Breast Surgery & Reconstruction


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Breast Surgery & Reconstruction


Ganga Hospital has grown steadily over the years due to constantly introducing cutting edge scientific advancements in the fields of Plastic Surgery and Orthopaedics and at the same time being patient centric in every decision that we take and every action that we do. We were among the first in the region to introduce microsurgery, re-plantations, early debridement, fixation and flap cover, On Arrival Block, microsurgery for lymphoedema, Ganga Air Ambulance and many more concepts in this region. Being pioneers haven’t made us lose the common touch. We are proud to say that we are among the very few hospitals in the world who do not charge the patient before taking the patient for emergency surgery. Many such initiatives by us have helped us gain the confidence of many patients over the years and we have become one of the busiest plastic surgery units in the world. We are proud to say that we not only get many patients, we also get a lot of doctors who come to observe and learn from us. We are proud to say that the Department of Plastic Surgery has trained more than 1600 doctors from 64 countries. No mean feat by any department throughout the world and very difficult to replicate!!!

With this background and with our constant thirst to serve the people with the latest advancements, we are now venturing into Oncoplastic Breast Surgery. Treatment of breast cancer has changed over the years. Breast Cancer responds to many modalities of treatment such as surgery, chemotherapy, radiotherapy and hormone therapy. These advances have improved the treatment of breast cancer and the average 10 year survival of breast cancer has increased to 83 % which is quite high for cancer. As a part of the treatment, breasts are removed and some women have their breasts disfigured due to radiotherapy after partial removal of the breast (Breast Conservative Therapy). With many people beating the disease, women want to move on. However they are constantly reminded of the disease whenever they see themselves in the mirror. Realising this, many advanced units throughout the world talk about removal of the tumour as well as reconstruction of breasts at the same surgical sitting and this has become the norm. Certain developed countries like UK and USA have even laws that mandate doctors offering breast reconstruction at the same time as removal of the tumour. So Breast Oncology surgery has now become Oncoplastic Breast Surgery as we now realise that reconstructing breasts are as important as removing them for cancer

When patients plan for breast reconstruction, it is important that they get the best method of breast reconstruction done. Poor means of reconstruction are as bad as no breast reconstruction. There are many ways to reconstruct the breast. With most patients in India needing radiotherapy, the best means of breast reconstruction is using the patients own tissues by microsurgery. It is now widely accepted throughout the world that the gold standard method of breast reconstruction is called “DIEP Flap”. Here the extra protuberant skin and fat in the lower abdomen which every women don’t like is removed along with the blood vessel supplying it and attached to the blood vessels in the chest and shaped into a new breast. This needs extensive experience in microsurgery as we need to chose the right blood vessel which supplies the skin and fat in the lower abdomen. We are proud to say that we are among the very few handful of institution who can offer this.

Having said that we are among the best in reconstruction we do realise and accept that treatment of breast cancer is more important and we offer the full gamut of breast oncology surgery such as Breast Conservative Therapy, Sentinel Lymph Node Biopsy, Skin sparing mastectomy and Therapeutic Mammaplasty.

Breast and Ovarian Cancers can run in families and we now have some genetic tests which find out whether a person is susceptible to breast cancer. Women who have the defective gene run a very high chance of developing breast cancer and many women such as the popular actress Angelina Jolie opt to get their breasts removed before they get breast cancer. This is called Prophylactic Mastectomy. At the same surgery, women also get breasts reconstructed from their abdomen. Thus this surgery drastically reduces the chance of the women getting breast cancer and also makes the women look better !!!

Catching breast cancers early is also very important and we offer regular screening for breast cancer so that we catch breast cancer early.

Keeping with our practice of being abreast with the latest advancements, we are proud to introduce the full gamut of oncoplastic breast surgery to Coimbatore. With every step we take, we always remind ourselves on the reason why we are what we are. This can be summarised in a single word called “Trust”. We just strive to maintain this trust by our patients and among those who work with us.


1. Know about Breast Cancer


Understanding Breast Cancer

What is cancer?


Cells are the basic building blocks of the tissues and organs of our body. Usually these cells divide to make new cells in a controlled manner and beyond a point the cells are replaced with new cells. This is how our bodies grow, heal and repair. Sometimes, this orderly growth of cells can go wrong due to the mutation or sudden change in the genes which control how cells behave. This can make the cells to divide abnormally producing more and more abnormal cells which then form a lump called as a tumour. These cells lack the ability to stay together, can easily detach from each other and spread via direct contact, lymphatics and blood stream to other organs in the body.


Where does breast cancer develop from?


The breast consists of multiple lobules producing milk which are connected to the nipple by multiple ducts. Breast cancer arises commonly from the cells lining the ducts of the breast and is known as Ductal carcinoma. If the abnormal cells have not breached the basement membrane, it is called as Ductal Carcinoma in Situ. If the abnormal cells lining the ducts have breached the membrane and is able to spread to other areas of the breast it is then called as Invasive Ductal Carcinoma. Similarly the cells lining the lobules of the breast can become abnormal producing cancer and this is called Lobular Carcinoma. Depending on whether the abnormal cells have breached the basement membrane or not, they are called as Invasive Lobular Carcinoma and Lobular carcinoma in situ. Sometimes the cells lining the connective tissue of the breast can become abnormal and producing a tumour called as phyllodes tumour.


What are the signs and symptoms of breast cancer?


The most common symptom of breast cancer is a lump in the breast. Other symptoms and signs of breast cancer are changes in the size and shape of the breast, bloody nipple discharge, changes in the breast skin and nipple, lumps in the axilla and occasionally breast pain. Early breast cancers may not present with any symptoms and signs and maybe found by routine screening. To more about symptoms and signs of breast cancer please click here.


How is breast cancer diagnosed?


Breast cancer is diagnosed by Triple Assessment which means Assessment is done by the following components namely.

  • Clinical Examination
  • Radio logical Assessment
  • Pathological Assessment by Biopsy
  • To know more about Diagnosis of breast cancer click here.

    Where does the Breast Cancer spread to?


    The Breast cancer spreads initially to the lymph nodes in the same side axilla by means of lymphatic system. Beyond that it can spread by bloodstream to the liver, lungs, brain and bones.


    What do you mean by Grading of Breast Cancer?


    The grade of breast cancer describes how abnormal the tumour cells look under the microscope compared to normal tissue. It indicates how quick a tumour tissue is likely to grow and spread. In breast cancer the pathologist looks at the biopsy specimen and classifies the tissues as low grade or well differentiated tumour, intermediate grade or moderately differentiated tumour and high grade or poorly differentiated tumour. High grade tumours may spread fast and may need more aggressive treatment.


    What is staging of Breast Cancer?


    Staging of Breast Cancer helps us to know the severity of the breast cancer based on how far it has spread. Staging is done based on the size of tumour, presence of enlarged lymph nodes and spread beyond lymph nodes to other parts of the body. This helps us to decide the treatment to be offered to the patient. In addition, it also helps us to know about the prognosis of the patient. Breast cancer is divided into 4 stages with Stage 1 &2 known as Early Breast Cancer (To know more Early Breast Cancer click here), Stage 3 known as Locally Advanced Breast Cancer (To know more about Locally Advanced Breast Cancer click here) and Stage 4 is known as Metastatic Cancer.


    How common is Breast Cancer?


    Breast cancer is the most common cancer among women in India and the incidence of breast cancer is increasing.
    Breast cancer accounts for about one third of cancers among women. The incidence of breast cancer among young women seems to be on the rise compared to women 25 years back.
    With modern methods of treatment the survival rate among women with breast cancers has increased to a 10 year survival rate of 83% . By regular screening methods we can detect breast cancers much earlier and improve the survival rate further.


    What are the treatment modalities to treat breast cancer?


    Breast cancer is susceptible to various modalities of treatment. This is good because the various methods can be used together to give a good result.The main aim of surgery is to remove the cancer tissue in the breast as well as the lymph nodes in the axilla. After removal of the tumour tissue by surgery, there can be some tumour cells which might have spread beyond the lump. These cells which have spread beyond the tumour are taken care of and killed by radiotherapy for cancer cells present locally near the breast and by chemotherapy and endocrine therapy for cancer cells that have spread beyond the breast.
    The various methods to treat breast cancer are

  • Surgery
  • Chemotherapy
  • Radiotherapy
  • Hormone therapy

  • What are the surgical modalities for treating breast cancer and how does it help?


    The surgical modalities for breast cancer can be divided into those procedures which remove the cancer tissue from the breast and those surgical modalities which remove the lymph nodes in the axilla. We would need to choose one procedure from each modality. The procedure that is chosen for each patient will depend on the size of the tumour, stage of the tumour, size of the breast, presence of multiple lesions and patient preference.The various surgical procedures to remove the cancer tissue from the breast are.


    Breast Conservative Therapy


    This can be done only for a small tumour in a large breast wherein we remove the breast cancer along with a small margin of tissue. If there are multiple lesions in the breast this procedure can not be done.The patient would definitely need radiotherapy after this procedure. By doing this we can conserve the breasts.(To know more about Breast Conservative Therapy please click here)

    Therapeutic Mammaplasty


    This procedure is done for slightly larger tumours in a large breast where in we remove a part of the breast and use breast reduction plastic surgical techniques to reduce the size of the breast. This breast would definitely need radiotherapy after the procedure.(To know more about Therapeutic Mammaplasty please click here)

    Mastectomy with Reconstruction


    Here the whole breast is removed. This is done for small breasts, multiple tumours in the breast and breast cancers which present in an advanced stage. We offer the full gamut of reconstruction possibilities for the patient. The best method of reconstruction would be autologous reconstruction where we take the patients own tissues such as the tummy, inner thighs, back or buttocks to make a new breast. Reconstruction of the breast is best done at the same time of the mastectomy or removal of the breast as the patient wakes up with a new breast, surgery is done in one operation and the cosmetic result of a breast done at the same time of removal of the breast is better than when reconstructed at a later date.

    Mastectomy


    Here the whole breast is removed. Some women may not want any form of reconstruction of the breast and would like to remain flat chested. They can use prosthesis in their bras if necessary or they can get their breasts reconstructed after some time.
    Surgical procedures to address the lymph nodes in the axilla


    Sentinel Lymph node Biopsy


    Sentinel lymph node is the first lymph node that drains the breast cancer. It is assumed that if this lymph node is biopsied and no tumour is found then more radical procedures such a axillary lymph node dissection can be avoided. However if tumour is found in the lymph node biopsied, a complete axillary lymph node dissection needs to be done. (To know more about sentinel lymph node biopsy click here)

    Axillary Lymph Node Dissection


    Axillary lymph node dissection is done when there is a lymph node which is palpable in the axilla or if sentinel lymph node biopsy is positive. Here the entire group of lymphatics in the axilla is removed. (To know more about axillary dissection please click here)

    What is “Neoadjuvant Chemotherapy” for breast cancer?


    When patients present with Stage III Breast Cancer in an advanced stage, chemotherapy is given initially to downsize the tumour followed by surgery so that there is less chance of recurrence.


    What happens during chemotherapy?


    Using an intravenous line, chemotherapy drugs are injected. As the drugs go to all parts of the body it helps to kill the cancer cells which have spread to any other part of the body. In certain tumours as in Stage III tumours it is used as Neoadjuvant Chemotherapy to decrease the size of the tumour. It is also given after surgery or when it has spread to different parts of the body. The regimen and drugs given can vary between different individuals based on the cancer, the stage of presentation and the ability of the individual to tolerate the drugs.


    Why is radiotherapy given?


    Radiotherapy is given to prevent recurrence of the breast cancer in the local area. It is given if the tumour is big or if the lymph nodes in the breast are involved or when procedures like Breast Conservative Therapy and Therapeutic Mammaplasty are done.


    What is hormone therapy?


    Some cancer tissues have receptors for hormones. When hormones attach to such tissues, the cancer cells tend to grow. So some medicines can be given so that the hormones do not attach to the cancer tissue and prevents it from growing. This hormonal therapy is usually given after the other modalities such as surgery, chemotherapy and radiotherapy are given. Usually these medications are given for 5 to 10 years.


    Weight


    A person is considered overweight when his/her BMI ( Body Mass Index) is more than 25 and considered obese when the BMI is more than 30. With increase in weight, women have an increased chance of getting breast cancer, increase their chances of recurrence and wound infection following surgery. This is true especially in women who have undergone menopause as the body gets the hormone estrogen from the fat. With more fat, there is more estrogen and more chances of developing breast cancer. With reduction in weight, the chances of breast cancer reduces. Hence a healthy lifestyle is encouraged.


    Exercise


    Studies have shown that moderate exercise for 4 to 7 hours a week reduces the risk of breast cancer. For those women affected with breast cancer walking 3 to 5 hours a week at an average pace increases their chance of surviving their disease. Exercising reduces the fat content in the body and controls the hormones which regulate how breast cells grow and behave. Women who do not exercise are encouraged to start slowly and exercise daily.


    Alcohol


    Drinking alcohol increases breast cancer by about 20% more than those who do not drink. It can increase the levels of estrogen and other hormones responsible for breast cancer. It can also damage the DNA in cells producing cancer.


    Smoking


    Smoking gives rise to many diseases in the body of which breast cancer is also one. It produces breast cancer in a younger age group, poor wound healing, failure in breast reconstruction and reduces the survival of those who smoke. Inhaling the smoke from others smoking has also found to produce breast cancers.


    Radiation before 40 years of age


    Radiation is often given to the chest to treat other tumours such a lymphoma at an early age before they are 40. The chance of breast cancer increases at an earlier age and is highest when radiation is given at adolescence when the breasts are developing. The chances of developing breast cancer can be as high as 22 to 40 times when compared to a normal person. Hence they need to be followed up frequently by mammograms/MRI. After completing their families, they can also go for prophylactic mastectomies ( Removal of breasts as a precaution before the onset of cancer) and reconstruction. This will reduce the rate of breast cancer by more than 95%. To know more about Breast Reconstruction. Please click here


    Age


    Breast cancer is most common in women between 40 to 60 years. However, compared to 25 years back we see a lot of women having breast cancers at an earlier age group. It is not uncommon to see women with breast cancers in their twenties and thirties. This is shown in the figure below, which depicts the percentage of breast cancers in each age group both today and 25 years back. This is probably due to our change in lifestyle and increasing westernisation.


    Healthy Food


    As breast cancer is increasing and is seen more in the younger age groups, it is widely felt that a change in the diet could be one of the reasons behind the change. Although no particular food is found to be a causative factor, it is found that breast cancer is less common in countries where the typical diet is plant-based and less in total fat content (Polyunsaturated fat and Unsaturated fat). Some feel that people who eat a diet rich in fat may have a high risk of developing breast cancer in later life even though they don’t become overweight.


    Prior Breast Cancer


    If a woman is diagnosed with breast cancer earlier, she is 3 to 4 times more prone compared to another woman in developing another cancer in the opposite breast and also in the same breast if she had undergone a lumpectomy earlier. Hence it is important that woman keep following up frequently which includes a

  • Monthly Self Examination
  • Yearly Breast examination by your doctor
  • Digital Mammogram/Ultrasound every 6months/year

  • Previous Pregnancies


    Women who have their first pregnancy beyond the age of 30 are more likely to develop breast cancer compared to women who develop breast cancer before the age of 30 years. When women are in their teens, the cells in the breast are immature and very active until their first pregnancy. During their first pregnancy, the cells become mature under the influence of various hormones. Being pregnant also reduces the number of menstrual cycles which also contributes to reducing the risk of breast cancer. Having a first child before the age of 30 years reduces the risk of breast cancer.


    Breast Feeding


    Breast feeding beyond one year helps to protect women from breast cancer. Breastfeeding less than a year has less benefit. The reasons why breastfeeding protects breast health are

  • Milk production protects the breast cells from damage
  • During breastfeeding, women don’t get menstruation which also helps
  • Women tend to have a healthier lifestyle during breast feeding
  • Breastfeeding is very good for the baby

  • Menstrual Cycles


    Women who have more menstrual cycles (periods) in their life have a higher chance to develop breast cancer than those who have lesser menstrual cycles. Thus women who start having menstruation earlier than 12 years, who develop menopause later than 55 years and who do not have any children are more prone to develop breast cancer. Of late it is found that girls have their onset of puberty and development of breasts at an earlier age due to various changes in lifestyle which increases the chances of estrogen influence to the breast and breast cancer.


    Hormone Replacement Therapy


    Hormone replacement tablets are taken to reduce the symptoms of menopause like hot flashes, change in mood and to prevent osteoporosis. However, it is found that they can increase the chance of breast cancer.
    Combination hormone replacement therapy includes the hormones estrogen and progesterone. It is found that within the first two years the risk of getting breast cancer and detecting it only in an advanced stage increases. The risk normalises within first two years of stopping the hormone replacement therapy.
    Estrogen-only Hormone therapy increases the chance of breast cancer only when it is used for more than ten years. This therapy also increases the chance of ovarian cancers.


    Oral Contraceptive Pills


    Women who take hormone containing oral contraceptives have a small increase in chance compared to that of the general population. The increase was about one new breast cancer case per 7,690 women who used hormonal contraceptives for a year. Women who take it for a longer time have an increase in chance compared to those who take for a shorter time.


    When should I be alert that I could have breast cancer?


    After puberty, it is recommended that all women do a self-breast examination and report if they feel any abnormalities in their breasts as breast cancer can occur even in very young women who are in their 20s. The abnormalities in their breasts that women should look for are


    Lumps in the breast


    Lump in the breast is the most common symptom of breast cancer. However, not all lumps are malignant. A significant proportion of lumps in the breast are benign. The decision on whether the lump in the breast is benign or malignant can be known by clinical examination by the doctor and additional investigations such as imaging and biopsy. Any new breast lump should be checked. Breast lumps that are malignant tend to be hard, rapidly growing in size, painless and not movable freely in the breast


    Change in the size and shape of the breast


    Compare the size and shape of both breasts in the standing position, sitting position, lying down position and with hands on both hips and above the shoulders. Any change in the size and shape of the breasts such as swelling in a particular area or retraction of the breast while doing any manoeuvre should alert you to see your doctor immediately.


    Lumps in the axilla


    Feel for any lumps in the armpits. lump and as well as the axilla, is highly suggestive of breast cancer,and you should go to your doctor immediately. However few non-palpable aggressive breast cancers may present with lymph node swellings in the axilla. These swellings are usually hard. At the same time lumps in the axilla can occur due to various reasons such as any minor infection in the upper limb, variety of systemic infections and leukaemia. Hence to be sure of your problem consult your doctor.


    Bloody nipple discharge


    Breast cancers may present with bloody nipple discharge. Nipple discharges which are of other colours could represent other benign breast disorders and should be checked by your doctor.


    Changes in the nipple


    Recent changes in the nipple such as nipple inversion, retraction of the nipple, scaliness of the nipple could be associated with breast cancer and should alert you to see your doctor.


    Changes over the skin of the breast


    Breast cancer could be associated with changes in the skin such as dimpling, puckering, thickening, reddening, ulcers or indentation. Any change over the skin of the breast should alert you to see your doctor.


    Breast Pain


    Only 10% of pain in the breast is due to breast cancer. Breast cancer is usually painless and hence ignored by many women. However, if there is pain and redness of the breast, it could be due to a severe form of cancer known as the inflammatory breast cancer.


    No symptoms and signs


    Early breast cancers do not present with any signs and symptoms. It is best to diagnose breast cancer at this stage as this will improve the chances of survival a lot and the patient may not need certain modes of treatment such as chemotherapy and radiotherapy. For this, the patient should have frequent screening of the breast.



    How do I do Self Breast Examination?


    The self-breast examination is to be done every month after puberty. This is to be done regularly every month around 4 to 10 days after periods when the breast is least painful. Performing the self-breast examination regularly at the same time will enable the women to know whether there was any change in her breast as breasts can differ due to hormonal changes with regards to when the breasts are examined in their menstrual cycle.


    Self Breast Examination is done by the woman uncovering her upper torso and looking in the mirror specifically for change in the size and shape of the breast and nipple. Any change in the nipple or the skin overlying the breast should also be noted. Then the breast is palpated from the nipple, concentrically outwards over both the breasts with the flat palmar aspect of the hand. After palpating the breasts, both armpits are also to be palpated to look out for swellings in the axilla. With both arms over the hips and above both shoulders, any change in the size and shape over the breasts, skin changes and nipple changes are to be noted. With the person lying down this procedure is repeated to feel for any lumps in the breast. Any abnormality felt should make you visit your doctor to rule out breast cancer.


    How helpful is Self Breast Examination?


    Identifying any abnormality in the breast early can help us diagnose and treat the breast cancer early which will improve the chances of survival and the patient may not need certain modes of treatment such as chemotherapy and radiotherapy.


    If I have any of the above signs and symptoms what is the next thing that I should do?


    The next thing that you should do is to immediately consult your doctor who would examine you and might do some investigations to find out the presence of breast cancer.


    What happens if I ignore these symptoms?


    Ignoring these symptoms might make your breast cancer become larger and may increase the chances of spread. This might decrease your chances of survival and you might present late.


    How is Breast Cancer diagnosed?


    Breast cancer is diagnosed by Triple Assessment which means Assessment is done by the following components namely


  • Clinical Examination
  • Radiological Assessment
  • Pathological Assessment by Biopsy

  • After clinical assessment, few investigations are done for further treatment. The investigations done can be broadly divided into*

  • Investigations to find out the presence of breast cancer
    Mammogram, Mammogram with Ultrasound, Ultrasound Guided Core Needle biopsy, Fine Needle aspiration cytology
  • Investigations to look out for spread of breast cancer
    Fine Needle Aspiration Cytology (FNAC) & Sentinel Lymph node Biopsy (SLNB) for lymph node spread to the axilla or armpit, Chest X Ray or CT chest for spread to the lungs, Ultrasound Abdomen or CT Abdomen for spread to the abdomen, X Rays of long bones or Bone Scan to find out spread to the bones & MRI brain for spread to the brain.
  • Investigations to assess the fitness for surgery & chemotherapy
    Blood Investigations, ECG, Chest X ray, Echocardiogram
  • Investigations for relaps
    PET CT (Positron Emission Tomography)
  • Genetic Studies
    BRCA 1 & BRCA 2 gene testing
  • Investigation for Breast Reconstruction
    To look out for the presence and the position of perforators, CT Angio should be done

  • *All the above tests will not be done for everyone. We have only enumerated all the tests. Tests that are needed for the patient only will be done.


    What is mammogram and why is it done?


    Mammogram is X ray imaging of the breast. It is mainly used for screening purposes as well as to find out the presence of non palpable breast lesions. With the advent of digital mammogram It helps us to find out the presence of small non palpable lesions better and also helps to rule out false positive lesions in the breast.


    What is Ultrasound and what is it used for?


    Ultrasound is an imaging device wherein sound waves are transmitted from the probe and depending upon the reflected sound waves we get an image which helps us to find out where the breast lesion is, whether the lesion is a cyst and helps us to find out non palpable breast lesions better. Using an ultrasound we can also guide the core needle to take biopsies.


    What is Core needle biopsy?


    A 2 mm small incision is made over the breast. Under ultrasound guidance, a core needle is inserted into the breast and a small amount of tissue is taken along with the needle. This tissue taken out is then sent for biopsy. The biopsied tissue is analysed by a pathologist who sees the tissue under a microscope and sees whether the tissue is a cancer or not. If there is cancer, further immunohistochemical markers such as hormone receptors like estrogen receptor and progesterone receptors are looked for in the tissue biopsied. This gives us a lot of information for further treatment. This is a office procedure and can be done in the clinic.


    What is Fine Needle Aspiration Cytology?


    In this a needle is injected multiple times into the tumour or the lymph nodes in the axilla under negative pressure and few cells are aspirated into the syringe. If the tumour or the lymph node is not easily palpable, it can be done under ultrasound guidance.These cells are analysed by the microscope to look out whether the tumour is benign or malignant. This is an office procedure and this can be done in the clinic.


    What is BRCA 1 and BRCA 2 gene testing?


    BRCA 1 and BRCA 2 gene testing is used to test whether a person has a gene which predisposes a person to breast cancer. This is a blood test and is done for women who present with breast cancer at an early age and have a strong family history of having breast cancer and ovarian cancer.


    What is Ductal Carcinoma in situ?


    When the cells lining the ducts have features of carcinoma, but haven’t crossed the basement membrane of the duct and is confined to the duct, it is called as ductal carcinoma in situ.


    How does this ductal carcinoma in situ develop?



    There are many stages in which the ductal carcinoma in situ develops. They are

  • Ductal Hyperplasia There is overgrowth in the number of cells lining the ducts
  • Atypical Ductal Hyperplasia In addition to an increased number of cells lining the ducts, the cells get converted to an abnormal appearance
  • Ductal Carcinoma in situ Here the cells lining the ducts show features of carcinoma, but they are confined to the ducts.
  • Invasive Ductal Carcinoma Cancer arising from the ducts have breached the basement membrane and spread to the other areas of the breast and beyond.

  • How does Ductal Carcinoma in Situ present?


    Most of the ductal carcinoma in situ present asymptomatically and are detected while screening with mammograms. A small percentage of patients may present with a small palpable mass or bloody nipple discharge.


    How common is ductal carcinoma in situ?


    Ductal Carcinoma accounts for about 17 to 34 % of mammographically detected tumours.


    Does Ductal Carcinoma in Situ need to be treated?


    Ductal Carcinoma in situ are precursors for breast cancers. They are not life-threatening. But they need to be treated so that they don’t get converted to invasive breast cancers.


    How is it diagnosed?


    DCIS is diagnosed with mammogram where they present as microcalcifications that are arranged in clusters and are of different shapes and sizes. With ultrasound guidance biopsy is usually done by a core needle biopsy. If the biopsy is inconclusive, excision biopsy where in the tissue removed in toto is removed.


    How is Ductal Carcinoma in situ treated?



    How is Ductal Carcinoma in Situ followed up?


    If lumpectomy had been done, there is a 30% chance of recurrence. With radiotherapy, the chance of recurrence reduces by 15%. Most of the recurrences are within the first five years. A patient who had a DCIS before has a higher chance of getting breast cancer back compared to the normal population in the same side breast if lumpectomy had been performed and also in the opposite breast. Hence patients need to be followed up regularly by

  • Monthly self-examination of the breast
  • Examination by the doctor every six months
  • Mammography screening once every year

  • What is Lobular Carcinoma in situ (LCIS)?


    Lobular Carcinoma in Situ (LCIS) is a carcinoma which arises and limited to the cells lining the milk-producing glands of the breast


    How is it diagnosed?


    LCIS is mostly asymptomatic and is diagnosed most commonly in biopsies taken from the breast. As it does not produce the characteristic calcification's, it is not easily seen on a mammogram.


    What is the significance of LCIS?


    Patients who have LCIS are more prone to develop an invasive carcinoma of the breast(30-40%) when compared to those who do not have LCIS (12.5%). Those who develop invasive carcinoma of the breast develop it over a long period from the onset of LCIS (around 10 to 15 years)


    How is Lobular Carcinoma in situ treated?


    As the LCIS are seen in multiple areas of the breast and as they develop into cancers after a long period, no specific treatment is needed other than regular followup.


    How is followup done for LCIS?


    Regular followup is needed for patients who have LCIS and this is done by


  • Monthly self-examination of the breast
  • Examination by the doctor every six months
  • Mammography screening once every year
  • What is Early Breast Cancer?


    Staging of Breast Cancer helps us to know the severity of the breast cancer based on how far it has spread. Staging is done based on the size of tumour, presence of enlarged lymph nodes and the spread beyond lymph nodes to other parts of the body. Based on this there are 4 stages of breast cancer. Stages I & II are generally called as Early Breast Cancer in which the tumour is generally less than 5 cms in size and the spread has been limited to the lymph nodes in the same side axilla


    How are non palpable breast cancers diagnosed?


    Non palpable breast cancers are generally diagnosed by screening. This is done by mammograms taken once every year above the age of 40 years. Women who have a strong family history may take mammograms above the age of 30 years. As the breast is dense in the younger age group, mammograms maybe coupled with ultrasound to find out the presence of non palpable breast cancers. Finding the breast cancer in this stage itself will be very good as the survival rates for these type of cancers is very high.


    How are palpable breast cancers diagnosed?


    Palpable breast cancers are diagnosed with core needle biopsy which is done in the clinic itself. This can be done with the help of ultrasound. A 5 mm small incision is made over the breast. A core needle is inserted into the breast and a small amount of tissue is taken along with the needle. This tissue taken out is then sent for biopsy. The biopsied tissue is analysed by a pathologist who sees the tissue under a microscope and sees whether the tissue is a cancer or not. If there is cancer, further immunohistochemical markers such as hormone receptors like estrogen receptor and progesterone receptors are looked for in the tissue biopsied. This gives us a lot of information for further treatment.


    What investigations are done for Early Breast Cancer?


    The investigations done can be broadly divided into*


  • Investigations to find out the presence of breast cancer

    Mammogram, Mammogram with Ultrasound, Ultrasound Guided Core Needle biopsy

  • Investigations to look out for spread of breast cancer

    Fine Needle Aspiration Cytology (FNAC) & Sentinel Lymph node Biopsy (SLNB) for lymph node spread to the axilla or armpit, Chest X Ray or CT chest for spread to the lungs, Ultrasound Abdomen or CT Abdomen for spread to the abdomen

  • Investigations to assess the fitness for surgery & chemotherapy

    Blood Investigations, ECG, Chest X ray, Echocardiogram


  • How is Early Breast Cancer treated?


    Early breast cancer is treated initially by surgery. If Breast Conservative therapy or Therapeutic Mammaplasty had been done the patient would require radiotherapy after chemotherapy. After surgery, the removed breast cancer is sent to the pathologist who examines the tissues under the microscope and confirms the diagnosis, tells us about the histology, grade of the tumour and whether the removed breast tissue has estrogenreceptors, progesterone receptors and Her2 neu receptors. The information provided by the pathologist is necessary to know whether we need to give chemotherapy, radiotherapy and hormone therapy.


    What are the surgical modalities for treating Early Breast Cancer?


    The surgical modalities for breast cancer can be divided into those procedures which remove the cancer tissue from the breast and those surgical modalities which remove the lymph nodes in the axilla. We would need to choose one procedure from each modality. The procedure that is chosen for each patient will depend on the size of the tumour, stage of the tumour, size of the breast, presence of multiple lesions and patient preference. The various surgical procedures to remove the cancer tissue from the breast are


    Breast Conservative Therapy


    This can be done only for a small tumour in a large breast wherein we remove the breast cancer along with a small margin of tissue. If there are multiple lesions in the breast this procedure can not be done.The patient would definitely need radiotherapy after this procedure. By doing this we can conserve the breasts.(To know more about Breast Conservative Therapy please click here)

    Therapeutic Mammaplasty


    This procedure is done for slightly larger tumours in a large breast where in we remove a part of the breast and use breast reduction plastic surgical techniques to reduce the size of the breast. This breast would definitely need radiotherapy after the procedure.(To know more about Therapeutic Mammaplasty please click here)

    Mastectomy with Reconstruction


    Here the whole breast is removed. This is done for small breasts, multiple tumours in the breast and breast cancers which present in an advanced stage. We offer the full gamut of reconstruction possibilities for the patient. The best method of reconstruction would be autologous reconstruction where we take the patients own tissues such as the tummy, inner thighs, back or buttocks to make a new breast. Reconstruction of the breast is best done at the same time of the mastectomy or removal of the breast as the patient wakes up with a new breast, surgery is done in one operation and the cosmetic result of a breast done at the same time of removal of the breast is better than when reconstructed at a later date.

    Mastectomy


    Here the whole breast is removed. Some women may not want any form of reconstruction of the breast and would like to remain flat chested. They can use prosthesis in their bras if necessary or they can get their breasts reconstructed after some time.
    Surgical procedures to address the lymph nodes in the axilla


    Sentinel Lymph node Biopsy


    Sentinel lymph node is the first lymph node that drains the breast cancer. It is assumed that if this lymph node is biopsied and no tumour is found then more radical procedures such a axillary lymph node dissection can be avoided. However if tumour is found in the lymph node biopsied, a complete axillary lymph node dissection needs to be done. (To know more about sentinel lymph node biopsy click here)

    Axillary Lymph Node Dissection


    Axillary lymph node dissection is done when there is a lymph node which is palpable in the axilla or if sentinel lymph node biopsy is positive. Here the entire group of lymphatics in the axilla is removed. (To know more about axillary dissection please click here)

    When will Chemotherapy be necessary?


    Chemotherapy drugs are injected intravenously. As the drugs go to all parts of the body it helps to kill the cancer cells which have spread to any other part of the body. Chemotherapy is necessary when the tumour is above 2 cms in size, has spread to a lymph node, absent estrogen receptors, Her 2 neu positive, unfavourable histology and high grade tumours. This is usually given within 6 weeks after surgery.


    When will radiotherapy be necessary?


    Radiotherapy is done when surgical modalities such as Breast Conservative Therapy and Therapeutic Mammaplasty are chosen as the preferred surgical modality. It is also necessary when the tumour is above 5 cms in size, has spread to a lymph node and has positive or close margins. This is generally done after surgery and chemotherapy have been completed.


    When will hormone therapy be given?


    After core needle biopsy and surgery, the tissues are sent for biopsy and the pathologist lets us know if there are receptors for hormones such as estrogen and Her 2 neu receptors. If the hormone receptor are present then hormone therapy is given. This consists of oral medicines taken for around 5 to 10 years. This is done after surgery, chemotherapy and radiotherapy .


    What is Locally Advanced Breast Cancer ( LABC)?


    Locally advanced breast cancer means that the breast cancer is quite large in size and has spread to the adjoining lymph nodes, muscles or skin. It has however not spread to the other sites in our body such as the lungs, liver or the brain. This is the most common presentation of women in India.


    Is this LABC survivable?


    With modern treatment options many patients do well and survive for a long period of time.


    How are patients with LABC diagnosed?


    Patients with LABC are diagnosed the same way as any other breast cancer is diagnosed. After clinical examination,the breast cancer is diagnosed by a Tru-cut biopsy. If there is an enlarged lymph node involved FNAC of the involved lymph node is then done. To know the extent of spread, a mammogram is done for the opposite breast, CT chest is done for the chest, Ultrasound abdomen is done for the abdomen and if necessary CT brain is done to know the extent of spread to the brain.


    How is LABC treated?


    To contain the spread of the tumour and to make it smaller, patients with LABC are treated with chemotherapy. The medical oncologist decides upon the chemotherapy regimen that you need to take and the number of cycles depending upon the biopsy report and the general condition of the patient. This is called neoadjuvant chemotherapy wherein the chemotherapy is done before the surgery. After finishing chemotherapy, surgery is done to remove the breast cancer and reconstruction can be done in the same operation as that of the removal of the breast. The patient would then need radiotherapy after the removal of the cancer. Depending upon the presence of the endocrine receptors, hormone therapy is started after completion of radiotherapy.


    What is the surgery done for LABC ?


    Surgery for LABC is divided into

  • Surgery for the breast
  • Surgery for the axilla
  • Reconstruction of the breast

  • The surgeon will examine the patient and will discuss with the patient regarding the correct procedure to be done for the patient.


  • Surgery for the breast
  • Breast Conservative Therapy (BCT)


    After neoadjuvant chemotherapy if the size of the tumour has reduced considerably and if the breast also does not have any other lesions such as DCIS or other tumours, then the breast lump alone can be removed with a small margin of normal tissue. The patient would definitely need radiotherapy after this procedure.

    Mastectomy


    When the lump is large and when there are multifocal tumours elsewhere in the same breast, it is better to undergo removal of the breast entirely. After removal of the breast, it is recommended that women prefer to undergo reconstruction of the breast at the same time. Many women may not want breast reconstruction and they can opt to get it done later if they want.


  • Surgery for the axilla

  • Sentinel Lymph node biopsy


    Sentinel lymph node is the first node that drains the tumour in the axilla. We inject the dye near the nipple and look for the first lymph node that it drains. We send this sentinel lymph node for biopsy and look out for the presence of any spread of tumour. If there is any infiltration of the lymph node by the tumour, then the patient would need a full axillary dissection.

    Axillary Lymph Node Dissection


    In this operation most of the lymph nodes in the axilla are removed.

    Reconstruction of the breast


    Most patients undergo mastectomy or removal of the breast. This is because of the large tumour size and multifocal tumours. Breasts can be reconstructed from the same time. As patients with LABC usually need radiotherapy, patients would need reconstruction with thepatient’s own tissues. There are several methods of breast reconstruction of which DIEP ( Deep Inferior Epigastric Artery Perforator) flap is considered the gold standard means of reconstruction. Here the skin and fat below the umbilicus is taken along with the blood vessel that supplies it and is connected to the blood vessel in the chest or axilla by microsurgery and this is shaped to form a new breast


    What is Phyllodes tumour of the breast?


    Phyllodes tumour of the breast is a tumour which arises from the connective tissue surrounding the ducts and glands of the breast. It usually arises in women in their 40s and may occur later than that.


    Is this a benign swelling or a malignant tumour?


    Most of the Phyllodes Tumour of the breast are benign in that they are limited to the breast. However, around 10 to 30% of swellings in the breast maybe malignant and there is a chance that it may spread to other areas in the body like the lungs and the brain. The differentiation between a benign swelling and a malignant tumour can only be made with the biopsy result where some predictors of malignancy are used to decide whether the swelling is benign or malignant.


    How does the Phyllodes tumour of the breast present?


    The Phyllodes tumour of the breast presents as a swelling in the breast which rapidly increases in size regardless of whether it is benign or malignant. If the size of the Phyllodes tumouris very large, it may then erode the skin producing an ulcer. As it does not spread by the lymphatic system, the lymph nodes in the axilla(armpit) or not enlarged.


    How is this condition diagnosed?


    The Phyllodes tumour of the breast is diagnosed by using a core needle biopsy or an incisional biopsy if there is an ulcer due to a tumour.


    How is this condition treated?


    The swelling needs to be excised with a wide margin of 1 cm on all sides. Excision of the swelling with a 1 cm margin on all the sides would result in removal of a big portion of the breast resulting in a partialmastectomy or simple mastectomy (Removal of the breast). Breast reconstruction with tissue from the abdomen, thighs or back can be done at the same time or done later. As the tumour does not spread to the axilla, sentinel lymph node biopsy and axillary dissection are not needed. If the biopsy shows the swelling as malignant, radiotherapy is added to prevent recurrence.


    What is done if the tumour recurs?


    If the tumour recurs, a repeat wide local excision of the tumouris done with a margin of 1 cm. If radiotherapy had not been given previously, it may be given.


    What is done if there is distant metastasis?


    Distant metastasis is rare and chemotherapy/ radiotherapy maybe tried in some patients



    2. Screening for Breast Cancer


    Screening for Breast Cancer

    What do you mean by screening and why is it beneficial?


    Screening is a means of finding out the presence of undiagnosed disease in a person without any signs or symptoms. This helps us to identify the disease early. By identifying the disease early in cancer, the patient has a better prognosis, survival rates and might not need some methods of treatment like radiotherapy or chemotherapy. Breast cancer is a very common cancer and when detected early many women are cured of the disease if identified early.


    What is the screening regimen for breast cancer recommended?


    Screening regimens for breast cancers are effective if done regularly. Screening regimen recommended for breast cancer is


  • Self Breast Examination once every month from the age of 20 years
  • Mammogram once every year from the age of 40 years
  • Examination by the doctor once every year from the age of 40 years

  • Why is screening by mammogram usually not done before 40 years of age?


    Screening by a mammogram is usually not done before the age of 40 years because the breasts are usually dense and some early lesions maybe missed by the mammogram.


    I have heard women getting breast cancer before the age of 40. How can we prevent it?


    Women can get breast cancers before the age of 40. There is an increasing number of women who get breast cancers before the age of 40 years. Women who are before 40 years need to do self breast examination and consult their doctor if they have any symptoms of breast cancer. Women who have a very high risk as those having the BRCA 1/BRCA 2 gene may have MRI before 40 years every 6 months / year.


    How do you do Self Breast Examination?



    Self Breast Examination is to be done by all women after they cross the age of 20 years. This is to be done regularly every month. A day in the menstrual cycle is chosen probably 5 to 10 days after periods when the breasts are less tender and painful. It is preferable to keep a constant day eg:- 6th day after the periods get over. One can remind themselves by placing a reminder on their phone or calendar.
    Self-breast examination is started by exposing both breasts in front of a mirror with the shoulders straight and with the arms by the side. One should look for any change in the size and shape of the breast, dimpling, puckering or bulging of the skin, inverted nipple or redness over the breast. The woman then palpates the breast with the pulp of the fingers to feel for any lumps in the breast. Palpation of the breast is to be done systematically, careful not to miss any part of the breast including behind the nipple and over the upper and outer extension of the breast called as the axillary tail. Then both hands are raised up and the breast is looked in the mirror to look out for any asymmetry, changes in the skin and nipple of the breast. The patient then lies down at an angle of 45 degrees placing few pillows underneath the head to recline and then feel the breasts for any lumps. If there is any suspicion of cancer, one needs to see the doctor as soon as possible.


    What do you do if you find anything suspicious during Self Breast Examination?


    If you find anything suspicious do not panic. The finding could just be a false positive ( not a cancer in spite of the positive finding). However, it is important that you see a doctor and find out whether it is a false positive finding or an early cancer detection. It is still better to have a few false positive findings than to detect cancers late which could have been found earlier.


    Will regular screening with the above regimen detect all breast cancers?


    Mammograms can miss about 5 % of tumours because the breasts are dense or if they are not clear on a mammogram. Mammograms can also produce false-positive results in 5 to 15% of cases and patients may need additional investigations like ultrasound and MRI to prove that they are not cancer. If a tumour starts growing after the mammogram had been done, there is a possibility that the mammogram couldn’t have detected the tumour. Nevertheless regularly following a screening protocol can result in early detection of breast cancers.


    When is MRI used as a screening tool?


    MRI breast is used as a screening tool in young patients who have dense breasts, patients who have breast implants which can obscure mammograms and for some patients for whom mammograms are doubtful.


    What are the other cancers that can commonly be detected early by screening?


    There are many other cancers that can be found out early by screening such as using Pap Smear for cervical cancer, Prostate Specific Antigen (PSA) for prostate cancer, Colonoscopy for colon cancer, UGI scope for oesophagal cancers and CT scan for lung cancers in people who have a very high risk.


    Mammography

    What is mammography?


    Mammography is X-Ray imaging of the breast


    How is mammography of the breast useful?


    There are two main uses of mammography namely


  • Screening Mammography Mammography is used to screen patients for breast cancer and it can be used to detect very early lesions which may not even be felt while palpating the breast. By detecting cancer early in the breast, the morbidity and mortality from breast cancer grossly reduces. Although we do not have national guidelines in India regarding screening for breast cancer in India yet, U.S Department of Health and Human Services (HHS) and the American College of Radiology (ACR) recommend screening mammography every year for women beginning at age 40.
  • Diagnostic Mammography Diagnostic Mammography is used to detect breast cancer when a patient has an abnormal clinical finding such as a breast lump or nipple discharge and is used to guide treatment regarding the same.

  • How should I prepare for the mammography?


    There are certain instructions to be done before coming for the mammography test. They are


  • Try not to schedule your appointment for mammography just before your menstrual period if your breasts hurt and are very tender at that time.
  • Do not wear deodorant, talcum powder or lotion under your arms or on your breasts on the day of the exam. They can appear on the mammogram as calcium spots.
  • Bring your previous mammogram reports as we may need to compare the present mammogram with the previous mammograms.

  • How does a mammography machine work?



    During mammography, a specially qualified radiographer will position your breast on a special platform on the mammography machine and will then compress your breast. X rays will then be passed through the breast to take the image. This is done in two positions, namely from above to below and sideways. The breast is compressed because


  • To even out the breast so that all tissues in the breast can be visualised
  • To allow a lower X-ray dose since a thinner amount of breast tissue is being imaged.
  • Hold the breast still to minimise blurring of images caused by motion.
  • Reduce X-ray scatter to increase the sharpness of the picture.

  • What will I experience during and after the procedure?


    As the breast is compressed by the machine, women who have a sore or tender breast may find it uncomfortable and may have some discomfort. If your breasts are tender during a particular time of the menstrual cycle, refrain from scheduling your appointment at that time and schedule your appointment at a time that will be comfortable for you.


    Is the radiation exposure safe?


    The amount of radiation that is emitted during mammography is so low that it safe to undergo a mammogram. Please do inform the doctor or a technician if you are pregnant so that this test can be avoided


    What are the limitations of a mammogram?



  • Mammograms are very difficult to read when a woman has got a dense breast, i.e. when the amount of glandular tissue in the breast is very high.
  • False negative results : With mammograms around 5 % of tumours may not be detected due to various reasons like dense breasts or if the malignant tissue is not clear on the mammograms.
  • False positive results : 5 to 15% of women may have features suggestive of cancer which may need additional tests like ultrasound or MRI to prove they are not cancer. Still, this is better than to miss cancer that could be detected early.


  • 3. Treatment for Breast Cancer


    Breast Conservative Therapy

    What is Breast Conservative Therapy/Surgery (BCS)?



    Breast Conservative therapy means excision of the tumour in the breast with a minimal margin of 1 mm followed by radiotherapy to eradicate any microscopic residual disease.


    What is the goal of Breast Conservative therapy(BCS) ?


    The goal of Breast Conservative Therapy is to


  • Excise the tumour in the breast entirely with a minimum margin of 1 mm on all the sides
  • To give a breast with good cosmesis
  • To achieve low recurrence

  • For whom is Breast Conservative Surgery done?


    Breast Conservative therapy is done in woman who have a small tumour in a large breast so that, after excision with a margin of normal tissue the breast still looks good. The patient must also be fit for radiotherapy. The tumour must be restricted to only one area of the breast. When you see us in the clinic we will make a decision as to whether Breast Conservative therapy would be applicable for you.


    For whom is Breast Conservative Surgery not done?



  • Breast Conservative Therapy is not done in patients with large tumours or small breasts because after excision the breast will not good especially after radiotherapy.
  • It is also avoided in patients who can not tolerate radiotherapy like pregnant women, patients who have previously received radiotherapy those with connective tissue disorders
  • It is also not done in patients who do not want to have Breast Conservative Therapy and radiotherapy.
  • If there is more than one tumour in the breast and if they are in different areas of the breast it would be preferable to undergo mastectomy (removal of the breast)
  • If the mammogram shows diffuse micro-calcification
  • If the patient has persistent positive margins after excision

  • If Breast Conservative Surgery can not be done what are the other option that I have if I would like to get my breast cancer excised and still have a nice breast?


  • If the tumour in the breast is large in a large breast, oncoplastic therapeutic mammoplasties can be done which is similar to a breast reduction. The patient would need radiotherapy after this procedure as well.
  • The patient may undergo a mastectomy (removal of the breast) followed by reconstruction of the breast.

  • Can Breast Conservative therapy be done if the axillary lymph node is present?


    Breast Conservative Therapy can be done whether the axillary lymph node is present or not.


    Do we necessarily need to do radiotherapy after Breast Conservative Surgery?


    Yes. Radiotherapy is essential after you do Breast Conservative Surgery.


    What are the chances of re-operation after Breast Conservative Surgery?


    Studies from UK* and Germany** have shown that approximately one in every 5 women would have a positive margin with Breast Conservative Therapy and that they would need re-operation to remove the tumour and of this 40% had to undergo mastectomy or removal of the breast. We would try to reduce this by doing a frozen section of the tumour. Where in we would biopsy the tissues while the patient is on the operating table and proceed according to the result.


    Therapeutic Mammaplasty

    What is Therapeutic Mammaplasty?



    Therapeutic Mammaplasty is a modification of the cosmetic breast reduction technique in which the cancer tissue and a wider rim of healthy tissue are removed to give a good shape to the breast.


    For whom is Therapeutic Mammaplasty done?


    Therapeutic Mammaplasty is done only for those


  • Who have large breasts
  • Who can tolerate radiotherapy
  • Breast cancer is restricted to one area of the breast

  • For whom is Therapeutic Mammaplasty not done?


    Therapeutic Mammaplasty is not done for women who have


  • Small breasts
  • Large tumours
  • Breast cancer was seen in multiple areas of the breast
  • Patients who can not tolerate radiotherapy like pregnant women, connective tissue disorders or those who had radiotherapy before

  • If Therapeutic Mammaplasty can not be done what are the other options that I have if I would like to get my breast cancer excised and still have a nice breast?



    If Therapeutic Mammaplasty can not be done due to the above reasons, the breast can be removed in toto and can be reconstructed using the patients own tissues or using silicon implants.


    Do we necessarily need radiotherapy after the surgery?


    Yes. After therapeutic Mammaplasty the patient would necessarily need to under go radiotherapy.


    Is it possible for another tumour to appear in the remaining breast?


    Yes. As only a part of the breast is removed, a tumour can appear in the remaining breast. Hence we need to investigate whether there are multiple tumours in the breast before we contemplate surgery.


    Sentinel Lymph Node Biopsy

    What is Sentinel Lymph Node?


    Sentinel lymph node is the first lymph node that drains the lymphatics from the cancer.


    What is Sentinel Lymph Node Biopsy?


    Sentinel Lymph Node Biopsy is a procedure in which the sentinel lymph node is identified and sent for biopsy.


    For whom and why is Sentinel Lymph node Biopsy done?


    One of the first questions that a patient asks the doctor when she has breast cancer is “How much has the cancer spread? ”When the cancer has not been found to have spread to the other parts of the body by clinical and as well as by investigations, Sentinel Lymph Node biopsy is done. By taking a biopsy of that node and testing whether it is affected by cancer one can know whether the cancer has spread


    How is Sentinel Lymph Node Biopsy done?



    The Figure above shows the first lymph node draining the tumour in the axilla called Sentinel Lymph Node Biopsy


    Why do we do Sentinel Lymph Node Biopsy? Can’t we just do axillary dissection for all the patients?


    Sentinel Lymph Node Biopsy helps us to avoid the complications associated with Axillary Lymph Node Dissection like lymphoedema, seroma and haematoma.


    How effective is Sentinel Lymph Node Biopsy done?


    Combining both Methylene blue and ICG(Indocyanine Green) to detect Sentinel Lymph Node Biopsy helps us to detect 99.5% of spread to the axillary lymph node*.


    *Guo Jetal. Comparison of sentinel lymph node biopsy guided by indocyanine green, blue dye,and their combination in breast cancerpatients: a prospective cohort study.World Journal of Surgical Oncology (2017) 15:196


    If the Sentinel Lymph node Biopsy is positive what is the next step?


    If the Sentinel Lymph node is positive, that means there has been spread to the axilla and the axilla has to be cleared of tumour by axillary lymph node dissection.


    If the Sentinel Lymph node Biopsy is negative what is the next step?


    If the sentinel Lymph node biopsy is negative, it means that there has been no spread to the axilla & axillary lymph node dissection need not be done.


    Axillary Lymph Node Dissection

    When and why is Axillary Lymph Node Dissection done?


    Breast cancer spreads through small lymphatic channels to the lymph nodes in the axilla (armpit). Lymph nodes are swellings in the axilla which filter the lymphatic fluid. When the lymph nodes get enlarged, they can be felt in the axilla. The lymph nodes can get enlarged due to breast cancer, infection and many other reasons. To confirm that the swellings are due to breast cancer, a test called Fine Needle Aspiration Cytology (FNAC) is done if the lymph node can be felt in the axilla. If no lymph node swelling can be felt, we find out whether the breast cancer has spread to the axilla by a technique called Sentinel Lymph Node Biopsy (SLNB). If we find that the breast cancer has spread to the axilla by FNAC or SLNB, we would then need to do an axillary dissection.


    What is Axillary Lymph Node Dissection?



    As a means to contain the spread of cancer that has spread on to the axilla, the lymph nodes, lymphatic tissue and fibrofatty tissue are removed from the axilla and at the same time the important blood vessels and nerves in the region are not damaged


    Is this operation done separately from the operation to remove the cancer or the breast?


    Usually, Axillary Lymph Node Dissection is done along with the operation to remove cancer or the breast. Sometimes when there is a recurrence of a tumour in the axilla, we would then do this as a separate procedure.


    What is the post operative protocol when axillary lymph node dissection is done?



    After Axillary Lymph Node dissection, there is a lot of lymphatic fluid and serous collection in the axilla which will be drained out by a tube from the axilla. The amount of fluid in the drain will be noted daily. The amount of fluid drained is expected to decrease with time and when the amount of drainage is little, the drain is then removed. The drain stays in the armpit for around 5 to 7 days. For some people, this may take longer for the drains to come out depending on the output from the drain. The patient can walk the next day. Gradual exercises are started for the upper limb corresponding to the side operated to remove the stiffness associated with the operation and also to reduce lymphoedema. The patients are discharged as soon as the drains are removed or when the patient is comfortable in taking care of the drains.


    What could be the side effects of this procedure?


  • Haematoma The armpit is an area which has a lot of small blood vessels which can easily bleed. A lot of effort is made to reduce the chance of bleeding. However, there is a small chance of bleeding later as the blood vessel that was closed can leak later due to changes in blood pressure. If that happens, then the patient is taken to the theatre immediately to drain the blood.
  • Seroma Seroma is a collection of serous fluid which gets collected. This is usually aspirated repeatedly with a needle. If on repeated aspirations, the seroma doesn’t settle, then the patient may be taken to the operation theatre for evacuation of the seroma
  • Lymphoedema As the lymphatic channels and lymph nodes in the armpit are removed, in 30% of individuals there is swelling of the corresponding upper limb which can be prevented by wearing compression garments and by some exercises

  • Why Ganga Hospital?


    Axillary Lymph node dissection is a very important component of the treatment for breast cancer as the lymph nodes need to be removed in toto and at the same time, the vital blood vessels and the nerves shouldn’t be damaged. After the axillary lymph node dissection, we take a photograph and give it to the patient for her records. By being transparent, we ensure that we do a thorough dissection in every case.



    4. Familial Breast Cancer


    Familial Breast Cancer

    My mother/ sister had breast cancer and I am worried that I may also get breast cancer. What are the chances that I may also get breast cancer?



    The risk of developing breast cancer is increased 1.5 to 3 times if you have a mother or sister who had breast cancer compared to those who don’t have any family history. However, the majority of women who get breast cancer do not have any family member who has the disease, and only around 20% of women have a true hereditary predisposition to get breast cancer.


    Can I be tested to find out whether I have an increased chance to get breast cancer?


    A simple blood test can be taken to find out whether you have certain genes that can predispose you to have a breast cancer such as BRCA 1 and BRCA 2 gene. Mutations in these genes account for only around 20% of those tumours with familial predisposition.


    For whom is genetic testing for BRCA1/BRCA2 highly recommended?


    Genetic testing for BRCA1/BRCA2 gene mutation in women is particularly helpful if there are*


  • Three or more cases of breast/ovarian cancer in a family
  • Two breast cancer cases in a close relative with one diagnose younger than 50 years
  • Two breast cancer cases in a family diagnosed younger than 40 years
  • Male breast cancer in the family
  • Breast and Ovarian cancer in the same patient in a family

  • * Balmana J et al. BRCA in breast cancer: ESMO Clinical guidelines. Ann Oncol. 2011;22(6):31-34.


    What are BRCA 1 and BRCA2 gene mutations?


    The cells in our body have multiple DNA and RNA. When this DNA and RNA multiply, there can be some damages. BRCA1 and BRCA2 genes help to repair these damages, help prevent cancer and so they are called tumour suppressor genes. When these genes under go mutation, the damages in the DNA and RNA are not mended and result in cancer.


    What cancers are produced by BRCA1 and BRCA 2 gene mutations?



    Cancers produced by BRCA1 gene mutation Cancers produced by BRCA2 gene mutation
    Breast Breast
    Ovary Ovary
    Fallopian Tubes Colon
    Prostate (Men) Pancreas
    Prostate (Men)

    What is the significance of BRCA1/BRCA2 genes with regards to breast cancer?


    BRCA 1 and BRCA 2 mutation carriers have a greater than 80 % lifetime risk of breast cancer and if diagnosed with breast cancer they have a 40 % risk of breast cancer on the other side. Of the two gene mutations, compared with other women who get breast cancer, the women with BRCA 1 mutations have tumours


  • That are higher gradetumours (they grow and spread faster)
  • Present early at a younger age
  • May not have hormone receptors that make them suitable for endocrine therapy

  • How frequent are the BRCA 1 and BRCA 2 mutations in the population?


    BRCA 1 and BRCA 2 mutations are prevalent approximately among 1 in every 300 women.


    I have tested negative for the gene mutation test. Does it mean that I will not develop breast cancer?


    The gene mutation test looks out only for certain genes which produce breast cancer like BRCA1, BRCA2, PALB2, CHEK2 and ATM genes. There are many more genes which can cause breast cancer which have not been found to date. Breast cancer is also more common in women without ant family history. So a negative test does not guarantee that you will not get breast cancer and you would need to get your breasts regularly screened for breast cancer just as everyone else would which is


  • Monthly self-breast examination
  • Annual Screening by Mammogram and palpation by the doctor

  • If I test positive for these gene mutations what are my options to prevent breast cancer?


  • Frequent Surveillance As the patients have a high risk of getting breast cancer, frequent surveillance is done to detect the breast cancer at an early stage. This method is adopted by many women who are not yet ready for surgery and they want to complete their family before surgery which is done by
    1. Monthly self-examination by the patient
    2. Mammogram/MRI screening every 6 months ( As the young breasts are quite dense mammograms may not pick the tumours)
    3. Examination by the doctor every six months
  • Chemo prevention with Tamoxifen Tamoxifen is a drug which acts against the estrogen receptors in the breast helping to reduce the rate of breast cancer. Tamoxifen helps to reduce the risk of getting a tumour in the opposite breast after one breast is affected. However, it has not been shown to help much in reducing the risk of getting breast cancer in the first instance.
  • Bilateral mastectomy(removal of both breasts) and reconstruction of the breasts Removal of both the breasts has shown that there is 90% reduction in breast cancer and 95% reduction of breast cancer if the ovaries had been removed earlier. Once they have been removed it is better to reconstruct the breasts at the same time in the same operation because
    1. The patient never worries that she didn’t have a breast, wakes with a breast, feels happier and is more confident
    2. Reconstructing immediately during the same operation preserves the skin and the reconstruction looks nicer for the women

  • What are my options for reconstruction after removal of both breasts?


    The options for breast reconstruction can be broadly divided into


  • Autologous reconstruction (using the patients own tissue)
    Using the patient's own tissues are the best form of reconstruction as they look better and feel better. Unlike implants, they don’t need to get replaced every ten years. Using microsurgery, the tissues are taken along with its blood supply and connected to the blood vessels in the chest or the axilla to make similar breasts. The doctor will discuss with you your best choices and the tissue along with its blood supply can be taken from
    1. Lower abdomen ( DIEP flap)
    2. The Inner thigh (TUG Flap)
    3. The lower Back (LAP flap)
    4. Latissmus Dorsi Flap (LD Flap)
  • Implant reconstruction Many women may not have enough tissue for reconstruction, may not be suitable for autologous reconstruction due to several health issues and some women may not prefer a surgical incision or a scar in a site other than the breast. For some, it could just be a personal preference. For these women, reconstruction with breast implants could be done. For more information regarding this please click here.
  • Combination of autologous reconstruction and Implant Reconstruction This method of using implants along with the patients own tissues are done when the patient doesnt have adequate tissue to reconstruct their breast to achieve symmetry. Example Latissmus dorsi flap and DIEP flap are often combine with implants to give better symmetry to the patient.

  • I am undergoing treatment for breast cancer in one breast. I just did my genetic testing and found that I have BRCA1/BRCA2 gene mutation. I am now worried that I may get breast cancer in the opposite breast. What can I do?


    The chance of having breast cancer in the opposite breast is about 40% if you have breast cancer in one breast. The hormone therapy that may be given for the first breast cancer may give some protection for breast cancer. However, there is always a high risk and hence prophylactic mastectomy and reconstruction of both the breasts can be done at the same time.


    What are the other genes that have been reported to cause breast cancer?


    The other genes to have been reported to cause breast cancer are PALB2 gene mutation, CHEK2 mutation and ATM gene mutation. The risk profiles of the causative breast cancer gene mutations are as follows


    Gene Risk of Breast Cancer (%) Increased Relative Risk Age at Which Prophylactic Surgery is Considered (yr)
    BRCA1 >80 10 25
    BRCA2 >80 10 25 - 30
    PALB2 34 - 58 2 - 4 35 - 40
    CHEK2 20 - 40 2 - 4 35 - 40
    ATM 20 - 40 2 - 4 35 - 40

    What are my chances to develop ovarian cancer if I am affected with BRCA1 and BRCA2 gene mutations?


    The risk of developing ovarian cancer by the age of 70 in patients with BRCA1 gene mutation is 33% and those with BRCA 2 gene mutation is 11%. Women with BRCA 1 gene mutation have a sharp increase in developing ovarian cancer beyond the age of 40 and women with BRCA2 gene mutation have a sharp increase in developing ovarian cancer by the age of 50 years.


    How can I prevent getting ovarian cancer if I have BRCA1/BRCA2 gene mutations?


    It is recommended that you have frequent checkups every 6 months from the age of 25 to detect ovarian cancer early by the following


  • Pelvic examinations by your gynaecologist
  • CA-125 levels in the blood
  • Trans vaginal Ultrasound

  • Removal of both the ovaries along with the fallopian tubes is recommended after the age of 35 and after when childbearing decisions are complete.


    I have just found out that I have tested positive for BRCA1 and BRCA2 gene mutations. Do I need to inform my family?


    It is recommended that you inform your family members as well as they may have the same gene mutation. Testing for the gene mutation early may help them prevent having cancer and the treatment of cancers such as chemotherapy, radiotherapy and hormone therapy. However, the decision to test themselves should lie with themselves and not be forced on.


    Are men spared from the effects of BRCA1 and BRCA2 gene mutations?


    Men are not spared from the effects of BRCA 1 and BRCA 2 gene mutations as they can also develop breast cancers. The risk for developing breast cancers is higher especially for those with BRCA2 gene mutations. Breast cancer can be detected in men by self-examination and if they detect any swelling, nipple discharge, nipple asymmetry they need to see the doctor immediately to rule out breast cancer.



    5. Breast Reconstruction


    Breast Reconstruction

    Pre OP

    Post OP

    Women are the backbone of today's society. They are the centre around which the whole family runs. From going through pregnancy, giving birth to children, waking up at odd times to feed the child, tolerating all the pranks of the children, feeding them what they like, teaching them after they come back from school women are really busy in taking care of the family. In addition, they excel in reading, work and are an important earning member of the family. Juggling between work and family is never easy and they do it very well everyday. They are also the stars of today's society hitting the headlines for their accomplishments.


    Immediate Reconstruction


    For women, the most common cancer is breast cancer. It accounts for around one-third of all the cancers (Fig 1). The incidence of breast cancer is increasing day by day which is shown in Figure 2 where the incidence of breast cancer is increasing in all the cities in India. Due to the changing lifestyle, it now affects younger people than before. 25 years back, breast cancer was affecting women predominantly above 50 years. Now, there is a significant amount of women who get breast cancer in their 30s and 40s which is the age where they are building up their careers and looking to have a good social life. As part of the treatment, a lot of women have their breasts removed. With advances in medicine, the average 10-year survival rate of breast cancer is around 83% depending upon the stage of presentation. Many women beat the disease and want to forget it. But each time they see the mirror they get reminded of it. They are not able to wear clothes of their choice. They get noticed when they go for public functions and women are very conscious of this throughout their lives.


    This can be a thing of the past. While removing the breast cancer, the breasts can be reconstructed in the same operation to remove the breast (Mastectomy) or even later. We prefer to reconstruct breasts in the same operation as the mastectomy due to the following reasons


  • Women wake up with the breast and they never feel sad or depressed that they don’t have a breast any time
  • It is all done in the same operation. A lot of women just want to get it done all at once
  • Reconstructing the breast at the same time allows us to preserve the shape of the breast as well as the skin over the breast which can make the breast look better than when done later
  • The flaps take radiotherapy well

  • The drawback of doing the reconstruction at the same time as the mastectomy is that it may take an additional 2 hours for surgery. With modern good anaesthesia techniques and experienced anesthesiologists, immediate breast reconstruction at the same time of the mastectomy is the standard of care worldwide.


    Delayed Reconstruction


    Some women might have had their breast removed and not reconstructed either due to ignorance or personal preference. They might have had their radiotherapy as well. Breast reconstruction can be done for these women as well. By using autologous reconstruction with the patient’s own tissue, it not only gives them the aesthetic breast but also give them additional skin from the abdomen which replaces the skin on the chest which was affected with radiotherapy.


    There are several ways to do breast reconstruction. The surgeon would have to decide according to each woman based on the need for radiotherapy, comorbidities of the patient, previous surgeries underwent by the patient, availability of tissue in the patient and the patient’s own expectations. It is also important that the surgeon chooses a method with the least complications as this will delay radiotherapy and chemotherapy for breast cancers. Accordingly, breast reconstruction can be broadly divided into


  • Autologous Reconstruction
  • Reconstruction with Implants
  • Combination of Autologous Reconstruction with Implant Reconstruction

  • Autologous Reconstruction


    In this method, the patient’s own tissues are taken along with its blood supply and connected to the blood vessels in the chest or in the armpit to make a new breast. Depending on where the patient has enough tissue we choose that area for our reconstruction. The tissues can be taken from


  • The lower abdomen ( DIEP flap)
  • The Inner thigh (TUG Flap)
  • The lower Back (LAP flap)
  • Latissmus Dorsi Flap (LD Flap)

  • Advantages of Autologous Reconstruction



  • As the patients own tissues are used the breast has the same texture as that of the breast
  • The breast will have a natural droop and will mirror the other breast while ageing
  • Both breasts will gain and lose weight and change shape over time as the other breast
  • The finished appearance of the breast will look better with time
  • Autologous reconstruction can withstand radiotherapy better
  • By taking tissues from the abdomen, inner thigh or the lower back the patient often looks better

  • Disadvantages of Autologous Reconstructions



  • Takes longer time to do the surgery compared to implant reconstruction
  • Surgery is done in another area of the body and leads to additional scars

  • Advantages of Implant Reconstruction



  • Takes shorter time to do implant reconstruction
  • No additional scars on the body

  • Disadvantages of Implant Reconstruction



  • Implants do not stand radiotherapy well and have high complication rates such as infection and implant extrusion with radiotherapy
  • As the implant is covered only by the skin and muscle, the breast may feel different compared to using your tissue
  • The breast reconstructed with an implant will not droop will not droop in proportional to the other chest resulting in breast asymmetry with time
  • The breast reconstructed with an implant will not add or lose weight corresponding to the other breast.
  • Over time a scar forms around the breast implant which may contract, make the breast look more spherical, feel harder and in some patients may even cause pain. This is called capsular contracture. Hence patients may opt to replace their implants with time
  • Breast implants may be associated with other complications like rupture, rippling, infection and animation deformity which may necessitate change of implants

  • Once the breasts have been reconstructed the patient finishes the rest of the treatment like chemotherapy and radiotherapy. If the patient desires nipple reconstruction can be done under local anaesthesia as a day case. Medical tattooing is done to recreate the areola.


    Breast reconstruction definitely makes women feel better compared to those women without reconstruction as they can get into clothes of their choice, socialise with people better, don’t get noticed when they go out, don’t get repeatedly asked about it and face the world with much more confidence.


    DIEP flap

    In the DIEP flap, the excess skin and fat in the lower abdomen below the umblicus is taken along with the blood vessels that supply it to make a new breast.



    The breast containing the breast cancer is removed. This is called as mastectomy.



    The skin and fat below the umbilicus is raised along with the blood vessel that supplies it. This blood vessel is carefully separated from the adjoining rectus abdominis muscles and is raised as a flap. As the muscle is not raised along with the flap, there is very less donor site morbidity after the operation.



    This tissue containing skin, fat and the blood vessels is called as the DIEP ( Deep Inferior Epigastric Artery Perforator Flap)



    The blood vessels supplying the flap are connected to the blood vessels in the chest or in the axilla (armpit) and is reshaped to form a new breast.



    Once the patient wears a bra, no one will know that the breasts have been reconstructed.



    Pre OP

    Post OP

    As the excess skin and fat below the umbilicus is taken away, the abdomen looks flatter and better. There is a long scar along the waistline which can be well hid with a panty. When a lady wears a pant, chudithar or a saree no one can notice the scar.



    After the wounds heal and on completion of chemotherapy and radiotherapy, nipple reconstruction can be done to recreate a nipple.


    The Inner Thigh (TUG Flap)

    TUG flap (Transverse Upper Gracilis Flap)


    What is TUG flap?



    The skin and fat along the upper inner thigh is taken along with gracilis muscle and it’s blood supply to constitute the Transverse Upper Gracilis (TUG) Flap. This flap is widely used for breast reconstruction.Gracilis is one of the many muscles in the inner thigh which is responsible for bringing the thigh towards the centre. As many muscles in the thigh can do the same action, taking this muscle leaves no functional problems. The skin and fat look like a “ melon slice” which can be made into a cone shape to form a soft and shapely breast. The peak of the cone becomes the nipple. The blood vessel accompanying the flap is then connected to the blood vessel in the chest by advanced microsurgery to form a nice breast of a good shape.



    The TUG flap from the inner thigh is shaped like a breast by folding it



    Primary nipple reconstruction is done



    For a patient who had breast cancer both sides, the breasts were removed both sides ,TUG flaps along with primary nipple reconstruction was done on both sides to make it look like breasts



    The final result after TUG flap reconstruction for both sides of the breast


    When is TUG Flap preferred for breast reconstruction?


    DIEP flap is usually considered as the gold standard method of breast reconstruction wherein we take the excess skin and fat from the abdomen to make a breast. This is because of the versatility of the flap and favourable donor site.TUG flaps are usedfor breast reconstruction for the following reasons


  • When the abdominal tissue can notbe used as in patients who have undergone abdominoplasty or other abdominal operations which can cause severe scarring
  • It is also used in women who are very thin who do not enough excess skin and fat in the abdomen.
  • It is also used in women who do not have good blood vessels supplying the abdomen
  • TUG flaps can withstand radiotherapy well. Hence it can be used in people who need to undergo radiotherapy

  • What are the advantages of TUG flap?



  • The TUG flap can give good reconstruction for breasts of small volume
  • Since it is the patient’s owntissues, it can withstand radiotherapy well,and there are fewer complications associated with radiotherapy
  • Since we use the patient’s tissues, it can result in the natural ptosis of the breast and give a superior cosmetic outcome
  • Nipple reconstruction can be done at the same time as the TUG Flap
  • The donor site is not visible as it is taken from the upper inner thigh. There is only a linear scar around the groin
  • It can also be used to add volume to an already existing breast tissue as in partial breast reconstruction after breast conservative therapy
  • It can also be used to add volume to the breast when combined with other flaps

  • Can breast reconstruction with this flap be done while removing breast cancer?



    Breast reconstruction with the TUG flap is ideally done during the same sitting as the removal of the breast cancer. When the reconstruction is done together with the removal of the breast cancer, most of the skin can be preserved if it has not been involved with breast cancer and can give a good result for breasts with a small volume. It can also be done in a delayed sitting. However, as the skin is not preserved, we may have to use TUG flaps from both sides to give a breast of a good shape.


    What is done during the preoperativeassessment?



    Before the operation, we evaluate the status of investigations and treatment of breast cancer. If the patient had not been evaluatedearlier, we do the necessary investigations for breast cancer. We would then assess the volume, ptosis, size of the breast and the donor sites for autologous reconstruction like the thigh, abdomen and back. We may take a CT Angiogram to know the position of the vessels. We would then discuss with the patient and her relatives about what needs to be done for breast cancer, how we can reconstruct the breast the best way and answer any doubts that the patient and her relatives may have.


    What will be the post operative care needed?



    The patient is evaluated in the microsurgical bay wherein the patient is near the operation theatre so that the doctors and specialised nurses can frequently visit the patient and look out for the viability of the flap and look out for haematoma. On the third day, we will mobilise the patient and try to make the patient sit down and slowly we will make the patient walk as soon as the patient is comfortable. We will also check the amount of fluid in the drains that are used to remove the excess fluid in the breast and the donor site in the thigh. When the amount of fluid in the drains reduce,we will remove the drains. Once all the drains are removed,and the patient can walk well, we will discharge the patient back home. The patient will need to stay in the hospital for a week. After discharge, we will see the patient once every week for two weeks. After the wounds heal,the patient is sent for chemotherapy if she needs it for her breast cancer treatment. Generally, the patient is sent for chemotherapy 3 to 6 weeks from the day of operation.


    What could be the complications of TUG flap?



    Fortunately, the complications of TUG flap are not very common. Any surgical procedure can have its complications. As it our duty to inform our patients of the complications that can arise we are enumerating the complications of the TUG flap namely


  • Wound healing problems
    As in any surgical procedure, there can be wound healing problems. Generally, they are addressed by few dressings.
  • Flap loss
    The blood vessel of the flap is connected to the blood vessel in the chest by advanced microsurgery. In spite of all our efforts, there can be a block in the blood flow through the connection. That is the primary reason why we keep the patient near the operation theatre so that the doctors and specialised nurses can see the patient and correct it early. If we detect any problem in the blood flow in the connection, we immediately take the patient to the operation theatre and try to correct it. Mostly we can correct the problem. However, at times, we may not be able to correct itand we may end up losing the flap. In that instance, we wait for the wounds to settle and can again do another procedure for breast reconstruction after the wounds heal well. This complication is, fortunately less and is seen about 2 to 3%.
  • Seroma
    Seroma is a collection of serous fluid under the flap or in the donor site. If the amount of serous collection is less, the patient can be observed once every week. If the amount of serous collection is more, the collection can be aspirated under ultrasound guidance.
  • Haematoma
    A haematoma is a collection of blood. If the amount of haematoma is less, then the patient can be repeatedly observed as it will settle down by itself. However if the collection of blood is more then we may take the patient to the theatre to remove the collected blood as it may compromise the blood flow to the flap.