My article on “Is Left Handedness a handicap in Surgical Training” published in Health Spectrum Magazine

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Click here to read the full article

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Lessons from Nature #1

#Patience #LessonsfromNature #Photography #Motivation #RohanKhandelwal

When I started doing bird photography, there used to so many instances when the bird used to fly away just as I was about to click it or the picture used to come out hazy. It was frustrating initially and many times I thought that I will never get a chance to click that particular bird again. But, with time I realized that patience does pay off.
This quote by Aristotle is so true “Patience is bitter but it’s fruit is sweet”. This is exactly what wildlife photography has taught me. There is a right time for everything and only after a lot of patience and hard work, does that moment arise.
So don’t lose hope and keep working towards your goal. Be patient when you are going through a rough patch, because ultimately you will come out on top. When the right moment comes, it will be magical…just like this pic!!

Yellow Fotted Green Pigeon

Yellow Fo0ted Green Pigeon

Lymphedema Workshop

Lymphedema is a common and debilitating problem in patients suffering from Breast Cancer. It affects 7-15% patients who undergo axillary lymph node clearance as a part of their cancer management.

Although it is usually mentioned as one of the side effects in the consent form, but very few patients are actually counseled regarding this dreaded problem. In our unit, we make sure that the patient is explained about this problem before they undergo surgery and we re-inforce these points after surgery as well.

To help out patients suffering from lymphedema, we organized a workshop, which was conducted by Ms. Mamta Goenka, who is an expert in lymphedema management. Her talks and demos were extremely beneficial for the patients and they ended up learning new exercises and facts about this problem. Ms. Goenka is soon going to post a video of her workshop on YouTube.

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Photography – my biggest stress buster!!

Photography has a different meaning in everyone’s lives. For me the love of photography started at a young age when I used to observe my uncle (who is an avid bird watcher) & my brother who used to click pictures with old camera’s which used photographic film. I feel photography was more of an art at that time, where one had to be frugal in the number of pics they clicked. Things have changed with DSLR’s coming into the market. Now one can click unlimited pics and then choose the best one.

The most exciting thing earlier was to wait for the camera roll to be developed and see the pictures and carefully catalogue them in an album. Nowadays people hardly get their pictures developed and most of them are now stored on the computer or a hard drive. I remember developing black and white pictures at school, where we had to be so precise about the exposure time and the chemicals to get the perfect picture. Now pictures can easily be modified on the hundreds of softwares available.

Even though so much has changed in photographic technology, my love & passion for photography remains the same…infact it has grown exponentially over the last few years. For me it is the ideal stress buster after a hectic day at work.

I feel the best gift one can get is a camera and that is one thing I will make sure my kids will have as soon as they are old enough to handle one.

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Rose ringed parakeet enjoying his meal

This post on the occasion of World Photography day will be incomplete, if I don’t share a picture. I got up in morning, not realizing that it is world photography day. I picked up my camera and walked into my backyard where I spotted this rose ringed parakeet happily enjoying his meal. He was totally oblivious to my presence and I was able to get really close and get some great pics of the bird. Hope you enjoy it. Keep clicking!!

Colors of Nature

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Nature never fails to amaze us with it's beauty & colors

Cape Town – South Africa from Chapman’s Peak. One of the most scenic drives I have ever been on.

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Colorful painted stork amidst the rain washed green grass

Kabini (Karnataka) is a paradise for nature lovers and wildlife enthusiasts.

Contraindications to Breast Conserving Surgery

Breast conserving surgery (BCS) is fast becoming popular but one should be aware of the the contraindications of this procedure in order to avoid high recurrence rates & complications.

Breast conserving surgery in simple words is lumptectomy (removal of the tumor with a normal rim of tissue). All patients following BCS require radiotherapy. Some of the contraindications of this procedure are related to the surgical aspect whereas others are contraindications for radiotherapy.

 

Absolute Contraindications

  1. Pregnancy – is a contraindication for radiotherapy, as it can lead to teratogenic effects.
  2. Two or more primary tumors in separate quadrants (multicentric tumors). Patients with multifocal tumors (two or more primaries in the same quadrant) can undergo BCS. [Fig 1]
  3. Diffuse malignant-appearing calcifications on mammogram 
  4. History of prior radiation to the breast area
  5. Persistent positive margins
  6. Inflammatory breast cancer

multifocal vs multicentric

 

Relative Contraindications

  1. History of collagen vascular disease – leads to increased radiotherapy associated complications
  2. Breast size to tumor size ratio [Fig 2] – Instead of the absolute size of the tumor, tumor/ breast ratio is a better indicator of whether the patient is eligible for BCS or not. Fig 2 – highlights two patients, both with identical tumor sizes but one patient has a large breast (leading to a small tumor/ breast ratio) whereas the other patient has a small breast (leading to a large tumor/ breast ratio). BCS is avoided in patients with large tumor to breast ratio as it leads to poor cosmetic outcome.

tumorbreastratio

 

Following are NOT contraindications to BCS:

  • Family history of breast cancer
  • Positive lymph nodes
  • Bilateral breast cancer
  • Lobular histology
  • Central quadrant tumor

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.