World Cancer Day 2018

On the occasion of #worldcancerday, I would like to share the picture of the youngest #breastcancer patient I have treated till now.

She is a 25 year old, mother of a 2 year old who came to me with a small breast lump which she picked up after reading a Hindi article on breast cancer.

Few things which I would like to highlight through this case:

1. Age at diagnosis is reducing. This was my third patient in the 20’s over the last 3 months. Majority of my breast cancer patients are in their 30’s.

So, if anyone you know is suffering from a breast lump, please get it checked.

2. Awareness is increasing, which is an excellent thing. I am seeing a lot of patients with stage 1 and 2 disease, which leads to better survival.

To help create more awareness, each one reading this post should tell one more person about breast cancer and it’s symptoms (painless breast lump, recent change in shape of the breast, bloody discharge from the nipple)

3. Another heartening point is the change in the society’s attitude towards these patients. Friends and family members are becoming more accommodating towards the needs of cancer patients.

Please share this message to create more awareness.

This message has been shared in public interest by Dr Rohan Khandelwal, who is a Breast Cancer Surgeon at Gurgaon / Delhi NCR

Unique case of multiple ductal papillomatosis

31 year old  nulliparous lady presented with serous nipple discharge from right breast since 3 months. She had no co-morbid conditions and no family history of cancer.

o/e – she had serous nipple discharge from 3-4 ducts (3,8,10 o clock). There were no palpable lumps in either of the breasts or axillae.

Nipple discharge cytology as negative for malignancy

On USG a very interesting finding was observed – there were ductal papillomas seen in ducts present at 3,8 and 10 ‘o clock position and the 3’o clock duct showed multiple ductal papillomas (3 can be seen in the USG image)

 

img_2406 img_2405

 

 

 

Considering the age of the patient, a decision was taken to carry out three microdochectomies and the HPE revealed benign papillomas in all ducts.

 

Reasons for highlighting this case:

  1. Ductal papillomas are the most common cause of bloody nipple discharge and they arise from the terminal duct lobular units. This patient presented with serous nipple discharge.
  2. Usually ductal papillomas are solitary. Only 10% of intra-ductal papillomas tend to be multiple. This patient had at least 4 papillomas on final HPE.
  3. Multiple papillomatosis are more frequently associated with hyperplasia, atypia, DCIS, sclerosing adenosis, and radial scar but in this case none of the findings were present.

 

 

 

Case by:

Dr. Rohan Khandelwal & Dr. Savita Chopra

Department of Breast Diseases & Cancer Care

W Pratiksha Hospital, Gurgaon

 

 

Have you been properly investigated before a breast augmentation??

Breast augmentation has become a very common procedure in India now and more and more ladies are opting for such surgeries. Many surgeons are also luring patients by giving them attractive packages.

In order to save some money, many times, pre-operative imaging of the breast (ultrasound or mammogram) is being avoided and the result is that lesions like cancer are being missed in some of these patients.

I have come across three such patients in the last 6 months. One of them was a 32 year old business executive, who had undergone a breast augmentation 4 months back and she presented with a lump in her left breast. I was surprised to find a 2×3 cm lump in her breast, which had all the features of malignancy. A tru-cut biopsy confirmed her worst fears and she was devastated after the diagnosis. Her initial response was one of disbelief and anger towards the doctor, who had not investigated her properly before the augmentation procedure.

In these patients, the management of cancer also becomes tricky because of the presence of the implant. Therefore, my request to all patients planning to undergo a cosmetic breast procedure, is to  ALWAYS get a pre-operative imaging assessment done and consult a trained breast surgeon, who can guide you properly.

Steps which should be take before deciding on a cosmetic breast procedure:

  1. Consultation with a breast surgeon – understanding the procedure, complications and possible outcome. Discussing your risk of breast cancer with the surgeon
  2. Clinical Examination to rule out any lumps
  3. Radiological investigations – USG, Mammogram, MRI (in certain situations like dense breast tissue in a young patient)
  4. Biopsy of any lesion detected on imaging

2013_04_24_15_00_32_739_Mango_MRI_12_450

Shocking case – Mastectomy done for an 11 yr old girl!!

Every day brings a new surprise in the life of a doctor but there are some cases which just make you feel angry & helpless and today’s case was exactly the same. Our receptionist had fixed an appointment and when she told me that it is for a 11 year old girl, I probably thought that she is going to turn out be a case of juvenile hypertrophy (enlargement) of the breast but what I saw when I examined the patient left me in a state of shock.

This sweet looking 11 year old kid walked in with her parents and they started telling me the history that she underwent a surgery of the right breast to remove a benign lesion (fibroadenoma) 2 months back and they came to our unit because the girl had noticed another lesion on the left side. Breast surgery at 11 years is usually not recommended as it hampers with the development of the breast during puberty and I immediately knew that something will not be right when I examine the patient. Examination of the girl turned out to be quite shocking. The surgeon (who was actually a gynecologist in a rural set-up) removed not only the lump but also the entire breast tissue on the right side leaving behind just a long scar on the chest (image). It took me a couple of minutes to get in terms with what I was seeing and multiple thoughts started running through my head after that:

IMG_20140725_115525

1. My initial reaction was that of anger towards the doctor who had done such a surgery without properly examining the patient or documenting it. Her notes before surgery mentioned no examination findings and the only thing written was ”work-up for surgery”. She had fortunately not examined the other breast, which also had a small lump and I am sure had she examined it, she would have done the same thing on the left side as well.

2. I felt sad for the girl & her parents very well knowing that there is going to be no development of the breast of the right side and the patient will probably have to go for an implant later on in her life.

3. This case reinforced the fact that breast surgery needs to come up as a dedicated branch in India, in order to prevent such cases. Also more awareness needs to be created among people regarding this branch and the fact that it does not deal with only breast cancer. Benign breast diseases are often ignored by patients and they usually approach local doctors for their treatment.

4. This case also reinforced the point regarding proper notes & documentation in all patients. This patient can easily take the doctor who did such a surgery to court and that doctor will have nothing in her defense

5. This case was a real eye opener with regards to the lack of knowledge which general practitioners/ general surgeons / gynecologists have regarding breast disorders and this needs to be addressed by proper refresher courses for these doctors.

 

Midline breast cancer without a lump in the breast: an extremely rare case

Sometimes breast cancer tends to surprise us and present in an unusual manner. In India, due to lack to awareness and a stigma attached with breast cancer, females from the rural set-up tend to present with locally advanced breast cancers. I happened to encounter one such case couple of years back and managing this case turned out to be quite challenging. We managed to publish this case in the Breast Disease Journal and it generated quite a discussion in all the forums where it was discussed. [Breast cancer presenting in the midline without a lesion in the breast: a therapeutic dilemma. Khandelwal R, Poovamma CU, Shilpy C, et al. Breast Dis. 2013 Jan 1;34(2):57-9.]

A 48- year- old post-menopausal lady presented to the Breast Clinic with complaints of a rapidly enlarging chest swelling for the last 8 months. The lesion had ulcerated one month back and she complained of a foul smelling discharge from the growth. There were no complaints of any lumps in the breast or axillae.

On examination, a 14 x 10 cms ulcero-proliferative lesion was seen over the midline of the chest extending 4 cms on either side of the midline. The lump had restricted mobility over the underlying chest wall. In addition, the patient had multiple, enlarged lymph nodes in both the axillae. No enlarged lymph nodes were felt in the supraclavicular fossa. No organomegaly was palpable in the abdomen.

Lesion over anterior chest wall

Lesion over anterior chest wall

A provisional diagnosis of soft tissue sarcoma of the chest wall was made but the presence of bilateral, hard axillary lymph nodes raised a suspicion of a breast carcinoma. Patient was then subjected to a CECT of the chest, which revealed a fungating soft tissue mass over the chest with bilateral axillary lymphadenopathy. MRI of the breasts failed to pick up any lesions in the breast. CT abdomen was unremarkable. A PET-CT done to look for distant metastasis, revealed a mildly hyper-metabolic anterior chest wall mass [SUV max 4.8] with bilateral axillary lymphadenopathy [SUV max 5.1]. There was no evidence of involvement of supraclavicular or internal mammary lymph nodes. No distal metastasis was observed on PET.

Following the imaging tests, an incisional biopsy of the lesion was performed, which to our surprise revealed an invasive ductal carcinoma (grade II) with DCIS. Immunohistochemistry revealed the tumor to be ER and PR positive but HER2 negative.

The case was extensively discussed in the tumor board and a decision was taken to treat the patient with neo-adjuvant chemotherapy. Patient received weekly Paclitaxel for six weeks, which was associated with a good response and the tumor regressed in size. A PET scan done following NACT revealed a residual lesion in the midline with bilateral axillary lymph nodes. PET scan did not reveal any lesions in the breast.

Following a good response to NACT, the patient was taken up for a wide local excision of the tumor with bilateral axillary dissection. As none of the breasts had any lesions, they were not addressed during the surgical procedure.  Patient had an uneventful post-operative period and three weeks later she was started on adjuvant chemotherapy, which was followed by radiotherapy to the chest wall.

Post Surgery

Post Surgery

Following completion of radiotherapy, the patient was started on Letrozole and was kept under regular follow-up. The patient remained symptom free for 1 year after surgery, after which she was lost to follow-up.

This was an extremely rare presentation of breast cancer and managing this patient was a therapeutic dilemma.

Importance of regular follow-up after Breast Cancer Treatment

It was quite sad to see this 68 year old lady come to the clinic yesterday. She was diagnosed with left breast cancer two years back and was treated with MRM, adjuvant chemotherapy and hormonal therapy at a private hospital. After her treatment was completed, she did not visit the oncologist again thinking that she has been cured and for the last 6 months she had been harboring this growth over the chest wall, which turned out to be a local recurrence.

Local recurrence after mastectomy

Local recurrence after mastectomy

Patients tend to think that when the treatment is over, they are cured of the disease, but that is not the case. Patients need to visit their oncologists/ doctors regularly after the completion of their treatment and this case points out the importance of correct and regular follow-up after breast cancer treatment.

The current guidelines regarding follow-up of breast cancer patients are:

  1. History & physical examination: Every three to six months for the first three years after the first treatment, every six to 12 months for years four and five, and every year thereafter.
  2. Mammography: If mastectomy has been done, then annual mammograms of the opposite breast. If  breast conservation has been done, then B/L mammography should be done annually.
  3.  Breast self-examination. Perform a breast self-examination every month. This procedure is not a substitute for a mammogram.
  4. Pelvic examination. If the patient is on Tamoxifen, annual gynecological check-up should be done because tamoxifen can increase the chances of uterine cancer.

One reason which deters patients from going on regular follow-ups is the fact that some doctors order unnecessary tests during these visits. One should be aware that the following tests are NOT recommended for regular follow-up care of breast cancer patients:

  • Blood tests like CBC, LFT, KFT
  • Chest x-ray
  • Bone scan
  • CT scan
  • FDG PET scan
  • Breast MRI
  • Breast cancer tumor markers – CA 15-3, CA. 27.29, CEA

39 fibroadenomas removed using just two incisions!!

Yesterday, we performed a marathon fibroadenoma surgery, where we removed 39 fibroadenomas from both the breasts (19 from the right breast and 20 from the left) just by making one incision in each breast. We used a crescent incision in both the breasts and comfortably removed fibroadenomas measuring as big as 5-6 cms through that incision. The entire procedure lasted 2 hours and the patient was discharged the same day.

Although the smaller fibroadenomas could have been left behind (because they are not malignant) but the patient was very apprehensive about them and wanted all of them removed. The importance of the single incision (periareolar crescent) is that it makes the end cosmetic result quite good. I am sharing some intra-operative pictures in this post. Will update the post-operative and follow-up pictures soon.

Marking of the crescent incision.

Marking of the crescent incision.

 Fibroadenomas marked along with the incision. Smaller lesions were not marked.


Fibroadenomas marked along with the incision. Smaller lesions were not marked.

 

6x7 cm fibroadenoma removed through the incision

6×7 cm fibroadenoma removed through the incision

 

5x5 cm lesion removed through the left breast

5×5 cm lesion removed through the left breast

 

Starting the closure. Will share the post-op and follow up pictures soon

Starting the closure. Will share the post-op and follow up pictures soon

Sweetest gift

Can't get sweeter than this

Can’t get sweeter than this

A very old breast cancer patient came to my OPD one day and started crying. She had been diagnosed with breast cancer at a hospital close to her village but because she could not afford treatment in a private hospital, she came to Delhi for free treatment. After examining her, I explained to her the treatment plan and got her investigated for surgery.

Within a couple of weeks we operated her and she went on to receive chemotherapy and radiotherapy afterwards. Following the completion of her treatment, I did not see her for a few months.

Then one day I reached the OPD slightly late as I was taking care of a sick patient in the ward and as I was approaching my room, I was greeted by the same lady with her short curly hair (this is what chemotherapy does to the hair…will write a post about this sometime later) and a wide smile on her face.

Once I settled down in my chamber, she came rushing in and put this huge packet on the table and said that it was for me. When I told her that I could not accept it, she became very sad and said that she had carried it 150 kms specially to gift it to me and insisted that I open it in front of her. I eventually gave in to her request and what I saw when I unwrapped the packet was really overwhelming. Inside it was a 2 kg fresh jaggery cake, which this lady had carried specially for me and I was very touched by her gesture. It truly was the SWEETEST GIFT I have ever received from a patient and that too from someone who was having difficulties funding her own treatment.

Sometimes the smallest gestures turn out to be the sweetest ones. 

Metalloman saved by magnets

If you call this junk food, wait till you read & digest this story!!

If you call this junk food, wait till you read & digest this story!!

This is a really interesting case (not related to Breast Cancer), I came across while working at Safdarjang Hospital. It was 2 AM, when this 16 year old boy was wheeled into the surgical emergency accompanied by his parents. He had developed acute pain in the abdomen which started in the morning and was getting worse by the minute. My junior immediately examined the patient & told me that he would require surgery as he had developed peritonitis (due to perforation of his intestines). As he started explaining the situation to his parents, they quietly came to me and started telling me about his history. What they told me was quite shocking!! This boy was consuming all kinds of objects including glass, light bulbs, buttons, batteries and magnets for the last 3 years(imagine this boy walking through the scanner at the airport!…the security guards would have been perplexed 😉 ) . In the past 3 years he never complained of pain in the abdomen (despite consuming a myriad of objects), but ironically he developed this pain within a week of stopping his unique diet (his parents had found out a week back and kept him under strict surveillance).

Without any delay we took the patient for an emergency surgery and what we found inside was truly shocking (I had seen cases of many cases of hair balls or trichobezoar in the stomach but this was something I wasn’t prepared for). His small bowel had multiple perforations and there were metallic objects jutting out from all the places (I usually wear two pairs of gloves during surgery but due to the nature of the case I had to wear an extra pair). We had to remove 2 feet of his small bowel as it was not salvageable and after finishing the case we cut open the bowel to see what all was there in the pandora’s box. What we noticed was quite astonishing….all the metallic objects had got stuck to the magnets which he had consumed. This was the reason his disease was restricted to that portion of the bowel. Had he not consumed those magnets, almost whole of this bowel would have been affected. We separated the objects from the magnet and painstakingly divided them into various categories.

We retrieved close to 350 metallic objects from the jumbled mass and it included 2 high power magnets (which literally saved his life), around 80 small light bulbs, 10 button batteries & more than hundred of his mother’s & sister’s hair clips (they were not happy to hear about this 😉 ). We clicked multiple pictures of these objects and the bowel (for which I am thankful to the anaesthetist and the poor intern whom we woke up at 4 AM to go to the OR with us). Unfortunately, I cannot share the pictures at present (as I have sent this case for publication in an international journal) but will soon share them on the blog.