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

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

Changes in 8th AJCC Classification of Breast Cancer

Recently, the eighth edition of the TNM classification of AJCC (American Joint Commission of Cancer) was released. This had a few notable changes from the 7th edition, which have been highlighted below:

  • Immunohistochemically detected tumor markers (ER, PR, HER 2 neu) that are known to have great practical treatment importance are now incorporated into the staging system to refine prognosis of breast cancer
  • The eighth edition of the staging system also uses genomic assays (Oncotype Dx, Mammaprint, PAM 50) when available to downstage some estrogen receptor-positive, lymph node-negative tumors.
  • Lobular carcinoma in situ is removed from the staging system because it is not a malignancy but a risk factor. It is no longer considered Tis.
  • The expert panel clarified that the postneoadjuvant therapy pathological T category (ypT) is based on the largest focus of residual tumor, if present. Treatment-related fibrosis adjacent to residual invasive carcinoma is not included in the ypT maximum dimension.

 

b1b3eb402a2efa10e715b109bc172f83.jpeg

Axillary Lymph Node Biopsy

Axillary Lymph node (underarm gland) enlargement is a common problem among Indian women.

Patient usually present with complaints of pain in the armpit and/or lumps in the underarm area.

Majority of the times these lumps are reactive in nature, that means they enlarge due to non specific causes like mild hair follicle infection, which can occur after shaving or waxing of hair.

On the other hand, these glands can also become enlarged due to:

  1. Infections like tuberculosis, which can be associated with weight loss & fever
  2. Cancers – commonest cancer which gives rise to underarm nodes is breast cancer. Axillary lymph nodes are the first point of spread from breast cancer.

 

An ultrasound can confirm the diagnosis of axillary lymph node enlargement and if these glands do not resolve after a course of antibiotics, they require a FNAC (fine needle aspiration cytology or in simple terms a ‘needle test’).

If FNAC is inconclusive, then an axillary lymph node biopsy is required to confirm the diagnosis. Axillary lymph node biopsy is a minor procedure, which can be performed as a day care surgery.

 

If you or anyone whom you know has underarm pain or lumps, it is best to get yourself examined by a surgeon.

 

 

Information provided by:

Dr. Rohan Khandelwal

Breast Cancer Surgeon

W Pratiksha Hospital

Gurgaon

 

Interesting Mammogram #5

41 year old lady with a left breast lump since last 6 years with rapid increase in size since the last 4 months. Patient was concerned that she is suffering from breast breast cancer and therefore got a mammography done and presented to my clinic.


A tru- cut biopsy was done and it revealed it to be a phyllodes tumor, which after resection turned out to be a malignant phyllodes tumor with Liposarcomatous differentiation. 

Case uploaded by:

Dr. Rohan Khandelwal

Breast Cancer Surgeon

W Pratiksha Hospital, Gurgaon 

Interesting Mammogram #4 

47 year old lady with complaints of bilateral breast pain since 3 months. Pain was non cyclical and relieved by oral paracetamol. She had a hysterectomy 6 years back and she was a known asthmatic.

On examination, she has multiple tender nodules in both the breasts, localised in the peri-areolar region. 

Mammogram revealed multiple, well defined, rounded densities in both the breasts with a rim of calcification around them (refer to figures). 

Multiple round densities in the breast


Ultrasound done revealed dense fibroglandular tissue with multiple sub-centimetric cysts in the breasts. 

Differential – 1. Multiple oil cysts with calcification 

2. Cysts secondary to fibroadenosis

Case managed by:

Dr Rohan Khandelwal

Consultant, Department of Breast Diseases and Cancer Care

W Pratiksha Hospital, Gurgaon  

Breast Conservation Surgery for Early Breast Cancer

Breast Cancer Surgery has undergone a lot of change in the last few years. Earlier, mastectomy (full breast removal) was the norm for breast cancer management, but nowadays if the cancer is detected early, Breast Conservation Surgery (BCS) can be carried out.

In breast conservation surgery (BCS), only the cancerous lump and some portion of normal breast tissue around it is removed, preserving the rest of the breast, thereby leading to a better cosmetic outcome for the patient. BCS is also psychological and physically better for a patient suffering from breast cancer. The overall survival, whether the patient undergoes BCS or mastectomy for breast cancer treatment, remains the same.

 

Breast conservation surgery should be carried out by a trained breast cancer surgeon (breast onco-surgeon). A frozen section analysis should be done at the time of surgery to confirm that the tumor has been adequately removed.

 

 

 

Information provided by:

Dr. Rohan Khandelwal

W Pratiksha Hospital

Gurgaon

 

Seroma formation – a common complication of axillary surgery

A seroma is accumulation of clear fluid in the body after surgery. It is a common complication which can occur in the underarm area (axilla) after breast or axillary surgery. In fact, axillary seromas have been seen even after axillary lymph node biopsy or sentinel lymph node biopsy for breast cancer

To prevent seroma formation, surgeons insert drains after breast and axillary surgery ( both cancerous and non cancerous). Drains are usually removed once the output falls below 40 cc for two consecutive days. Early removal of drains is a common cause which can predispose to seroma formation after breast cancer surgery. 

Patients usually develop fluid collections within 5-7 days after surgery and they present with pain and swelling in the axillary region. Diagnosis of a seroma can be made by your breast cancer surgeon and in case of any doubt, an axillary ultrasound can confirm the diagnosis (image)

Axillary Seroma

Axillary Seroma

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Management of an axillary seroma is relatively simple. They can be aspirated under local anaesthesia. Patients might require 2-3 aspirations before the seroma subsides.

Sometimes fluid collections can become infected and can give rise to pus formation in the axillary region. These situations can be avoided if seromas are detected and aspirated in time.

 

 

Information provided by:

Dr. Rohan Khandelwal

Consultant, Breast Surgeon

W Pratiksha Hospital, Gurgaon