Breast Oncology and Surgery
Breast Oncology and Surgery

Overview

Pioneers of breast health care in Pune, Orchids Breast Health offers a full range of state-of-the-art breast health services designed to ensure the best possible experience for each of our patients.By preparing individualized treatment plan for every patient, providing them with an uplifting environment and using the most advanced equipment available, our team strives to provide the ultimate standard of care and clinical excellence. Open to women with all forms of breast conditions, of all age groups, from all strata of the society, we provide wholesome care to our patients right from the diagnosis to post-treatment care.

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Scope of Services:
Oncoplastic Breast Surgery:

One major focus at Orchids is Breast Oncoplastic Surgery, which combines the principles of Breast Cancer surgery as well as aesthetic surgery. All over the world, the gold standard of protocol for Breast Cancer is to avoid total Mastectomy in patients using conservative techniques along with plastic surgery. Dr. CB Koppiker is one of the pioneers and fathers of Breast Oncoplasty in India and has performed the largest number in the country. He is an international expert invited now on many global forums to perform surgeries, where he has used innovative and cost-effective methods.

He has done the largest number of breast surgeries in the country; he has performed more than 2000 breast surgeries till date inclusive of more than 700 oncoplastic surgeries, above 200 breast reconstructions and above 750 sentinal node excisions.

While this surgery definitely has aesthetic benefits, it is completely safe with respect to removal of the cancerous tissue as well, and has virtually no severe complications.The patient is sent home in one night. Even the nipple-areola region can be saved in most of the surgeries, allowing the breast to look just as it had before the surgery. And the patient does not have to worry about her breast’s appearance as she ages either- it would still remain intact, since the implant reconstruction ensures that it does not sag. Aside from demonstrating improved survival outcomes and improved treatment success rates, this technique also shows plunging rates of depression among women. The patients are happier, not only with the way their breasts look, but also with the fact that they are alive and unharmed, with no complications. They are also happy that they do not have to stay in the hospital for long, and that they overcome their ordeal with a shorter recovery time.

Oncoplastic Breast Surgery’ can be a boon to women who require a mastectomy, or breast removal surgery. Patients needing a mastectomy are given an immediate reconstruction with such finesse, that the breasts look better, and the patients, happier. The surgery has also reduced the numbers of mastectomies performed, therefore relieving the patients from the physical problems, breast removal would have otherwise caused. With this surgery, patients do not have shoulder stiffness, massive swelling of the arm or problems with their postures, as can be seen because of mastectomy. There are many women, whose breasts have drooped after 40. The surgery gives them better looking breasts. In June 2015, a research study was conducted on 150 operated patients from Orchids Breast Health Clinic, and 93% patients reported to having a high level of satisfaction.

Given the increased acceptance of Breast Oncoplasty in the medical community as well as Breast Cancer patients, a need for formalised flagship program for breast surgeons has been idenitified. Dr. Koppiker and the University of East Anglia at UK have started a 3 years Masters in Breast Oncoplasty degree program for aspiring Breast Oncoplastic surgeons.

Oncoplastic Breast Surgery’ has multi-faceted positive impacts and advantages. It kills two birds with one stone- the patient loses cancer while gaining new breasts, and a more satisfied sense of self.

Imaging
Digital Mammography With 3D Tomosynthesis

After clinical examination by the breast surgeon, patient (40 yrs) is subjected to mammography in our clinic- Digital mammography with 3D tomosynthesis. It detects Stage 0 of Breast Cancer and is particularly used for detecting cancer in Indian women, since they have dense breasts. It has a plastic screen instead of a metal one, making the procedure painless. It acquires a series of images in 90+ slices, making the procedure accurate and quick, taking only 3-4 seconds. Screening with mammography has resulted in 15-20% reduction in mortality due to breast cancer. Sensitivity of mammography is 68% & specificity is 75%.

  • Mammographic sensitivity for cancer detection varies
  • 85.7%–88.8% in entirely fatty
  • 62.2%–68.1% in extremely dense
  • Digital mammography: Improved sensitivity and accuracy for cancer detection relative to those of film-screen mammography in women with dense breasts (83.6% vs 68.1%, P = .051)
  • One of the major limitations of 2D mammography is due to tissue overlap. Overlapping tissue can obscure a lesion causing a false negative result (missed cancer 15-30%). DBT overcomes this limitation by creating 3D images of breast, obtaining multiple 1mm low dose slices of the breast from various angles as the xray tube moves in an arc over the breast. The images are reconstructed using an iterative reconstruction (not isotropic like CT/MRI). For the patient, nothing changes. Positioning, compression, views, time for procedure are pretty much the same. Reduces call back rates. Improves detection & characterization of breast lesions
  • After abnormality is seen in mammography, ultrasonography is performed by radiologist on ——– machine. Whole breast US Incremental cancer detection rate above that of mammography was 3-4 per 1000, has limited role for screening. (ACRIN 6666). It is Used for characterization of breast lesion. Cornerstone for diagnostic workup. Used extensively for biopsy guidance. It is modality of choice for palpable masses in young patients. It is Good for differentiating solid & cystic lesions and for For detection of axillary lymphadenopathy. Color Doppler and elastography further help for characterization of lesions.
  • Automated Breast Volume Scanner
  • Acquires whole series of consecutive B mode pictures & reconstructs 3D data sets of entire breast volume.
  • Depicts global breast anatomy & architecture.
  • Useful in multifocal lesions
  • Good for screening in dense breasts
Interventions:
  • Trucut biopsy- USG guidance
  • Vacuum assisted biopsy- for small lesions, papillary lesions, scarless removal of fibroadenomas Stereotactic biopsy is performed if the lesion is not seen in USG i.e. microcalcifications.
BREAST ULTRASONOGRAPHY / ULTRASOUND (USG)
Ultrasound is an imaging test by which images of your breast can be viewed on a screen for detecting cancer, by sending high-frequency sound waves through it. It is the poor man’s MRI. At Orchid’s, we use ultrasound in combination with mammography, to increase the sensitivity of the test to nearly 90-95%. Ultrasound is the best way to find out the type of an abnormality (whether it is a benign or a malignant tumour, a fluid-filled cyst or solid mass) seen on mammography or felt by physical examination and takes about 5 minutes. It helps in better identification of very small breast lesions that are not easily felt by physical examination.It is also used for detecting changes in the breast that can be felt but cannot be seen on a mammogram. In case of a suspicious lesion, a USG guided needle biopsy is performed, where ultrasound is used to accurately guide the biopsy (tissue removed from the body for examination)
AUTOMATED BREAST VOLUME SCANNER (ABVS)

High-density breasts make it difficult to detect tumour in these breasts using a mammogram, as both the dense tissue and tumour appear white. This is a common occurrence in India and therefore, at Orchids, we use the Automated Breast Volume Scanner (ABVS).

Why this technique?

ABVS is a standalone system that creates a 3D image of the entire breast, thus providing a comprehensive view of the breast and making tumour detection easy. The most important aspect of this system is its automated scanner arm. This automated arm ensures precision, improved patient comfort and reproducibility, as it reduces human errors and does not depend on an operator for the process. It can assess and store the breast scans, as well as provide a more understandable representation of the breast’s anatomy and architecture, thus making it efficient in detecting tumour.

MAMMOGRAPHY
After clinical examination by the breast surgeon, patient (40 yrs) is subjected to mammography in our clinic- Digital mammography with 3D tomosynthesis (machine name). Screening with mammography has resulted in 15-20% reduction in mortality due to breast cancer. Sensitivity of mammography is 68% & specificity is 75%.
Mammographic sensitivity for cancer detection varies
85.7%–88.8% in entirely fatty
62.2%–68.1% in extremely dense
Digital mammography: Improved sensitivity and accuracy for cancer detection relative to those of film-screen mammography in women with dense breasts (83.6% vs 68.1%, P = .051) One of the major limitations of 2D mammography is due to tissue overlap. Overlapping tissue can obscure a lesion causing a false negative result (missed cancer 15-30%). DBT overcomes this limitation by creating 3D images of breast, obtaining multiple 1mm low dose slices of the breast from various angles as the xray tube moves in an arc over the breast. The images are reconstructed using an iterative reconstruction (not isotropic like CT/MRI). For the patient, nothing changes. Positioning, compression, views, time for procedure are pretty much the same. Reduces call back rates. Improves detection & characterization of breast lesions Automated Breast Volume Scanner Acquires whole series of consecutive B mode pictures & reconstructs 3D data sets of entire breast volume. Depicts global breast anatomy & architecture. Useful in multifocal lesions Good for screening in dense breasts
Interventions:
  • Trucut biopsy- USG guidance
  • Vacuum assisted biopsy- for small lesions, papillary lesions, scarless removal of fibroadenomas
  • Stereotactic biopsy is performed if the lesion is not seen in USG i.e. microcalcifications.
ELASTOGRAPHY:

During breast cancer, the elastic properties of the affected tissues are altered. Elastography is a new technique that detects this change in elasticity and maps it by imaging. It is non-invasive, so the patient need not worry about getting any scars. It is used for characterization of difficult areas. But, doesn’t sonography detect changes in the breast as well? Why should one opt for elastography instead? Elastography has a major advantage over sonography. Better resolution and clarity result in accurate detections. Whereas, sonography, alone, has the following limitations:

  • It cannot distinguish between ultrasound echoes of a normal and a cancerous tissue, that are produced equally.
  • It cannot capture areas deep inside the breast, affecting the imaging of dense breasts (as those seen in Indian women).
  • It may have trouble distinguishing from other pathologies.
  • It cannot show micro-calcifications
  • It cannot detect cancers at cellular level.
Benefits of elastography:
  • It is reproducible and easily performed.
  • It helps to characterize lesions detected on grey scale ultrasound.
  • It is useful in planning the management of masses that appear stiff (as they are suspected to be malignant).
  • It is used to analyze and differentiate between solid tumours, cysts and other areas of concern during breast ultrasound exams.
BIOSPY
OPEN BIOPSY: OPEN BIOPSY IS UNACCEPTABLE AND IS NOT THE GOLD STANDARD OF TREATMENT.
Open biopsy is a surgical procedure, where a cut is made through the skin to expose and remove tissues. It is indicated only when the breast lesion has been studied using mammography or ultrasound, and the lesion has been diagnosed. It is important to note that open biopsy has been made obsolete for diagnosis. Biopsy (to identify the tumour or illness, when an abnormality is found on imaging) requires inserting a needle inside a lesion on the breast, to remove tissue or cells for examination and analysis. The diagnosis of such suspicious lesions makes it easier to decide the future procedure. As this process only involves a needle, it is painless, scarless, does not change the aesthetics of the breast, and since it is a short OPD procedure, it doesn’t require going to a hospital. This increases the comfort and ease of the person towards this procedure, and the results can be obtained in just two days.
Depending on the lump, the further procedure is decided:
  • If the lump is benign (not harmful), no further procedure is required.
  • If the benign lump is more than 3 cm, a simple needle excision may be required.
  • If the lump is cancerous (malignant), further treatment is planned.
  • By international standards, minimally invasive biopsy is the most advisable.
Here, at Orchids, we provide four types of biopsies:
  • i. FNAC: It is the simplest method of diagnosing breast cancer but a high inaccuracy makes it unreliable and thus is not recommended. This technique involves insertion of a needle, under local anaesthesia, in the breast lesion to determine its identity (benign or cancerous).
  • ii. TRUCUT BIOPSY: Trucut biopsy is the gold standard of diagnosing breast cancer. Trucut biopsy provides several advantages over FNAC, as it has 98% accuracy in detecting breast cancer (benign, pre-malignant and malignant cases), is painless, scarless, and takes 15 mins in the OPD. This type of biopsy uses a thicker needle for removing tiny bits of lesions, which are then identified and can even be saved as further test, if diagnosed as cancerous.
  • iii. VACUUM ASSISTED BIOPSY (VAB): The VAB device is a state-of-the-art instrument at Orchids, which provides 99% accuracy in diagnosing even the smallest of lesions (0.2 mm- 0.3 mm size), or even accumulation of (calcifications) calcium salts in the breast, indicating early cancer. It is done within 15 minutes in a day care or an OPD setup, relieving the person from the hassle of going to a hospital. Since it does not involve any surgery, this procedure is virtually painless, scarless, stitchless, and does not distort or damage the aesthetics of the breast either.
  • iv. ROBOTIC STEREOTACTIC BIOPSY: There are certain early indicators of cancer such as micro-calcifications, which cannot be diagnosed by physical examination or ultrasound, or even by biopsies using mammogram or sonomammogram. Robotic stereotactic biopsy is the preferred in such cases. This biopsy entails a stereotactic robotic arm which guides the needle in the right place with a 100% precision, thus providing a huge advantage over other biopsies, to diagnose even the smallest of breast lesions accurately, painlessly and scarlessly.
RISK REDUCTION CLINIC
The Risk Reduction Clinic at Orchids Breast Health is a multi-disciplinary program designed to identify, counsel and manage women at high risk for hereditary breast and ovarian cancer (HBOC). Current research has identified important genetic and lifestyle-associated risk factors for HBOC. Identifying individuals with these risk factors and implementing closer surveillance and risk reduction techniques may detect these cancers earlier, thereby leading to better prognosis and outcomes. On advice of the clinicians, interested females above age 21 years receive an in-depth pre-genetic test counselling involving collection of personal and family health history by our genetics counsellor. Thereafter, DNA isolated from blood or saliva samples, collected from these individuals, is sequenced for identifying mutations in genes involved in HBOC. Post-test counselling of the patients by clinicians involves discussions on the implications of the genetic testing report and actions to be taken, thereof. Risk assessment involves a combination of genetic test reports, imaging parameters and lifestyle assessment. Identified high-risk patients are referred to the clinicians at the Risk Reduction Clinic who will advise appropriate actions based on the specific details of the case. On a case-to-case basis, these actions may involve prophylactic mastectomy with breast reconstruction or prophylactic oophorectomy, lifestyle and diet modifications or increase in disease surveillance as per globally accepted medical guidelines. Orchids Breast Health is one of the very few clinics in India which has established a streamlined protocol for genetics-guided surgical management of HBOC in high-risk patients.
GENETIC CLINIC
“Hereditary Breast and Ovarian Cancer Syndrome" (also known as HBOC) is most commonly caused by mutations in one of two genes: BRCA1 and BRCA2. These mutations increase the risk for breast, ovarian, pancreatic, prostate, melanoma and possibly other cancers. A very important phenomenon called mutation (i.e., change in nucleotides in DNA) affects the genetic material within the cell. The mutations could either be spontaneous, induced by radiation/carcinogens or inherited in nature. Genetic testing involves identification of mutations in disease causing genes to determine their biological significance in normal physiology and disease etiology. Unlike most other medical tests, genetic tests can reveal information not only about the person being tested but also about that person’s relatives. The incidence of breast cancer (BC) is on the rise in Indian women. It is estimated that the current life-time risk for developing BC in urban Indian women is 1 in 22. Half of the women with a diagnosis of BC are under the age of 50, which is a decade earlier than that seen in the west. India has the highest BC incidence-to-mortality rate in the world mainly attributed to late-stage presentation and hence, poor treatment outcomes. It is plausible that about 10-15% newly diagnosed BC cases in India have a strong familial history or inheritance patterns. The oncology community in major cities is now actively integrating preventive genetic screening in their routine practice. World-over, the general public is now well-sensitized to genetic risk of HBOC, consensus medical guidelines for genetic testing are in practice majority medical centers are offering genetic services and several genomics companies are providing technology solutions for affordable genetic sequencing. More and more educated women with family history of HBOC are aware about this topic and willingly coming forward to identify their risk of developing these cancers. Even though several global and Indian genomics companies offer such genetic tests, the cost of the test remains a barrier. Genetics of HBOC is also an ever-evolving and important area of cancer research. In addition to the BRCA genes, several other genes have been identified to contribute towards the development of these cancers. Therefore, genetic testing panels inclusive of multiple disease-causing genes are now being recommended in assessment of HBOC risk. Importantly, given the paucity of well-trained breast oncoplasty and reconstruction surgeons in India, this type of surgery has not yet found its way in mainstream breast cancer management protocols in India. On the flipside, these advances have resulted in a steady increase in the rate of unwarranted prophylactic double mastectomies in the west.
TREATMENTS
SURGERY:
Breast Lumpectomy:Many Cancers of the Breast are cured by a simple excision of the tumour with a healthy margin all aound. This is checked with a “frozen section” on table by a Pathologist to confirm that there is a good clearance of the tumour. Often this excision is accompanied by simple rotation of the surrounding Breast tissue to give a good cosmetic result. Sometimes a more complex Breast Oncoplastic procedure ay be required for the needful.
Breast Reconstruction: It is our belief at Prashanti Cancer Mission that no woman should lose her Breast to Cancer. Often we are forced to resort to a Mastectomy for various reasons. We counsel and offer such patients immediate Breast reconstruction. This may be in the form of a “Muscle flap” borrowed from the back or a Breast implant or occasionally both. Depending on the size of the tumour in the overall background of the Patients build and structure , this decision is taken. The other advantage of immediate Breast reconstruction is that ,both excision and reconstruction can be achieved in a single sitting with minimum psychological stress to the patient.
Bilateral Mastectomy and Preventive Mastectomy: Often women present with tumors in both the breasts which require Mastectomy on both the sides. It is our to reconstruct the breasts on both the sides with either Muscle Flap or Implants or both as the case may be. In a few instances some patients or their family members suffer from a very rare but definite “Familial Breast Cancer”. If the genetic analysis in these predisposed patients indicates impending risk of Cancer ,we can offer a “prophylactic Mastectomy on one or both sides “ and reduce the risk of developing a Cancer by upto 97% . Such patients will also be given the option of immediate Breast reconstruction for all the reasons mentioned above.
VACUUM ASSISTED BIOPSY (VAB)
The VAB device (a mammotome) is an extremely useful instrument which is used for diagnosing very small lesions with 100% accuracy and is also used to remove benign lumps/lesions without a surgery. It is a painless, stitchless and scarless procedure and is done under local anesthesia. It is done in the OPD (in-house), therefore requiring no hospitalisation, and is done in 5 minutes, after which the woman can go home. This process actually allows us to biopsy very tiny lesions of 0.2mm-0.3mm in size or even calcifications* in the breast which may be indicators of very early cancer or precancerous lesions. This also gives the opportunity to remove benign lumps like fibroids, papillomas and complexcysts without a scar, under local anesthesia in a day care or an OPD setup. This procedure gives nearly 100% accuracy in diagnosing breast diseases. Calcifications* - Accumulation of calcium salts in the breast.
SENTINEL NODE BIOPSY
Breast cancer can spread through lymph vessels , to structures called lymph nodes, which are present in the axilla. Lymph is a clear-to-white fluid, unlike our red coloured blood, and is responsible for carrying white blood cells that provide protection to our bodies against bacterial infections. This lymph is filtered in the lymph nodes, which are located in various areas of the body, one of which is the axilla or armpit. They are also present in the neck, which you can feel when you have tonsillitis. These nodes are a part of our immune system and there is always a possibility that the tumour in the breast will spread to the axillary nodes.
Removal of tumour from the axilla has neither been easy nor free of lasting damage. In the past, women not only underwent mutilating breast surgeries or total mastectomies, but also endured radical surgeries to remove all the nodes from the axilla. And with the axilla having 40-50 nodes, one can only imagine how precise and careful the surgery had to be done.
However as of today, there has been tremendous change in the recommendations for handling the axilla. There have been major studies to identify a single node in the axilla. This node is called the sentinel node, also referred to as the watchman of the axilla. The significance of this node is that it is the first lymph node to encounter cancer cells. Therefore, identification of this node allows quick biopsy and accelerated diagnosis.
Sentinel node biopsy is performed during the same surgery on the breast. This process involves injection of a radioactive nuclear dye in the breast under the areola. This dye travels through the lymphatic system, first into that single node, that is, the sentinel node. The sentinel node is then identified with a special instrument called the (gamma camera picks up the radioactive dye containing lymph node) It is then biopsied and sent to a histopathologist, who provides the diagnosis within 15 minutes.
This technique is useful because, if the node is diagnosed as negative, it would mean that the patient has no disease, thus saving her from extensive surgery where the rest of the nodes would have to be removed. And being a biopsy, it is painless as well as scarless, therefore the patient neither bears scars, nor has to undergo surgery.
ALLIED SERVICES
CHEMOTHERAPY AND CHEMOTHERAPY DAYCARE:
Chemotherapy is a vital treatment method that uses medication to target cancer cells and control their growth. Our hospital has a state of the art daycare. Our comfortable chemotherapy day care facilities provide a supervised environment for safe treatment administration. Patients receive chemotherapy infusions with medical oversight, ensuring a convenient and secure experience.
LYMPHEDEMA MANAGEMENT
Lymphedema is a potential side effect of breast cancer surgery or radiation therapy, and can appear months or even years after the treatment. Lymphedema occurs on excessive collection of lymph, causing swelling. Swelling is a regular side effect of breast cancer surgery and radiation therapy. In typical cases, this swelling lasts for a few weeks after treatment, pertaining to the treatment area, and heals with time. However, if the swelling persists for a longer time and seems to spread to areas not involved in treatment, such as the entire arm, underarm, chest or upper body,it indicates a lymphedema. Generally, lymphedema appears within 1-5 years after treatment, but its risk doesn’t disappear completely.
COUNSELLING AND SUPPORT
Cancer - the name brings with itself a host of emotions. Right from the diagnosis through the treatment, it is a journey of reviewing one’s life and thinking of how one would like it to be. Emotions during this phase are intense and along with the care from doctors, and other health professionals, a dedicated and confidential psychological and emotional support service for patients, their families and caregivers is required. At Orchids, our counsellors help not only the patients but also their entire family.
PATIENT COUNSELLING
A trained counsellor explores a patient’s issues in a safe and supportive environment. Emphasis is given to help people respond to challenges and the associated emotions in healthy ways. In a warm, friendly environment, our counsellor helps sort out several issues that a patient may be dealing with when diagnosed with cancer, such as: coping with one’s physical reactions to cancer (side effects of treatment, fatigue, pain or sickness, changes in body image) relationship and family issues (change of roles, responsibilities) personal issues (sexuality, spirituality, activities, self-esteem) dealing with emotions (anger, depression, distress) dealing with everyday issues (financial, change in lifestyle, making decisions) The barrage of negative emotions can be drain patients, caregivers and family members. Our counsellor understands the transient nature of emotions and is equipped to show you different ways of perceiving situations and dealing with emotions. Counselling is confidential, ensuring the utmost comfort. Asking for trained professional help is highly encouraged; as it means taking charge of our feelings and metal well-being.
CAREGIVER COUNSELLING
Cancer is difficult to deal with emotionally, not only for the patient, but also for their caregivers. Keeping strong and positive at such times and supporting them throughout can be difficult. To unload the burden of buried emotions, caregivers need someone to talk to. Therefore, counselling for caregivers is also strongly advised. When the entire family undergoes counselling together, the patient feels the support of her/his caregivers, and the caregivers, in turn, can keep up the hope and faith needed to keep encouraging their loved one.
NUTRITION
Doctors and nutritionists insist on maintaining a proper and healthy diet, with the right amount of exercise, to reduce the risk of many diseases. Indeed, your diet has a major impact on your well-being. The National Cancer Institute and the American Cancer Society estimate that 35% of all cancers are associated with diet. While having the right diet and getting proper nutrition is important to maintain your health and reduce the risk of breast cancer, following a proper diet with required and permitted food items during chemotherapy is essential. Our nutrition counsellor at Orchids Breast Health Center guides the patients undergoing therapy to stick to a proper diet.
NUTRITION DURING TREATMENT
When you are going through chemotherapy and/or radiation, the body’s immune system is depressed and is unable to fight infections. Therefore, it is necessary to set up and follow a proper diet, by consulting with a nutritionist or your doctor.