Scar-less surgery for breast fibroadenomas

Fibroadenomas are the most common cause of a breast lump. They usually develop in patients between the age groups of 15-30 years and can cause distressing symptoms. Patients usually present with a painless lump, which moves around in the breast, which is why it is sometimes referred to as a ‘breast mouse’ as well.

The exact cause of fibroadenomas is unknown but it is hypothesized that it develops due to hormonal fluctuations. Majority of the patients present with a single lump in the breast but approximately 10% patients can present with multiple fibroadenomas (read about the interesting case of a lady with 39 fibroadenomas – https://docrohan.wordpress.com/2014/04/29/39-fibroadenomas-removed-using-just-two-incisions/), in both the breasts.

Clinical features of fibroadenomas

As mentioned previously, patients notice a lump in the breast which is usually painless. Pain can develop in fibroadenomas as they increase in size and this pain can also increase in intensity before the periods. Sometimes fibroadenomas, are detected during screening ultrasounds/ mammograms as well.

Risk of cancer in a fibroadenoma?

Whenever a lady is detected with a breast lump, their first concern is that it can be cancerous. Fortunately, fibroadenomas are non- cancerous (benign lumps) in the breast. The risk of cancerous change in a fibroadenoma is less than 2%. Those patients who have a family history of breast cancer are at a higher risk of developing cancer, which is why family history is one of the indications to surgically remove the fibroadenoma.

How is the diagnosis of fibroadenoma made?

Fibroadenoma is usually a clinical diagnosis (made by taking the history and examining the patient) supported by a breast ultrasound. In patients, where the ultrasound reveals atypical features, a tru-cut biopsy / needle test is recommended before proceeding for surgery

Can fibroadenomas be managed without surgery?

Unfortunately, there is no medicinal treatment available for fibroadenomas. Various drugs have been tried but they fail to resolve fibroadenomas which are above the size of 1.5 cm.

Do all fibroadenomas require surgery?

As mentioned previously, fibroadenomas are non cancerous breast lumps and all patients with these lesions don’t require surgical management. The indications for surgery in a patient with fibroadenoma are:

1.       Family history of breast/ ovarian cancer

2.       Lumps more than 4-5 cm in size

3.       Fibroadenomas associated with pain

4.       Fibroadenomas which are increasing in size

5.       Fibroadenomas which are causing cosmetic problems for the patient

Patients with small (sub-centimentric) fibroadenomas do not require surgical intervention and they can be followed up by doing serial ultrasounds every 6 months. If on the repeat ultrasounds, there is increase in size noticed, then the patient can consider surgical removal.

There are two surgical options for fibroadenomas. The traditional surgery involves making a small cut over the breast (at a site where the scar can be concealed), most commonly, over the outer border of the nipple (as it gives the best cosmetic result). After making the incision, the lump is removed and the incision is closed using absorbable subcuticular sutures (so that there are no needle marks on the surface of the skin).

The other option which is gaining a lot of popularity is VABB (vacuum assisted breast surgery) or scar-less breast surgery. In this technique, the fibroadenoma is removed using a special machine and with just a 2mm incision which does not need to be stitched. The advantages of VABB over traditional surgery are:

1. Scar-less procedure – 2 mm incision
2. Multiple fibroadenomas (at different places in the breast) can be removed using a single incision
3. Faster recovery

22 year old girl with a 4 x 4 cm fibroadenoma in the right breast

2mm scar after surgery



VABB is done using a special machine and under ultrasound guidance, which ensures that the entire lump is removed during surgery.

Fibroadenoma surgery (whether open or VABB) can be done as a day care procedure, where the patient gets discharged on the same day of the surgery. There is minimal pain in the post-operative period, although VABB can sometimes be associated with bruising which settles over a few days. Cold compresses & a sports bra can further reduce the pain and bruising after surgery.

Can fibroadenomas recur in the other breast after surgery?

As mentioned previously, 8-10% ladies have a tendency to form multiple fibroadenomas. These ladies can develop fibroadenomas in the future, at different places in the same breast or in the other breast. This can be monitored by doing regular scans after surgery.

If you have any further questions regarding fibroadenomas, please feel free to contact Dr. Rohan Khandelwal.

Information provided by Dr. Rohan Khandelwal

Lead Consultant & HOD, The Breast Centre

CK Birla Hospital, Gurgaon

rohankhandelwal@gmail.com

Online consultation – +91-7988252759

Important Images in Surgery Part 2

In continuation of the previous session, you can video on important images in surgery (part 2) in this thread.

You can download the PDF of this session by clicking here –

important-images-part-2-final-pdfDownload

Important images in Surgery – Dr. Rohan Khandelwal

Image based questions are now frequently asked in all entrance exams. You can watch the first part of important images in surgery on youtube.

The pdf of this session can be downloaded

important-images-in-surgery-1Download

Common causes of breast lumps in lactating mothers

Breastfeeding is a mother’s gift to her child and herself – there are innumerable advantages of breastfeeding to both the mother & child but sometimes mothers can face some difficulties during breastfeeding. One of them is the development of breast lumps during breastfeeding.

Breast lumps during breastfeeding can not only lead to anxiety in the mother but can sometimes be a sign of something as ominous as cancer. The common causes are:

Milk collection (Galactocele) – this is probably the most common cause of breast lumps in breastfeeding mothers. It commonly occurs due to a blocked duct and the patient can feel a painful lump in the breast. It can sometimes also occur, if breast milk is not emptied at regular intervals.

Management of a galactocele/ milk collection can range from emptying of breast milk either by feeding or by using a breast pump. Hot fomentation/ gentle massage also works well in this condition. If the problem occurs frequently, then one should consult a lactation expert/ doctor for further evaluation

 Breast abscess/ mastitis – this is inflammation of the breast tissue which can progress to pus formation as well. It is secondary to a bacterial infection and you would be surprised to know that the source of the bacteria is the child’s mouth. These bacteria can enter through the nipple (more common in ladies with cracked/ sore nipples) and lead to infection.

Patient usually develops intense pain in the breast, which can be associated with redness and fever as well. If one notices any such symptoms, they should visit their breast surgeon immediately. In the initial stages, this condition is managed using antibiotics. In case, pus develops, then the surgeon is left with no option but to drain the pus out by performing a minor surgery.  If the abscess is very large, your doctor might also recommend stopping breastfeeding using a drug.

Breast cancer – can sometimes be detected during breastfeeding. These lumps can initially be mistaken for a milk collection but unlike milk collections, they don’t respond to simple measures and keep on increasing in size. Sometimes these lumps might even be painless.

Due to these two reasons, cancers can often increase in size before they are detected in breastfeeding mothers.

If a mother notices a lump in the breast during breastfeeding, which does not settle in a few days, she should immediately visit a breast cancer surgeon and get herself evaluated. If the surgeon is suspecting a cancer, they will order an ultrasound followed by a needle biopsy to confirm the diagnosis.

These are some of the common causes of breast lumps during lactation. It is good to be aware of these lumps and one should not delay meeting a doctor in case they notice such problems. Having said this, majority of the mothers have an uneventful lactation period.

Over the last few years it has been seen that mothers are reducing the duration of breastfeeding due to professional commitments. Given all the advantages of breastfeeding for the mother and the child, this world breastfeeding week all ladies should pledge to complete breastfeeding at least for 6-8 months.

 

This information has been provided by

Dr. Rohan Khandelwal

Principal Consultant, Breast Cancer Surgeon

The Breast Centre

CK Birla Hospital, Gurgaon

 

AIIMS June 2020 Surgery Questions

 

This PDF contains the Surgery Questions which were asked in the recent AIIMS June 2020 exam. The detailed video will soon be uploaded on my youtube channel.

AIIMS JUNE SURGERY RK

Breast Cancer Care During COVID19 – my experience at CK Birla Hospital, Gurgaon

The current COVID19 pandemic has affected the way all doctors practice and oncologists are no exception. Over the last 2-3 months, we have witnessed a lot of changes in treatment protocols, attitude of cancer patients towards their disease and the behavior of newly diagnosed breast cancer patients. Rather than going into technical details regarding the treatment protocols which we are following (which are an Indian modification of American/ European guidelines, most suited for our breast cancer patients at CK Birla Hospital), I will be discussing changes which we have made as doctors and how are our patients coping with the pandemic.

When the lock-down was announced in mid March, fear & panic is what prevailed amongst the patients and they were initially apprehensive in coming to the hospital for their surgery/ chemotherapy. But by early April, it was clear to patients that COVID will persist for a few months and although the world might be in lock-down but the cancer brewing inside their body would continue to grow and they would need to fight it out.

This change in patient attitude coupled with the proactive management at CK Birla Hospital (specially measures taken to improve patient and staff safety), we were able to carry out breast cancer treatment smoothly, even during the lock-down.

During the two months of lock-down, 94% of our breast cancer patients continued their chemotherapy. The ones who skipped some cycles were patients with metastatic disease, who wanted a ‘chemotherapy holiday’. In this period, my unit also operated 22 breast cancer patients. The number of benign (non cancerous) breast surgeries dipped dramatically during this period but we have seen a rebound increase in such cases since the lockdown norms have been eased.

After talking to a lot of friends & colleagues in UK/USA, I realised that I will only be able to take care of my patients if I stay healthy and disease free. To ensure that, in addition to the measures implemented by the hospital, I have also started using extra precaution in the form of a 3M 6200 mask with two p100 filters, which keeps the smoke plumes (thought to be a the leading case of infection in surgeons & anaesthetists) away. Of course, my OCD of hand washing has also served me well during this period 😊.

Our breast cancer patients have also adapted well over the course of the last 2 months. Our unit has a very active cancer support group known as ‘Vijay’ and all the members have devised new methods to keep in touch with each other during these tough times.

In the pre-covid times, old patients used to visit the new patients on the day of their surgery/ first chemotherapy. This is has been replaced by zoom group calls to support newly diagnosed patients. Even our treatment completion celebrations have undergone a lot of change. Earlier, these used to be elaborate affairs where the patient’s family & the treating team would participate actively, but now we have toned it down (but not stopped it, as it is a very important landmark in the patient’s life) to a simple cake cutting with everyone wearing masks.

To summarise, my biggest learnings during this period have been

• Cancer care has to go on but we should be willing to adapt our treatment strategies after a thorough discussion with the patient
• The safety of the treating team & patients is of paramount importance in order to deliver seamless breast cancer care during this outbreak

 

 

This article has been written by,

Dr. Rohan Khandelwal

Principal Consultant – Breast Cancer Surgery

CK Birla Hospital, Gurgaon

rohankhandelwal@gmail.com

Lessons from nature by Dr. Rohan Khandelwal

How badly do you want to succeed?

I clicked this picture a year and a half back and this one moment is associated with a lot of life teachings.

This juvenile tailor bird, while learning how to fly, landed in my balcony. Being an avid bird photographer, I immediately took out my camera and quietly started observing (and clicking) the little one’s repeated attempts to make it over the railing.

In between, the mother kept coming and encouraging the young one but after 30-40 mins of struggle, the little one gave up and found shelter besides a huge pot.

Minutes later, the mother appeared with a treat for the young one and after feeding him, she started coaxing the young one to try once more.

Finally, with the help of the mother, the young one flew from one balcony to the other.

The entire saga lasted for about 1.5 hours (and I skipped my meal) to click at least 200 pictures but this is the one which made my day.

Lessons which I learnt from this moment

1. You need to be patient to achieve big results and never be scared of failure during this path to success
2. If you don’t want something badly, you will give up without a fight. So have a burning desire to achieve your goal
3. Every now and then you need somebody to mentor you/ give you a push. Identify the right person and have full faith in them.

photography #lifelessons #patience #lessonsfromnature #RohanKhandelwal

Breast Cancer Care During COVID19 outbreak

At present, almost half the world is in lock-down due to the corona virus outbreak and it is difficult to predict for how long this situation might remain the same. In India, it is almost certain that the lock-down due to COVID 19 will be extended till at least end of April. Even though we are in a state of lock-down but our body is still functioning and that means diseases like cancer might still be growing inside our system. So how does one deal with a problem like breast cancer/ breast lump during this period.

Tips for existing breast cancer patients

1. Remain in touch with your treating breast cancer surgeon/ breast cancer oncologist. They will outline the treatment protocol during this period
2. If you have an early stage breast cancer which is curable, you should not defer your treatment during this period, as it can lead to progression of the cancer.
3. If you are suffering from cancer which has spread to the body (metastatic breast cancer), then discuss with your doctor if the chemotherapy frequency can be reduced or if you can be shifted to hormonal therapy/ oral treatment for the time being.
4. Corona virus infection is usually severe in patients who are suffering from pre-existing conditions like cancer, diabetes, hypertension. So, please take all precautions to prevent infections

• Eat a healthy/ balanced diet. Avoid outside food.
• Make sure you take your daily dose of  vitamin C. This can either be in the form of a supplement or just a glass of lemonade
• If you are undergoing chemotherapy (which can lead to reduced immunity and white blood count), please monitor the blood counts and if they are low, consult your breast cancer doctor immediately
• Wear a mask whenever you are venturing out of your home, especially, when you are going to the hospital
• Maintain strict hand hygiene. Wash your hands multiple times a day and use a hand sanitizer liberally

 

 

 

 

Recently detected a breast lump – what should you do during this period?

During the lock-down, lot of ladies are taking out time to carry out breast self examination and they are picking up new breast lumps. If you are one of them, I would advise that you consult a breast lump surgeon immediately. This consultation can either be an online consultation or a physical visit to the hospital. In an online consultation, if the doctor feels the need to carry out a physical examination, he/she would call you to the hospital.

A breast lump should not be ignored because if it is cancerous, it can increase in size during this period. A mammography or an ultrasound should be done after physical examination and if the lump is suspicious, a biopsy/ needle test should be done to confirm the diagnosis. If the breast lump turns out to be non cancerous (benign), then the treatment can be deferred till the time COVI19 situation improves. Your doctor can provide you medicines during this period to deal with the problem/ breast pain associated with the lump.

If the lump turns out to be breast cancer, as I have highlighted above, please consult your doctor and make a treatment plan which is suitable to you.

These are testing times for everyone, including patients. One has to be cautious about not getting infected by the virus as well as make sure that their breast cancer/ breast lump treatment doesn’t suffer. If you follow the tips which I have highlighted above, you can tide over this phase without compromising your health.

 

 

This information has been provided by

Dr. Rohan Khandelwal

Breast Cancer Surgeon

CK Birla Hospital, Gurgaon

To book an online consultation with Dr. Rohan Khandelwal, click here

 

All breast fibroadenomas don’t require surgery

Breast fibroadenomas are the most common cause of breast lumps and they are commonly seen between 15-30 years of age group. We usually see a lot of anxious women presenting to the Breast Centre at CK Birla Hospital, Gurgaon with this complaint and all of them have two common questions:

• can it turn into breast cancer?
• does it require surgery?

I will address these two questions in the text below but before that I would just like to give you some information regarding breast fibroadenomas.

Clinical presentation  – Breast fibroadenomas usually present as painless (non painful) breast lumps which keep shifting their position within the breast. These lumps can remain the same size for long periods of time but sometimes they can present with pain, rapid increase in size. Approximately 10% women can have multiple fibroadenomas [read about the lady with 39 fibroadenomas in both breasts].

There is no known cause for fibroadenomas and no well defined risk factors.

On examination, these lumps are usually firm in consistency and mobile, which is why jokingly they are also known as a ‘breast mouse’.

Diagnosis of a fibroadenoma can be made out on an ultrasound of the breast (which is the preferred imaging technique in patients less than 40 years of age). If a mammogram is done, you can see a ‘popcorn appearance‘ of the lesion.

 

Majority of the fibroadenomas can be clearly made out on an ultrasound but if a lesion is showing some atypical changes, then a tru-cut biopsy/ FNAC (needle test) is recommended to confirm the diagnosis. This is also indicated in patients with a family history of breast cancer.

Coming back to the two questions which all patients with breast fibroadenomas have running through their mind during their visit to a breast surgeon:

• Can fibroadenomas turn into breast cancer?  —  Multiple studies have shown that the risk of a fibroadenoma changing into breast cancer is negligible (less than 2%). It is usually more in patients who have atypical fibroadenomas or an existing family history of breast cancer. Patients with a family history of breast cancer should not ignore these breast lumps and should get a biopsy to confirm the diagnosis.
• Do all fibroadenomas require surgery? —- Well, not all of these breast lumps require surgery. There are certain indications to surgically remove these lumps:

1. If the fibroadenoma is more than 5 cm in size. Such a fibroadenoma is known as a ‘giant breast fibroadenoma’.
2. If there is a family history of breast cancer. In such cases, it is advisable to remove the lump.
3. If there is rapid increase in size of the lump or it is associated with breast pain which is not getting controlled with medicines.

Surgical removal for fibroadenomas is usually a minor surgery which is done as a day care procedure. The incision for this surgery is usually made around the areola (peri-areolar) as this incision heals with minimal scarring. Sometimes the incision can be made in the skin fold under the breast (infra-mammary crease). Some patients can candidates for scar-less fibroadenoma surgery, in which the lump is removed via a 3-4 mm incision using a special machine.

Peri-areolar incision – scar is hardly visbile after a month

Those patients who are not candidate for surgical excision are asked to follow-up at regular intervals, usually 6 months to 1 year. In addition to this, they are asked to monitor the size of the lump. In case there is a rapid increase in size of the fibroadenoma, they are asked to return immediately. Unfortunately, there is no credible medical management of fibroadenomas.

 

Information provided by:

Dr. Rohan Khandelwal

Breast Cancer Surgeon in Gurgaon

CK Birla Hospital

Dr. Rohan Khandelwal also performs scar-less fibroadenoma surgery at CK Birla Hospital

All underarm lumps are not cancerous

Ladies commonly present to our Breast Cancer unit with complaints of lumps in the underarm region (axilla) and their first concern is always breast cancer, but not all axillary lumps are a sign of breast cancer. In this article, I will highlight the common causes of under-arm lumps/ swellings, which ladies can develop:

• Axillary lymph node enlargement – this is the most common cause of underarm lumps. Lymph nodes are present all over the body and they serve as filters. Breast drains into armpit (axillary) lymph nodes. Therefore, if there is any cancer/ infection in the breast, it can lead to enlargement of these nodes. In such situations, we get an ultrasound of the breast and underarm region to confirm the enlargement. Diagnosis is confirmed by a needle test known as FNAC (fine needle aspiration cytology) or lymph node biopsy in some cases.

Another common cause of enlargement of these nodes is after shaving/ waxing of  underarm hair. This can lead to momentary enlargement of these nodes (reactive  lymphadenopathy), which usually settles down with time or with a course of antibiotics.

• Accessory axillary tissue – ladies usually come with a large lump in the underarm region but give a history that it has been present over a long period of time or has increased in size post-pregnancy or after breast feeding. This is due to extra breast tissue present in the armpit region, which increases after pregnancy and lactation. For most ladies, it is a cosmetic problem because of which they are unable to wear cut sleeves clothes. Some ladies might complain of pain in the swelling as well. An ultrasound should be done to rule out any other condition and surgery can be done to get rid of this problem.

 

Accessory axillary breast tissue

 

• Sebaceous cyst in the underarm – This is a lump which forms due to a blocked hair follicle duct. It can remain painless till it becomes infected. It is a superficial lesion which can be managed with a simple removal of the lump. If the lump is infected, it can initially be managed with antibiotics before surgical removal

 

Sebaceous cyst in underarm region

 

• Breast cancer – Cancerous lumps can primarily develop in the underarm region or cancers can present as lymph nodes in the underarm region. In either case, an ultrasound/ mammogram is required, followed by a biopsy to confirm the diagnosis. Proper staging of the breast cancer is important before management

 

Malignant axillary lymph nodes on mammogram

 

• Breast tuberculosis – is a common diagnosis in India. It will either present as an abscess in the underarm region or enlarged lymph nodes (covered earlier) in the axillary region. Diagnosis can be made by a needle test or lymph node biopsy. Treatment usually involves taking anti-tubercular drugs for a period of 6-9 months, depending on response.

 

As I have highlighted above that breast cancer is just one of the causes of axillary lumps. Having said that, it is best that you visit a breast unit whenever you notice a lump in the breast or underarm region. After taking a history and carrying out clinical examination, the breast surgeon will order an imaging test, which would either be a mammogram or ultrasound or both. This would be followed by a tru-cut biopsy/ FNAC to confirm the diagnosis. In some cases a lymph node biopsy might be required to clinch the diagnosis.

 

For further information or to book an appointment, please contact

Dr. Rohan Khandelwal

Breast Cancer Surgeon

CK Birla Hospital, Gurgaon

rohankhandelwal@gmail.com