Dr SM Bose http://drsmbose.com Sun, 16 Dec 2018 19:02:30 +0000 en-US hourly 1 https://wordpress.org/?v=5.0.1 Few examples of Early breast cancer http://drsmbose.com/few-examples-of-early-breast-cancer/ http://drsmbose.com/few-examples-of-early-breast-cancer/#respond Wed, 11 Apr 2018 11:14:25 +0000 http://drsmbose.com/?p=1141 Symptoms of breast cancer are usually an area of thickened tissue in the breast, or a lump in the breast or in an armpit.

 

  • Pitting or redness of the skin of the breast, like the skin of an orange
  • A rash around or on one of the nipples

 

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SPECIALIZED MANAGEMENT OF BREAST CANCER http://drsmbose.com/specialized-management-of-breast-cancer/ http://drsmbose.com/specialized-management-of-breast-cancer/#respond Wed, 11 Apr 2018 10:16:51 +0000 http://drsmbose.com/?p=1136 Multimodality treatment : Dr.Bose has vast experience and expertise in the total management of Breast Cancer -Diagnosis, Multimodality treatment ( surgery, chemotherapy, Hormone therapy, Referal for Radiotherapy ).

He has been practiting Breast Conservation Surgery in early breast cancer and also in locally advanced breast cancer after downstaging the tumour size with pre-op chemotherapy

He is one of the few surgeons who has been himself administering chemotherapy and hormone therapy to breast cancer patients and hence the patients do not have to run to multiple spcialists and there is no interruption in the complete treatment.

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FEW EXAMPLES OF EARLY BREAST CANCER CASES http://drsmbose.com/few-examples-of-early-breast-cancer-cases/ http://drsmbose.com/few-examples-of-early-breast-cancer-cases/#respond Wed, 11 Apr 2018 10:16:25 +0000 http://drsmbose.com/?p=1134 A young lady of 25 years, was diagnosed to have locally advanced breast cancer; did not want total mastectomy at any cost. Was given 4 cycles of chemotherapy, the response was very good. Underwent segmental mastectomy and axillary clearance.Given two more cycles of chemotherapy followed by radiotherapy. Breast Conservation operations done on both sides in a lady of 65 years, who did not want to loose her feminity by undergoing total removal of her breasts; she is disease free since her surgery done about 10 years back. Few More Cases Of Breast Conservation Surgery.

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FEW CASES OF ADVANCED BREAST CANCER http://drsmbose.com/few-cases-of-advanced-breast-cancer/ http://drsmbose.com/few-cases-of-advanced-breast-cancer/#respond Wed, 11 Apr 2018 10:15:54 +0000 http://drsmbose.com/?p=1132 Advanced Breast Cancer, unfortunately is a common presentation in our country because of multiple factors and they pose lot of problems in their management. Not only it is difficult to undertake surgery in them to irradicate the cancerous tumour but the total outcome is also not very satisfactory.

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FEW ILLUSTRATIVE CASES OF ADVANCED BREAST CANCER http://drsmbose.com/few-illustrative-cases-of-advanced-breast-cancer/ http://drsmbose.com/few-illustrative-cases-of-advanced-breast-cancer/#respond Wed, 11 Apr 2018 10:15:25 +0000 http://drsmbose.com/?p=1130 Advanced cancer of left breast in a lady of 53 yrs, had met several surgeons for 2 yrs , but labelled unfit for surgery as she had only one lung , her left lung had not developed since birth .After proper counselling, she was given chemotherapy for four cycles , the response was moderate. Operated upon, had excision of all the involved tissues and skin grafting , much more than what is removed in classical Radical mastectomy. Because of her poor condition she could not be subjected for further plastic reconstruction.

She was followed with chemotherapy, radiotherapy and hormone therapy . She remained disease free for 7 years, developed local recurrence, which was excised , 2 years later again developed malignant subcutaneous nodules at a few places, was put on chemotherapy orally , responded well and she is presently disease free, her whole body MRI metastasis work up does not show any evidence of disease.

Another Case of Advanced Breast Cancer Treated By Extended Radical Mastectomy Advanced Breast Cancer in a elderly malnourished lady with gross infection. Infection Controlled, Pre-op.
Chemotherapy Followed by Surgery, Chemotherapy, Radiotherapy& Hormone therapy Total treatment finished in 6 months .

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BREAST ABSCESS http://drsmbose.com/breast-abscess/ http://drsmbose.com/breast-abscess/#respond Wed, 11 Apr 2018 10:12:57 +0000 http://drsmbose.com/?p=1128 Infection of breast tissue , particularly in a lactating mother is a problematic issue. The age old treatment followed by all surgerons consist of antibiotics, incision and drainage of pus and regular dressings. This leads to a painful, prolonged period of illness, necessiating stopping of breast feeding to the child , mutilation of the breast and many other related problems.

Dr.Bose has been treating breast abscess cases in a different manner, drainage of pus by aspirations and antibiotics.

This has given excellent results, no painful dressings, breast contour remains good, breast feeding can continue, Depending upon the size of abscess cavity, aspiration has been done 2 to 5 times for complete cure of the problem . The procedure has been appreciated greatly both by the patient and the surgeons himself.

A very large sized breast abscess in a lady treated with Aspiration Technique Pus being aspirated , almost pain free procedure First Aspiration – 500 ml of thick pus BENIGN BREAST DISEASE

Total Colectomy in a young man , has been suffering from Ulcerative Colitis for long opened up specimen – showing extensive diease Large Multi Nodular Goitre of long duration Specimen – Total Thyroidectomy

To start with the patient had been very apprehensive about the mutilation of her figure; but now feels extremely happy and satisfied with the cosmetic outlook and feels as if her breast has not been operated upon.

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School Children need protection from tobacco consumption: CAG & Consumer Voice http://drsmbose.com/school-children-need-protection-from-tobacco-consumption-cag-consumer-voice/ http://drsmbose.com/school-children-need-protection-from-tobacco-consumption-cag-consumer-voice/#respond Wed, 11 Apr 2018 09:51:53 +0000 http://drsmbose.com/?p=1120 Citizens Awareness Group and Delhi-based NGO, Consumer Voice, underlined the need for strict implementation of the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution Act, 2003 (COTPA) in the region to protect children from tobacco consumption.

Read More

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Diseases of Breast http://drsmbose.com/diseases-of-breast/ http://drsmbose.com/diseases-of-breast/#respond Wed, 21 Jun 2017 13:35:00 +0000 http://drsmbose.com/?p=1037 BREAST  CANCER :

In India, Breast cancer is the second most commonly found cancer disease in females , although it is spreading very fast, like a wild fire. Cancer of uterine cervix is the commonest cancer seen in Indian females but in metropolitan cities like New Delhi, Mumbai, Chennai, Bangalore , breast cancer has over taken the incidence of cancer of cervix.

Breast cancer has fairly good prognosis but only if detected at an early stage  ( Stage I ) but unfortunately, in India majority of  cases are seen in stage III only when outcome is not very good.

The modern management of breast cancer consists of multimodality treatment – surgery, chemotherapy, radiotherapy, hormone therapy etc, the sequence of application and number of therapies used depend upon the stage of the disease, general condition of the patient and choice of the treating specialist.

Breast cancer can be seen in males also ( 1 out of 100 breast cancer patients) and they have to be treated in the same manner as in females.

Early Breast Cancer :

In this the first line of treatment is surgery followed by other therapies.

In early breast cancer surgery:

  1. One can remove the entire breast known as Total mastectomy and this is combined with Clearance of axilla on the same side to remove all the lymph nodes ; and the combined procedure is known as MRM ( Modified Radical Mastectomy).
  2. One can undertake only removal of the tumour along with rim of normal breast tissue all around the tumour usually combined with axillary clearance. – known as segmental mastectomy ; and the total procedure is known as BCS (Breast Conservation surgery).

It has been established that both BCS and MRM give equally good results , the only significant difference being that there is 5% increased risk of local recurrence after BCS .

In India, BCS is done only by a very few surgeons. I have been undertaking BCS for the last thirty years and I am quite happy with the results. It gives good cosmetic looks and therefore patients are also very satisfied.

[See image gallery at drsmbose.com]

BENIGN BREAST DISEASE :

Following diseases are included in this category :

Fibroadenoma of breast :  mobile swelling in the breast, usually seen in young females, it may be a single or multiple in number, it may be small in size or may attin a very big size. Most of these require surgical removal or some of the small ones may respond to medicines.

As fibroadenomas are mostly seen in young females, cosmetic results are very important.

I undertake the operation in such a way that the cosmetic results are very good, the scar is hardly seen and the shape and size of the involved breast remains the same.

 

Tuberculosis of breast : Tuberculosis is a very common problem in India, mostly seen in Lungs, Lymph nodes, Intestines, female genitalia etc but rarely seen in breasts also. It becomes very difficult to diagnose this condition as there are not very many leading symptoms and signs.

I have seen a few young ladies from well to do families who had this problem, could not be diagnosed for a long time, luckily I could detect it , treated them and were cured of the problem.

NON TUBERCULOUS GRANULOMATOUS PROBLEMS OF BREAST :

These are infrequent problems seen in breast , present with progressively increasing swellings or ulcers ( wounds ) in the breast, does not heal with usual treatment with antibiotics,dressings etc. I have seen a few of these cases, managed them with medicines, dressings and subsequently operated upon them and they have been cured of the problem. ( photographs )

BREAST ABSCESS:

Breast abscess is commonly seen in young mothers during their early feeding activities , particularly amongst first time mothers , who are not experienced in breast feeding their kids.

Breast cancer cases are usually surgically treated with incision and drainage, leaving behind an open purulent cavity , which has to be dressed frequently and requires a long time for complete healing and lot  of pain for the patient.

I have been treating these breast cancer patients with drainage by undertaking aspiration, which may be required on a number of occasions.

I have been undertaking this form of treatment for the last fifteen years and have been successful almost in all the patients, even treating patients with 400 to 500 ml of pus on the first aspiration. In three patients , who required repeated aspirations for more than five times, I placed a drainage in the dependent part and all the three patients recovered in due course of time.

[See image gallery at drsmbose.com]

 

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Versatile Local Anaesthesia http://drsmbose.com/versatile-local-anaesthesia/ http://drsmbose.com/versatile-local-anaesthesia/#respond Tue, 30 May 2017 12:25:31 +0000 http://drsmbose.com/?p=897 Surgery has become a common procedure for relief of medical problems. Gone are the days when operation was a dreaded procedure with a high mortality (death) and complication rates. I tell my apprehensive patients that there are more accidents and resultant deaths on the roads ofChandigarhthan in all the operation theatres of Tricity and this comparison seems to give lot of confidence and solace  to patients and their worried relations.
Surgical procedures have not only become safer but they are relatively pain free also, particularly if one compares them with the past experience. Major credit for this not only goes to better surgical techniques but also to safe anaesthesia and quick recovery from its after effects.
The type of anesthesia a patient receives depends on the procedure being performed, the physical and emotional status of the patient and also on the preference by the surgeon.

Anaesthesia can be administered mainly by three techniques

  1.  General or total anaesthesia in which the patient as a whole is put to sleep
  2.  Regional anaesthesia in which the region to be operated upon is blocked to sensations – epidural, spinal and caudal anaesthesia are the common examples of this
  3.  Local anaesthesia in which only the operation site is anaesthetised facilitating pain free surgical procedure.

We shall be considering the last, the local anaesthesia, in detail. Number of techniques  are available for giving local anaesthesia.

  1.  by infiltration of a chemical agent in the concerned area, which produces loss of sensations and operation can be undertaken without causing discomfort to the patient. The commonest drug used is Lidocaine in injection form, can be diluted and used in the strength of 0.5 to 2.0 %, the effect lasts for about 30 to 45 minutes. Addition of Adrenaline prolongs its effective time for 60 to 70 minutes; and addition of Hyalurinase extends its area of effectiveness. Newer drugs like Etidocaine in concentration of 8mg \ Kg with Adrenaline can provide satisfactory local anaesthesia for 120 to 180 minutes.
  2. Ring Block – local anaesthetic agent is used in the form of a circumferential ring so that the sensations below the block are blunted. This form of anaesthesia is commonly used for fingers, although previously I have seen it being used for a limb also.
  3. Blockage of  nerve– either for surgical procedure or to relieve excruciating pain in an area where other methods have failed- common examples being blockage  of trigeminal ganglion in the face, coeliac axis block in the abdomen
  4.  Tumescent techniques – in this  larger amounts of anesthetic drug is used in dilute concentrations (0.05-0.1%) with Adrenaline (1:1,000,000). The anesthetic concentration is extremely small, allowing large amounts of solution to be used without reaching toxic levels and therefore it is quite safe.

The patient remains completely alert during local and regional anaesthesia. Addition of sedation either in mild or moderate doses not only potenciates the effect of local anaesthetic agent but also induces sleep \ drowsiness in the patient, the effect is beneficial not only for the patient but for the operating surgeon also.

The usefulness of local anaesthesia has been known for a long time but its versatility has been appreciated recently because of popularity of Day Care surgical procedures, the financial implications, suitability in relatively poor risk and elderly patients where general anaesthesia would be more risky. The non availability of a competent anaesthetist ,  sophisticated  anaesthesia equipment and absence of proper  post operative monitoring of a surgical patient have forced many surgeons to utilise local anaesthesia more frequently. It is good to have a standby anaesthetist but the surgeon himself can learn and administer local anaesthesia easily.

I shall like to share my recent experience with two of my patients who had undergone major operations under local anaesthesia as the anaesthetist did not find them suitable for general or regional anaesthesia and they could not be left without operations.

A lady of 55 years of age was found to have cancer of breast along with encephalitis resulting in marked impaired neurological functions.  Operation was started with an aim to excise the tumour under local anaesthesia, but as the surgical procedure proceeded we could undertake total excision of the breast along with clearance of the axilla, the operation that she really required. She made an uneventful recovery, was given additional appropriate treatment for breast cancer and she rewarded us with complete recovery from her neurological problems and two years have passed and she is disease free.

A lady teacher of 65 years of age, belonging toGuwahati,Assam, had recurrent attacks of severe pain in her abdomen for the last five years because of large number of stones in her gall bladder. She has been suffering from Bronchial Asthma for the last 30 years, incapacitating her for any physical activity. Investigations revealed her lungs functioning only at 20% level and she was denied surgery in her home and neighbouring states also. Her brother, a senior plastic surgeon by profession, wanted some relief from recurrent attacks of excruciating abdominal pain. General or regional anaesthesia were considered to be too risky, surgery was started with local anaesthesia with mild sedation and our efforts were rewarded when we could complete the operation – removing the large sized gall bladder packed with multiple stones. We were pleasantly surprised to find the patient walking to the wash room just six hours after her surgery and she boarded the train 48 hours later for Guwahati, it is more than four months and she is much better than what she was before surgery. Chest physiotherapy and counseling have played an important role in her recovery.

Local anesthetics,  used properly, are safe and have few major side effects but in high doses they can have toxic effects because of their absorbtion. This may have effects on  breathing, heartbeat,blood pressure, and other body functions but are seen quite infrequently.

The take home message – people usually are very reluctant to divert from a well established routine procedure and try a new one but unless one practices it, one will never realise its value or develop expertise in it.

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Disappearing Art of Clinical Practice http://drsmbose.com/disappearing-art-of-clinical-practice/ http://drsmbose.com/disappearing-art-of-clinical-practice/#respond Wed, 26 Apr 2017 12:39:45 +0000 http://drsmbose.com/?p=902 In November 1966, the practical part of my MS examination was being held inAmritsar. It was very cold but the sight of my examiners – Prof. SSAnand, A.K.Basu, BNBRao, GC Sharma, Eggleston etc. had made it icy cold for the 20 odd examinees who had collected there from all over northIndia.  It was the first of the five sessions spread over 3 days. The examiners arrived for the long case. Just prior to me there was a candidate from my PG Institute, who had failed twice before. He presented a case of lump inRIF, 5 cms in diameter, firm in consistency, dull on percussion, slightly tender and mobile. The examiners asked for the diagnosis and he said appendicular mass; of course he did mention two or three other possibilities in his differential diagnosis. Prof. Anand, the internal examiner for the candidate roared- “you said the mass is mobile ?”, “ yes sir” – the candidate mumbled; Prof. Anand- “you idiot, in my 40 years of surgical career, I have never seen an appendicular mass to be mobile, I am ashamed of you, get out and come after 6 months”; and there the poor chap’s entire examination came to an end. The importance of clinical examination, elucidation of physical findings and their proper interpretations could not have been hammered more appropriately. 30 years later while examining a DNB candidate at Pune, when I found that the candidate could not evaluate the fixity of a breast lump or tell me whether the thyroid nodule had mediastinal extension or not, I became very annoyed and also very depressed. Like Prof. Anand, I could not debar the candidate from the rest of the examination, but I definitely made sure that he would not pass this time however good his remaining sessions may be. Fixity of breast tumour and mediastinal extension of a goiter are important findings and the management depends upon this.
In this era of CT scan and MRI, Ultrasound and Mammography, it is not unusual to see a large no. of clinicians, and I dare say particularly the younger ones, do not even bother to get up from their cushioned chairs to examine the patient, they coolly write down sophisticated and expensive investigations and depend entirely on their results.  Anyone complaining of abdominal malady is subjected to US or CT or MRI scan upper GI endoscopy or colonoscopy or may be both. Modern day clinicians are completely dependent upon the imaging results, little realizing that the imaging expert may be a novice and the observation and interpretation may be far from being reliable or correct one. It has been proved beyond doubt that at times the investigation results may be inaccurate, moreover the results have to pass though human eyes and minds.

A large no. of surgeons will easily testify that the actual operative findings are at a great variance with the imaging results. An imaging result of inoperable case easily turns out to be resectable and vice versa. I feel that 90% of the cases can be easily diagnosed on clinical examination alone and decision taken for the line of treatment.

A few cases managed by me during the last 2-3 years will illustrate and prove my point of view:

A 85 years old NRI has been complaining of recurrent attacks of acute abdominal pain with nausea and mild abdominal distension for almost 50 years. He was extensively investigated inCanada, no cause was found. Every attack brought him to the hospital emergency, where he was treated with analgesics and antispasmodics, IV infusions, antibiotics etc. On examination I noticed mild abdominal distension and increased bowel sounds. On detailed questioning, he gave me the history of abdominal kochs about 50 years back for which he had recd. ATT for 9 months. My diagnosis was sub acute intestinal obstruction and advised him exploratory laparotomy. The patient was surprised that I had advised him surgery without undertaking imaging investigations but he consented for it. Exploration revealed a solitary stricture in the terminal ileum and stricturoplasty cured his long standing problem Recently a former patient of mine brought her old father, who was being treated with chemotherapy for lung cancer on the basis of chest X-ray and CT scan of the chest. I could elicit history of frequency and hesitancy of micturition suggesting BHP. Rectal examination revealed a huge malignant tumour of prostate and the diagnosis was established following FNAC. We have forgotten the dictum- if you do not put your finger in the rectum then you put your foot in it. Doing a PV or PR examination should become a routine with every abdominal examination.

I can easily recollect at least three patients during the last 1 year, who were referred to me for urgent appendicectomy following US scan in two and  CECT in one patient. I was not impressed on clinical examination and rectal examination revealed hard faecal matter in all the three cases and manual evacuation and enemata cured the so called appendix patients.

A patient of intestinal obstruction was being treated as a case of acute pancreatitis with paralytic ileus. Exaggerated bowel sounds with metallic tingling clearly gave the diagnosis of mechanical obstruction but no one had put his stethoscope on the tummy. All of us have been taught these basic steps right from third year of our undergraduate days but we easily forget the golden teaching. Present day surgeons of course do not carry a stethoscope anymore so the auscultation is already a forgotten step.

A young man of 30% electric burn complained of abdominal pain and I was called to see the case. The plastic surgeon in charge  of the case, the GE specialist , dermatologist had  seen the patient and he was being treated with antibiotics, analgesics, purgatives, tranquilizers etc. and then the opinion of a general surgeon was sought. He had superficial burns on the left side of abdomen and left thigh but was complaining of pain on the right side. He had guarding, tenderness in the right lower abdomen and I could elicit psoas spasm also. I lifted the bed sheet below the waist line and I was horrified to see a huge swelling in his right thigh, very tender, raised temperature and his distal pulsations were absent on that side. There was some oozing of blood stained fluid from two three puncture sites in the femoral region. The nurses have been puncturing the femoral vein to obtain blood samples resulting in huge false aneurysm of femoral vessels with secondary infection. He was being dressed on alternate days but no one had bothered to examine him completely.

I was once called by a very senior urologist to examine a senior faculty member who was complaining of pain and swelling in the lower abdomen and was being treated as a case of BHP for the last six months.  There was a large globular mass in the suprapubic region which was thought to be distended urinary bladder. I asked the patient to go and pass urine, he did that but the swelling did not regress at all. Subsequently he was found to be having leomyosarcoma infiltrating into urinary bladder and sigmoid colon.

I can easily recall three female cases of cancer breast seen by me last year, one chief engineer, another one wife of a CEO of a corporate hospital, and third one being Professor in an university , all three of them had  lump in the breast , FNAC were carried out , all were reported as negative and cleared for cancer. But the swellings went on increasing, they came to me for second opinion and  clinical  examination revealed locally advanced stage, FNAC repeated elsewhere were positive. False negative reports are not uncommon for in cytology but if your clinical examination is good then you should ask for repeat FNAC  or may be for excision biopsy but only if you have done the clinical examination and your fingers tell you that the lump looks suspicious.
Detection of cervical lymph node in a breast cancer case or an inguinal lymph node in a patient of anal canal or genital cancer completely alters the stage of malignancy but we still do not bother to do complete examination. Similarly not measuring a breast lump exactly with a scale or caliper can easily alter the staging of the disease and thus the line of the management.

Worst instances of non application of clinical examination are seen in emergency or triage areas. Haemodynamically unstable patients, even of head , abdominal and  chest  injuries are sent to radiology department for CECT, MRI, US scan etc. and they spend 2 to 3 hours over there unattended and uncared for; and scores of instances can be easily found when  the patients have crashed down. We forget that only two or three decades earlier these investigations were non existent and careful, repeated bed side clinical examination could elicit the same information

Absence of clinical examination have converged our vision to a tubular one, we do not see a patient in totality. Take for example a patient of blunt trauma to abdomen, Ultra Sound scan shows laceration leading to haemoperitoneum, he is taken to OT without a detailed clinical examination and the patient collapses after intubation as no one detected the massive haemo-pneumothotax in him.

Failure to undertake proper clinical examination not only leads to incomplete diagnosis but also leads to misguided management.

It seems the present day doctors are treating the images, photos and laboratory reports of the patient and not the human patient. The money spent on useless investigations is the bonus that the patient pays for the careless attitude of the doctor.  Clinical examination can be performed any where and at any time. The best part is that clinical examination can be made repeatedly and this is of immense value not only for diagnosis but also to evaluate the progress of the disease. A patient of acute abdomen may not give the diagnosis of acute appendicitis at the first clinical examination but a repeat examination conducted after 1 to 2 hours later if demonstrates the presence of guarding, rigidity and tenderness   then the diagnosis is obvious. You do not require a CECT to diagnose appendicitis.  It is also important to remember that the clinical examination results can be elicited by different clinicians and compared.

It is also important to remember that in the present era  when patient –doctor relationship is of so much importance, it is the clinical examination that brings the two together as  it involves human touch and some closeness between the two , which is not possible in any technology, however advanced it may be.

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