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.

 

Calcified Fibroadenoma

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 tissue

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

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

 

Primary & nodes

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

 

What does BIRADS on your mammography/ ultrasound report mean?

Lot of times in my Breast Clinic at CK Birla Hospital, Gurgaon, I get patients who come and tell me that they are suffering from stage III breast cancer. When I ask them how do they know about that, the answer which I usually hear is that “my mammogram/ ultrasound report shows BIRADS III.” Not only patients but I have also seen some doctors getting confused with the BIRADS reporting.

BIRADS (Breast Imaging Reporting and Data Systems) is a standardized way of reporting breast radiology reports.  This helps radiologists categorize patients from a score of 0-6 and it helps breast cancer surgeons in taking decisions based on this score. Having a uniform reporting system is useful because patients might get their radiology and breast disease treatment done at different places.

The score doesn’t imply the stage of cancer and patients should be aware of this to avoid unnecessary anxiety after seeing the radiology report.

  • BIRADS 0 means an incomplete investigation – This usually occurs when a mammogram is done in a patient with a dense breast and it does not yield any meaningful information. In such a case, usually an ultrasound or MRI Breast is done

 

  • BIRADS 1 is a negative scan, which basically implies that there is no lesion in the breast and everything is normal. In these patients we advise them to follow up after 1 year

 

  • BIRADS 2 is suggestive of a benign lesion, which has essentially a 0% risk of cancer and these lumps don’t require a biopsy. They can be followed up in a year’s time. Simple cysts, most typical fibroadenomas fall under this category.

 

  • BIRADS 3 lesions are probably benign and these breast lesions/ lumps should be followed up every 6 months (short term follow-up). These lumps do not require a biopsy/ FNAC but if you have a family history of breast cancer, then the clinician might be inclined to do more tests/ biopsy at this stage rather than wait for 6 months.  Fibroadenomas, duct ectasias can fall under this category of lesions.

 

  • BIRADS 4 breast lumps/ lesions are suspicious lesions and they need to be biopsied to confirm the diagnosis. They are further sub-divided into 4a, 4b, 4c which implies low, medium and high risk for cancer. These patients should be counselled accordingly and a tru-cut/ core needle biopsy should be scheduled as soon as possible. Atypical fibroadenomas, suspicious microcalcifications, duct papillomas usually fall under this category of lesions

 

  • BIRADS 5 lesions are highly suggestive of malignancy and the risk of cancer in these breast lumps is more than 95%. All patients with these breast lumps should be subjected to the tru-cut biopsy, which is preferred over a FNAC (fine needle aspiration cytology)

 

  • BIARDS 6 lesions are when a radiological test is done after confirming the diagnosis of breast cancer.

 

The table below summarizes the BIRADS score and the action which needs to be taken in each category.

The Radiology Assistant : Bi-RADS for Mammography and Ultrasound 2013

 

So the next time you receive your mammography / breast ultrasound report, don’t be surprised to see the BIRADS score. Discuss the report with your radiologist and breast cancer surgeon and take action accordingly. Remember, that all breast lumps are not cancerous and all of them don’t even require a biopsy/ FNAC test.

 

This information has been provided by

Dr. Rohan Khandelwal

Principal Consultant,

The Breast Centre

CK Birla Hospital, Gurugram

How medical students can utilise this lock-down period efficiently

I was in my 2nd year of post-graduation during the 2009 swine flu pandemic. 4-5 days after an emergency 24 hour duty, I developed symptoms of flu along with high fever. As per the guidelines issued, I got my test done and was detected with swine flu. Fortunately, I just had mild infection but i was forced to undergo a 12 day quarantine.

Being a second year surgery PG, when the surgical opportunities in the emergency duties are plenty, I was initially a bit frustrated but within a day or two, I decided to utilize that time wisely. I set aside 3 tasks for myself during that period and made sure that I finished them before going back to the hospital.

1) I planned to revise bailey and maheshwari for my upcoming MRCS exam

2) Submit two scientific papers in pubmed indexed journals

3) Segregate my wildlife pictures into various folders for handy use

I realized that doing just one thing the entire day wouldn’t be possible, so I allocated 4-5 hours to studies and 1 hour each to the other two tasks. This left me with enough time to exercise, watch TV for 1-2 hours a day.

At the end of the 12 days, I had accomplished all the three tasks and felt extremely happy while returning to work.

A lot of undergraduate students are going through the same phase during this lock-down and I would highly recommend that you follow these simple steps to make the most of this period

1) Make a realistic study plan for yourself : Don’t be over ambitious, otherwise you will feel disappointed at the end of 21 days. At the same time, don’t set yourself a very simple goal because that would lead to you wasting a lot of time on social media or watching netflix

2) Use this free time to work on your hobby : You might not get such a period for a long time after this. Don’t forget to read that book which has been lying on your shelf since a long time or pick up the canvas and re-juvinate your passion for drawing. These hobbies would be your stress-busters for the rest of your life and they will also allow you to break the monotony during this lock-down period

3) Each day spend quality time with your family members: Watch a movie together or play some board/ card game. You will treasure these memories life long.

4) Exercise/ meditate for at least one hour daily: I’m sure your mother’s would be pampering you with delicacies but you don’t want to end up gaining 2-3 kg’s during this period. Also, this would help you in staying sane during this phase when all you are hearing is gloomy/ depressing news regarding COIVD19

5) Try to learn some new skill – there are a lot of free courses on internet. You can probably learn a new language or hone your photography skills by doing these courses.

I have also set a few goals for myself during this period and I would like to share them with you. Will update you at the end of this period regarding the progress which I have made regarding these.

• Apply for Fellow of American College of Surgeons (FACS)

• Publish two articles regarding my breast cancer patients

• Me and Dr. Ila have sighted and clicked more than 120 Indian birds over the last 10 years. I want to print a book with all these images for our reference

• Do a online course to improve my photography skills

I hope this posts helps the undergraduate students plan these days better. Do reach out to me if you are able to make a list for yourself and keep sharing your progress with me. It will motivate me to achieve my targets as well.

covid19todolist #RohanKhandelwal

PS – attaching a pic of me and Dr. Ila Jain Khandelwal which we clicked during our swine flu quarantine period.

Support the healthcare workers during COVID19 outbreak

Healthcare workers across the world are fighting an unprecedented battle against coronavirus. The least we can do is to support them and appreciate their efforts.

Imagine a soldier returning from battle – he would be welcomed with open arms and would be pampered by friends/ family members. Is that the same happening with doctors who are risking their lives daily and working in sup-optimal conditions for 24-48 hours at a stretch. No!! Not at all. Resident doctors and PG’s are being asked to vacate their hostel/ PG accommodations because the landlords are scared that they might bring infection into the house. Their rooms are not being cleaned, they are not being served proper food. Would we do the same thing with a soldier as well??

All healthcare workers appreciated the public display of support on Sunday but is a single time act of kindness enough to support these brave souls who are risking their lives everyday? As a doctor, it is my humble request to the general public to please support all healthcare workers on a regular basis during these tough times.

– Say a simple ‘thank you’ to these people. It will help in keeping their spirits high

– Don’t ask them to vacate their rooms. They are well aware of the risks and none of them would want to infect their friends/ family members

– Stop hoarding masks/ hand sanitizers/ essential medicines. You would be surprised to know that a lot of doctors don’t have access to proper PPE’s. They are having to do with cloth masks which offer little or no protection while treating patients. Hydrochloroquine has disappeared of shelves and it is unavailable to a lot of health care workers.

– Listen to the precautions they are highlighting on a regular basis. That is the only way to reduce the spread of this condition.

These are tough times for everyone. Least we can do is to support our #COVIDwarriors at this time.

Dr. Rohan Khandelwal

A doctor, teacher and a concerned citizen