that are particularly popular among players accustomed to larger bore trombones and looking for an open blowing jazzer that sounds like a jazzer.

The 32H trombone has a. These are fantastic trombones and no one makes anything like it among the modern makers. Chinese made BBb contrabass trombone based on the Miraphone contra, nearly identical specs.

Quality on these has certainly improved. Its not in the same league as the original but at a fraction of the cost, certainly gets the job done. This one is in very good condition with a decent hardcore.

Beautiful late s Conn 6H with the deco engraving. These are highly in demand now, and very hard to find with this engraving and in good condition. The lacquer isn't in great shape and might actually come off when I sonic clean this horn, so no guarantees you'll get it with this patina unless I don't clean it.

Otherwise very nice condition and a tremendous player. One of the most versatile commercial trombones ever made. It has an open wrap 88H bell section with a. Threaded leadpipes and linkage upgrade on the valve. Here's a custom made Conn 8H that was assembled for Alan Kaplan. This one has a special order 8" bell flare and a. For the bargain hunters that lurk on the website, here's a very nice playing 36B that isn't going to win any beauty contests.

If shiny trombones isn't your thing, this might be the medium bore trombone for you! This one has an 8" bell,. Just finished an in house restoration on this vintage 88H. Serial dates it to early Texas production. We've just replaced the inner tubes with new ones. Valve has been serviced and the instrument has had all dents removed and it has been relacquered. It is top notch shape now and is a beauty. We tried a new bell brace design on this one to see how it would turn out and the results are promising.

The core is really something special on this trombone. It projects like crazy! As with all our full conversions: New inner tubes, threaded leadpipe receiver, bell voodoo, open wrap oversized valve section, Brassark seamed tenor slide crook and this one gets a seamed copper MV42 leadpipe. We have about 10 of these out in the world now, and this one is available. Beautiful Giant Alexander BBb tuba with 5 valves. In excellent condition with a Winter hard case.

Plays amazing and throws a lot of sound. Some minor cosmetic blems and a few small dings but overall very clean. A totally unique vintage Holton large tenor trombone with a screw off bell flare. Great for traveling and also just as a darn good trombone. This instrument has a dual bore. This one is in excellent condition with great slide action and no dents.

Some minor cosmetic blems in the lacquer. This is an absolutely stunning vintage trombone, all in glorious Conn red brass. This trombone has a. It is a bit front heavy because there is no counterweight but the clean look of the horn is something to behold. The sound is velvety and beautiful. It looks like it has been relacquered once a long time ago and done very well. The sound this little trombone puts out is nothing short of unbelievable.

This is a tremendous playing little sports car. The model 6vii New York was the most open of all of the model 6 variations and this one is no exception.

This trombone has been around, owned by many prominent players and is now up for sale again. It has small specs: I love the classy look of this beautiful vintage Alexander French Horn. The is the same as the famous model used by tons of hornists around the world.

It is all gold brass and the bell is made in the old "gusset" style of fabrication that yields amazingly vibrant bell flares. I think this one is from the late s, guessing from the engraving. It is in fantastic condition and includes the original case.

Here is one of the original Larry Minick tenor trombones made in the s. It features a one piece gold brass Minick bell, the amazing Minick rotary valve with open wrap, Conn 88H style slide with Minick leadpipe as well as a straight neckpipe allowing for a valveless trombone.

This instrument is a formidable orchestral instrument. It has a dense and dark sound quality and really projects amazingly well. The blow is open and free and the rotary valve is excellent, being similar to the Trubore design with a straight port on the open Bb side of the trombone.

Overall in very good condition with no major damage or dents. There are some patches on the handslide covering up worn spots so no holes develop.

Comes with a case. I've never seen this before, but this is a Bach C large bore cornet. Ideal for orchestral cornet work and would be awesome on a Soldier's Tale. In fantastic condition with bright silver plate and no signs of wear or dents. Has a bell flare. Terrific sounding rare Bach cornet. A gorgeous Bach large bore Bb cornet, refinished and silver-plated by Zig Kanstul. Early NY production, all stamps are clear and matching.

There is a patch on the back of the main bell bow. Here's a well made, quality German alto trombone that isn't going to break the bank and be fairly easy to learn. It is a model Challenger in Eb and in good overall condition with some minor dings and cosmetic scratches in the lacquer.

It is unlacquered and in overall very good condition. Some signs of use on the contact points and a few small blems here and there. Extremely versatile and mouthpiece specific, smaller mouthpiece sounds commercial and bigger piece gives a great orchestral sound.

Open blow and fast response. Slide action is good but does have some chrome wear. The slide has been widened to accommodate the Thayer valves and larger necks.

Very nice used Shires large bore tenor trombone in very good condition. Some minor wear on the slide contact points and the neckpipe. Very clean overall and a solid playing trombone.

Has a 1G bell flare which is a gold brass bell with soldered rim on the original shires bell mandrel. An axial thayer valve with open wrap and gold brass tuning slide. The slide is a TB which dual bore bach style slide.

Three leadpipes included, no case. Here's a beautiful playing Bach Mt Vernon model 12 trombone, with a lightened slide work done in the s by a tech in San Francisco. Some minor lacquer wear and scratches. Tubes are all in good shape and seem to be original.

Beautiful Bach Mt Vernon model 36, looks like original lacquer. Slide crook has been off and touched up, looks like gold brass outer slide tubes. The bell is stunning, one of the nicest MV36s I've had come through the shop. Lots of good notes in this one. Stunning Bach Mt Vernon model 36, gold brass bell. The bell is glorious, the slide is excellent one small spot of wear on the top inner tube with only some minor lacquer wear on the bell from some adhesive residual.

Ultra lightly used Greenhoe 88HT-G. This features the thin gauge red brass 88H bell, Greenhoe valve with open wrap and standard. This trombone is in excellent condition and shows little signs of use. A few minor cosmetic lacquer blems but otherwise it is very clean.

Plays extremely well and the valve is even with blow and timbre on both sides of the trombone. These are no longer in production, so get this one while you can.

This is handmade by my good friend Markus in Herzogenrath Germany. It is beautiful to look at and hear, as well as play. A used friendly bass sackbut this is one of the best "bangs for your buck" you can get info for a high quality professional level instrument. This one has 3rd position bell to slide relationship. Very nice Shires large bore orchestral tenor trombone with some nice modifications.

This is set up to play similar to a vintage 50's Conn 88H trombone, so if you are a fan of those instruments but looking for something a bit more modern and open blowing this trombone could be right up your alley.

The bell is a 2RVET7 flare, which means conn taper red brass bell with thin rim wire and unsoldered bead. The valve section is a standard Shires rotary with open wrap. The slide is a TW47, wide style. You'll notice that the previous owner had a tuning slide bow guard installed on both the main and F attachment tuning slides ala s 88H style.

This is an extremely good playing trombone with a beautiful vibrant and focused sound with a lot of warmth and depth. Here's a lightly used Miraphone BBb tuba, model , about 5 years old. It has been well maintained and is very clean, showing a few small dents and some minor cosmetic wear.

The is maybe the most popular BBb tuba in the world, used by students and professionals for its versatility and ease of playing. The craftsmanship is top notch. This one includes a very nice Glenn Cronkhite gig bag with backpack straps.

Beautiful lightly used Shires trombone with some special components on this one. It has a one piece TII 5G bell, which is a single sheet of gold brass made on the newer bell mandrel based on a Bach style bell. It has a soldered rim and it is a fantastic playing and sounding bell. Comes with a trubore valve, a free blowing and even valve designed by Steve Shires.

It has a nearly new TB47GL slide, which has gold brass outer tubes and is a bach style slide with Bach length. This helps Bach style players feel a bit more comfortable with the length slide they are used to.

Mated with this bell section is a gold brass tuning slide. Really a phenomenal playing orchestral trombone all around in excellent condition. Here's another ultra clean Shires tenor trombone made in Massachusetts.

Regarded as one of the best trombone makers in the world. This Shires has a 2R bell red brass flare with unsoldered rim, original Shires mandrel and a trubore valve. The trubore valve offers a straight airflow on the open side of the horn and a gentle swoop of the tubes for the F attachment side, one of the best and most even blowing valves on the market.

This one also has a TB47 slide which is a wide bach style slide. This one is in excellent condition showing little use, it is about 3 years old. This is a special trombone. Mated with this bell flare is a Shires axial "thayer" valve, Shires TB47 bach style slide and a Shires "S" seamed yellow brass tuning slide. If you're after a classic vintage Bach but want something that plays a bit more modern and predictable, this might be the horn for you. There is some cosmetic wear on the valve and slide but overall very clean.

The bell is unlacquered raw brass and has a glorious patina. The bell has shires mounts and is modular. Here is a new, demo model Shires Michael Davis Plus trombone. Made by Steve Shires in Massachusetts. This horn is top tier craftsmanship and delivers amazing performance and versatility. The bell is a yellow brass 8" flare and the slide is a nickel. Basically the best 3B style trombone ever made. The slide action feels fantastic in the hand, there is a thin but not flimsy brace on the slide that feels just right.

This horn was a demo model and is new but has been tested in the shop. A desirable s vintage Conn 6H Jazz Trombone,. In very good condition with some worn spots on the hand grip. The bottom outer slide tube has had the nickel oversleeve removed to save some weight. Antique Cornet made by John Heald of Massachusetts. One of the finest makers of cornets of his day, Heald had many patents for instrument design. This is a very well made period instrument. I've recently had Robb Stewart go over the instrument, installing a small nickel patch on a split tube, as well as remove dents.

He reports the valves are tight with excellent compression for an instrument of this vintage. The King 6B or "Duo Gravis" is prized for its bright color and edgy bite that works extremely well in commercial settings.

This one is in very good condition overall with some minor cosmetic wear on the contact points. Super cool and rare Conn 78H from the s. This one is a terrific player and is made from all sheet red brass. Inner tubes are chrome plated. As such, this is like a bigger bore jazz trombone. Amazingly responsive and would be extremely versatile in a variety of professional settings.

Simply a terrific trombone from my favorite era of Conn trombones. A brand new Markus Leuchter bass trombone, specially made with a 9" gold brass bell with a nickel garland. Also optional is a 9" gold brass bell without the garland.

Has a dual bore. This bass trombone is incredible. Its not only one of the easiest instruments to play but the sound is absolutely stunning and vibrant. Completely hand made by Markus in Herzogenrath Germany.

A brand new Markus Leuchter contrabass trombone in F. Totally stunning and epic giant trombone. I personally use one of Markus's contras and I can't say enough good things about this instrument.

It is by far one of the best sounding and easiest to play contras available in the world. Made from all gold brass, chrome inner slide and totally handmade by my good friend Markus in Herzogenrath. This is a beautiful custom built tenor sackbut by Markus Leuchter in Germany, brand new. It features a 4th position bell, hand engraved garland and decorations, chrome plated nickel inner slide tubes, handmade water key and tuning bits to A and A Just wanted to ask for your opinion on using waxy maize starch as opposed to dextrin or maltodextrin in post-workout shake.

I started with creatine a couple of months back as per your suggestion and have noticed gains in my lifting capacity but not so much of muscle gain. I am now looking to gain some big ass muscle and hence have a few questions.. How effective are the gainers available in the market? Are they really effective? What is the best gainer out there in the market which is really helpful for ectomorphs like us?

How much of it should be taken per day? Is 1 scoop after breakfast and 1 after workout enough or should i be taking more? Hey Sushant, glad you got some gains man! Does that make sense? I agree with what other people are saying. Some other favourites of mine are: Still not as good as making your own though. As for how much you should consume to grow? But your overall intake should be enough for you to gain weight on the scale and improve on your strength in the gym.

Surrounding training though you can take advantage of a pretty potent advantage that nutrient timing offers. Would it be possible, especially increase my arm size. You should get started soon though!! However, if I wanted to workout 4 times a week, do you think there would be any negative high calorie effects associated with taking that many calories?

My understanding of the health component of consuming a lot of calories is that it depends on where those calories are going. What a great article, I love the fact that you use research studies to back up your claims. Your photos are also a great testament to your hard work. How gluten free friendly are you guys? I eat a ton of beans and plenty of potatoes.

Lots of guys eat tons of rice and quinoa. Pizza and pasta have never been big favourites of mine even from a taste perspective. What dosages do you reccomend for me personally?

Very good article though. I was re-reading the article and was wondering, do I mix 90g of protein, g of carbs, and 15g of creatine also or triple it so it would be g of protein, grams of carbs and 45g of creatine? Would I mix the 3, drink it before, after or during my workout?

When would I have to drink the fish oil? I would start with 30g whey protein and 60g maltodextrin. If that goes well and it comes time to increase, then up it to 60g whey protein and g maltodextrin. Hey man, I started taking 2 2. I know that creatine has a unique relationship with water but if i have a lot of water, will i flush the creatine out of my system when i go to the bathroom?

You want to take in a bit more than you need for that reason. What is the best dosage for the NutraSea Fish oil? Just pour into a tspoon and consume once a day? Yep, consuming once a day is perfect. Or are you just using water in your shakes? Are there any advantages or disadvantages to using milk instead of water? Milk is a surprisingly potent workout drink, considering how ridiculously slowly we digest it!

It has a lot of muscle-building benefits built into it, since there are so many rad vitamins and minerals in there, alongside a great source of protein. You may dig this article, too: I have a very limited budget so I would just like to ask if buying creatine and whey protein will be enough? Or should I buy whey protein and fish oil isntead? I am a beginner when it comes to working out so forgive me for this question. I also read that there are harmful side effects when using fish oil, are those claims true?

You can certainly ask your doctor though! I would also get kidney stones.. Or bowel movement would stop or go crazy if you get what I mean lol.. You think this program can help me. Almost all of us run into our share of mishaps, struggles and challenges with this stuff—I know I did!

Yes, I think our program could help. We take a pretty methodical approach to this and the goal is to make you even more resistant to injury, not set you up for it. You may want to get clearance to do squats and deadlifts again, too. You may find value in this article, too: On non-lifting days I try to eat as much whole nutritious food as possible.

When it comes to starches my go-to favourites are: There are tons of options out there—another big favourite for a lot of healthfully-minded dudes is quinoa. Do you consume the same amount of supplement servings on your rest days as well, or is it only on workout days? Are there any alternate body building supplements without Creatine, because doctor suggested me not to use because. Creatine is not suitable for me.

And fish oil is still a great addition to your daily nutrition. However, the protocol seems a little scary. What do you suggest? I was thinking of going for whey protein first. But would that not add a lot of gains? I hope I converted that right. I wanna gain muscles so bad.. I went through the comments and i hope that you reply on the few ones on top.

That will clear out and help me a big time. Hey Sultan, I try to answer every single question! Do i have to take creatine dosage plus add creatine it to my drink for workout day or the drink is enough? The workout drink is more than enough creatine for the day! Hi Shane my name is Ryan, I just so happened to stumble across one of your articles a couple hours ago and since then have thoroughly enjoyed most of what your website has to offer.

Must say very impressed! A lot has changed since high school, I am 20 years old now and 5 months away from shipping out for basic training for the military cant enlist until braces are off. Now couple years later terrible diet, virtually no excersise, and no supplements. I am 6foot 1 and pounds. Not chubby at all but def fat has hidden my 6 pack away: As I said I have a few months to jump back on board and I am dead serious about getting in the best shape of my life.

I just bought YMCA membership and signed up for swimming lessons. I want to bulk up with some serious muscle mass and burn some of this 22 percent body fat and get it back down to healthy level. Or will I need to make adjustments? Most people need to make some adjustment or another, as everyone is a little different.

Yep, the workout shake will still work. Just stick with a single dose—for now at least. Hope you decide to join us man!

What would you suggest? We live in Toronto too. Seems like a great place to train at! Fish oil timing is one of those cases. This program sounds awesome! And man, looking at this site just makes me so excited to join and try! Thanks for the heads up Oliver! Hey Shane, thanks for your reply. I noticed that you have updated the links, but not all of them. The ones of whey protein and Maltodextrin are still invalid.

Do you mean what do we mix the powders with? Some of our guys use milk though and use a bit less whey and maltodextrin so that it has the same overall nutrient breakdown. I only weigh 47kg. Can you please suggest me a good one. They seem to be broken right now, as bodybuilding.

Sorry for the confusion! So which one will give me better result. Still working on it! Hi Shane, thanks for the great post here. The info you guys provide has been very helpful in my quest to gain weight.

I just started using the fish oil that you have recommended thanks for the links and you were right, this stuff is really quite easy to take. However, I just read a study which links omega 3s to a higher risk of prostate cancer. I was wondering if you have read this study yet? I figured I will talk to my doctor about this one before continuing with the omega supplements.

Oh man that study has been making waves! Interestingly enough, fish oil actually reduces your chance of getting prostate cancer in several other ways: Aaaaand keep in mind that MOST studies still show that consumption of omega 3s reduces your risk of prostrate cancer! The media is always coming out with sensational stuff like this, as this new research is shock worthy and increases readership.

Thanks Shane, what a great article! As a ectomorph struggling to put on weight this is very helpful. I was going through the comments and must appreciate the fact that you take the time to answer all questions your readers have.

Most of my doubts got clarified as I went through your answers. No problem Misha, glad it helped! And this post is broscience all the way. Just eat and lift heavy.

My legs could use a lot more work though. I looking to gain another 10 to 15 pounds of muscle. I train for strength as well for definition. You may not be a hardgainer at all, just a poor eater! You sounds like a good fit for this program, yeah. We can definitely bulk up the stilts, and nothing will do a better job of giving you a strong balanced physique than squats and deadlifts! Hey Shane, what is your opinion on oatmass as an alternative to maltodextrin?

Or, rather, blended oats, as they are essentially the same, right? This stuff is working! However, Ive gained unwanted fat in my middle section, and thighs, where that was never happening in the past. I weigh now around lbs. I still appear skinny to most, but I may be average. Do youvthinkbthos program is right for me?

Most guys have a bit of this or that mixed in, often in the form of carrying a little bit extra around the middle hehe. Now, here comes the problem: Does you guys or any one of your clients ever got ANY stretch marks on your skin due to rapid muscle building?

A lot of us ectomorphs have stretch marks from growing UPwards though. A lot of us take to puberty by rapidly shooting sky high instead of getting muscular, it seems. It awes me how much you guys are into this for us, ectomorphs. The past two weeks I merely stood at my current weight. I want to have the leanest possible bulk ever cutting being an ectomorph? I know what you mean. By super leanly bulking you can always maintain your strength of being lean while adding on the new strength of being strong and healthy.

You need to gain weight to grow, so a calorie surplus is your friend! I like to track using the vein on my bicep. I take creatine with some food and use whey after workout but how to use dextrose and maltodextrin: Shane, I read that you use 15g of Creatine when you try to gain some weight.

Is this true or is our maximum of creatine as being an ectomorph much higher? Yeah I used to take 15g of creatine spaced out over a couple hours. Some creatine might have been flushed out, yeah. Hey Shane I wanted to know other than the days im working out and making that double dose shake, should i be having just a regular whey protein shake the days im off? And is having all that protein healthy for you? Universal Torrent is a pretty good gainer, although once you start having several servings at once the cost quickly adds up!

The maltodextrin they load the stuff with costs them pennies and costs you several dollars. I figure may as well just buy it yourself, mix your own perfect ratio, and save a bit of money. Can trim the doses down and fiddle with things if you ever decide to cut or anything. Getting your protein from a variety of sources is best, and yep whey protein is a totally valid place to get it.

I get more than enough there. Can you refresh the links of the lists of supplements please. Thanks in advance for your reach article that helps me a lot.

Lets say will I have to increase my protein intake overtime? And I also read that your body absorbs about 25g of protein in an hour so what would be the point of doubling your protein intake if it would all be converted into waste?

I am looking forward to stop drinking Gatorade as it contains quite a lot of sugars, and buy maltodextrin instead as it looks much healthier, thank you Shane for your time and keep it up! Your site is great. Thanks for the kind words Juan! Comments like yours are why I love writing blog articles so much. Gold Standard is sweet. ON is a good company. Bananas are sweet too, and a great source of vitamins and minerals as well as being a good source of carbs.

I think Gatorade is made out of sucrose, which contains fructose. Fructose is absorbed very differently from glucose and not necessarily in a beneficial way.

Not the best thing to be taking in high doses while training. I mean bananas have so many amazing things going for them. If you like the flavour of Gatorade, you could try adding a scoop of Xtend to your drink. You can buy flavouring like citric acid separately too. Yep, you can develop an intolerance from eating too much of anything, really!

If your body can only absorb 25g of protein in an hour then drinking more than 25g of whey in an hour will just mean that it takes longer than an hour to digest all of the protein! If we just peed calories out if we ate them too fast that would be the best news ever for chubby guys and gals, who, presumably, could eat entire cakes just fine so long as they ate them quickly enough.

I use a protein shaker 20oz. You could drink 1 in the change room beforehand, 1 in the gym and 1 after. Thanks Shane for all the help and advice. Can i make this with milk or is the taste not gonna be as good?

Also how much milk would you use if you use 28 oz of water? You could probably make it with milk so long as you feel good while drinking it.

Could be that fat soluble vitamins, like vitamin D, work better in whole fat milk. Shane im sure you answered this somehwere but since carbo gain doesnt have a scoop how do you measure out a serving size? Or how many scoops would i use if i used the scooper from the gold whey box. The tub should have nutrition information on the side … but who weighs their food? Right now Jared and I are trying waximaize maltodextrin is way more enjoyable — waximaize seems to be the twin of corn starch and it came with a scoop.

And can you help me choose the best creatine brand? Dextrose tastes like milk sugar, and waximaize tastes like cornstarch — up to your taste buds! Might be better for the teeth, too? Have it right after you finish your workout. That will double the dose and give you some extra calories and extra protein to play around with. No need to double the creatine, although you could! I am 17 years of age. I know eating more and being beastlier in the kitchen is easier said than done, so just take it day by day and try to build up progressively better and better habits!

After all your gains, do you still take supplements? I mean, when people reach their goals in terms of bodyweight, do they stop taking supps easily? I ask because in my country supps are overtaxed, so I see it as an investment, instead of a cheaper alternative to food. I stress constantly about it, and I just been thinking about anything that could help me with building muscle drug-free is a go, so supplements are my first choice.

Buuut… people become hostage to this shit. I wonder if it would be possible to drop naturally, with ease, them once I packed those 20 lb. Would you guys mind telling me a little about your thoughts and experiences? I used to wonder that all the time myself. Ergogenic supplements SuperPump, NO xplode, jack3d, etc: I felt like I went from being superman to a weak old man when I stopped training with them.

The homemade ones are very cheap, and, for MOST people, cheaper than their whole food equivalents. You can accomplish your gains and then use very minimal dosages or stop using them entirely. Gainers QuickMass, Serious Mass, etc: Kind of useless to begin with and massively overpriced. Food replacements, like whey protein: Stuff like fish oil you might want to take forever. Stuff like vitamin D is tricky to get naturally, as you need to be outside a lot to encourage your body to synthesize enough of it.

Most people need to supplement with it or drink milk, which is fortified with it. Anyway, the short answer to your question is no: If nutritious whole food is cheaper and more accessible for you and you have the appetite to eat it then you could forget about supplements altogether! Good luck gaining your final 20!! Supplements are still cheaper than most whole foods, but not as cheap as you might think. It is still cheaper taking malto than buying whole food price per calorie , but in the specific case of whey and pre-wo, they are way off the range.

Yeah, that helped a lot! So, did you stop taking supps entirely now that you reached your final weight? I really like it, and I like having goals to work towards. I still take supplements. It sounds like things are different where you live — I do know that food in Canada is expensive relative to other countries — but whey here in Toronto is muuuch cheaper than, say, chicken breasts, steak or ground meat. If you call it a supplement I also absolutely adore coffee!

I have a nice hot mug before pretty much every workout and love it pretty heartily. As for your creatine questions: Not everyone gets water retention from creatine. All the extra muscle you built while on it … that will stay.

How much lean mass can you expect to gain? I went in an added a bunch of studies to the creatine section today. Well, that was the original plan. To be completely honest, I did take around g of malto after workout days for a few weeks and gained some weight.

Not that much, though, never passed on my max weight. Maybe 1 or 2 lbs. VERY slowly, way slower than I would see elsewhere. One thing is the scale moving slowly, other thing is the scale not moving at all!

Had problems with whey concentrate, might try isolate. Focus on moving up your weight on the scale each week instead i. Now that you have my info, my questions: Do you recommend otherwise, and how many servings per day and when is the best time? Please mention the creatine servings too. I noticed last year, although not sure, that briefly taking Whey with milk induced mildish stomach pains. Also, how much cardio should I do?

Is a minute session good enough? I usually go start with 1 set wide pull-ups, 1 set push-ups, then 1 set dumb-bell chest-press, 1 set crunches. REST, repeat 3 times. I substitute the chest-press with the lat pulldown on alternate days, and also include bicep curls, and traps sometimes, and holding a dumbbell while squatting.

What do you suggest overall, and how is my plan looking? Where would I be in 3 months? You live in a place where you pretty much only have access to fish, green vegetables and eggs? Sounds like some sort of super-health haven! As for creatine, you want around 6g a day. Your body needs about 3g per day, but we lose a few grams when we take it. We do some dynamic stretches, a few mobility drills and practice our lifting technique at the beginning of every training session.

Different programs are constructed in different ways. As for a specific workout program for you, I would follow one made by an expert! You could use our program which I obviously think is the best one out there ever , or any other number of great programs out there. Definitely thinking about joining the program but have some questions about what I can expect in your program.

Nevermind — the email bounced from the account you have attached to your comment. Shoot us an email at us bonytobeastly. Hey shane i was wondering how many scoops of the carbo gain using the scooper from the gold standard whey is equivalent to 1 serving? If i am trying to put on a good amount of weight do you sugesst using the 3x dose? A whey scoop holds about 30g 24 of which is protein. For every nice full scoop of whey you put in the drink, put 2 kind of wimpy scoops of maltodextrin in.

As for how much you should take, I would let your abs decide. I handle them well, as do most naturally lean super skinny dudes, so a triple dose works well for me.

Start with a single, scale it up. Thanks a lot man that def helps…Il be putting in 4 wimpy scoops of cargo gain then for a double dose!

Are you drinking this concoction only on workout days? If so, does this mean your daily caloric intake swings quite a bit between workout days vs. Yes and often yes! We seem to respond pretty well to cycling carbs and calories. You could skip a snack or shrink the serving sizes of some meals, etc. Excellent article with studies. I read most of them and went out to buy the 8 lbs of Maltodextrin.

I went to research more into Maltodextrin and came across this study http: Our diets DO affect our gut flora, and the healthier and more balanced our diet tends to be the healthier and more resilient that flora tends to be.

WebMD is telling me that these foods commonly cause symptoms to flare up:. Currently, it is unclear how environmental factors contribute to the development of disease. Dietary studies in both mouse models and humans demonstrate large shifts in the composition of the microbiota dependent on diet [16], [25], [26], [27]. Likewise, human studies comparing obese and lean twin pairs demonstrated changes in Bacteroidetes prevalence and a decrease in microbial diversity in obese individuals [47].

The last line says: If these individuals carry other risk factors for CD genetic variants of anti-bacterial response genes such as ATG16L1 or NOD2, for example , this may result in the development of disease in these susceptible individuals. These findings describe a potential disease mechanism linking the ubiquitous dietary additive MDX to microbial changes in the intestine of CD patients and suggest a novel therapeutic area for the prevention and treatment of inflammatory bowel disease.

You are also, of course, perfectly welcome to play it safe and get your carbs from somewhere else! What changes did you make in the October update? I might have a bad memory, but could it be that you had glutamin in there before?

If so, why did you drop it? Hey LJ, the changes are prrretty small. We added in a little excerpt from Alan Aragon, explained the methods behind our madness a little more clearly, and we added in a couple more reference studies. Last month we made a slightly more significant change though — we added a TON of new studies, we switched over to recommending Amazon.

Amazon is one of the few sites that stocks it. Consume lots of easily digested proteins, carbs and calories surrounding your training and in general … but still get the majority of your calories from minimally processed nutritious whole foods. Creatine is the most powerful legal muscle-building supplement out there, and it also happens to be cheap, healthy and very very well researched for decades now.

Fish oil helps you get a more balanced fat intake and it has a bunch of promising effects on your health and body composition. Vitamin D is a fat soluble vitamin, so taking it alongside a fat like fish oil allows it to be properly absorbed.

Vitamin D fortified whole milk is another effective way to get your vitamin D in. Anyway for now i was really hoping if you could help me anyway with some tips, having just bought some malto and whey i made my first post workout drink of double dose, and for 30 mins afterwards i felt pretty sick lol. I train 3 times a week doing all the major compound lifts, I eat around calories a day but it seems nothing is paying off right now, being stuck at this size is becoming really disheartening, really knocking my confidence man.

I was wondering if maybe you had any tips for me, tired of being this skinny where i can see my hip bones lol. Being in the UK is great. One of the strongest and most helpful guys in the community, Steve, is British. Yeah some people handle the drink better than others.

The best thing though is to get a really firm grasp on the fundamentals of lifting and eating to build muscle. Shane I think you saved my life… I started bodybuilding a few times, never really bulk any weight… So this time I was determined to use steroids… Gladly I found your website. Now I would have a question… In my country gainers are much more cheaper than protein, so I will use Serious Mass.

The serving size is gr. Could you tell me please how much sould I take during a day, and if I must take-it in non-workout days too? I have some financiar issues, but when I will overcome those, definitely I will sign up for your program. Gainers are usually cheaper than protein but more expensive than maltodextrin. Buying protein and maltodextrin and mixing it up yourself is often cheaper. Definitely the same idea — the ingredients in Serious Mass are first maltodextrin and second protein albeit a blend.

Whole foods will be markedly better. I just noticed the new pictures that u put up of yourself.. I wud also like to share that i gained 5 more kgs since i last messaged you so i weigh in at My aim is muscle gain especially in the arms. Can i mix whey or a protein blend and mix it up with milk, bananas and peanut butter to achieve the same effect as Serious Mass?

Have you used Serious Mass or Combat before? Musclepharm Combat 4lbs blend or Serious Mass 12 lbs? Keeping in mind my aim of muscle gain and of-course cost effectiveness. Eagerly waiting for your reply.

No, the effect would be different. Weight gainers do work for ectomorphs — they provide carbs, protein and calories, after all. Man, I felt like such crap after taking them. Bananas are badass at building muscle. Same deal with peanuts and milk — totally badass in all kinds of subtle ways in addition to being great sources of macronutrients and calories. As for gaining in your arms, stay tuned!

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