President Dr. S. EDWIN KINS RAJ Dr. E. PRADEEP KUMAR

VOLUME -2 ISSUE - 8 2020

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PresidentDr. S. EDWIN KINS RAJ

KINS Hospital, Kuzhithurai P.O629163

CELL : 7540083776Email: [email protected]

Hon: SecretaryDr. E. PRADEEP KUMARGheeth Hospital, Kozhivilai,Kaliyakkavilai P.O. - 629 153

CELL : 9787234321Email:[email protected]

Finance Secretary

Dr. BINISH JOSEPH .BBabu Home,Koickalthoppu,Kanjampuram P.O - 629154


EditorDr. PRIYA SOLOMON

William Hospital Campus,Main Road, Marthandam - 629 165


Co -EditorDr. VINODHINI PRADEEPGheeth Hospital, Kozhivilai,Kaliyakkavilai P.O. - 629 153


Dear Friends ,At the outset, I would

like to congratulate ourNational IMA Presidentelect: Dr.J.A.Jeyalal for add-ing pride to MarthandamIMA. He is a leader whoalways finds a way to makethings happen. A man ofgreat ideas, great purposewhich is bigger than himselfand a potent man capableof fighting a tidal wave ofnegative momentum. I wishhim all the success and mayGod give him enoughstrength to accomplish hisgoals. This month also sawus conducting regular meet-ings after a long hiatus.

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Yours in IMA service,Dr.Priya Solomon.

MESSAGE FROM THE CO EDITORDear friends,

This month was Pinktober. Thisentire month is dedicated to theawareness about Breast Cancer. We havea pink motif running throughout thisissue to signify the celebration of thestrength and survival of cancer patients.

We also had International Daughters Day thismonth. A daughter is the happy memories of the past,the joyful moments of the present, and the hope andpromise of the future. We recieved cute photos of all yourangels which has been portrayed in a beautiful gallery.

We had our non virtual monthly CME and it was areal joy to meet friends in person after so many days.

Let us now look forward with hope that we maybe able to celebrate Diwali, Christmas and New Year withthe same energy as previous years.

I take this oppurtunity to convey mycongratulations to Dr.J.A.Jayalal who is taking office asNational IMA President 2021. It is indeed a great pride toall of us to see a member of Marthandam IMA reach suchglory.

My heartfelt thanks to Dr.Priya Solomon who hasbeen doiung a tremendous job as Editor and the officebearers for carrying the indomitable spirit of IMA withuntiring passion and fervour. With Cheers,

Dr.Vinodhini Pradeep

It was indeed great balm to our souls to finallymeet all our friends. With this tempestous year finallybecoming a gusty wind, we look forward to conductingall the remaining festivities in a gala way. As CulturalSecretary, I humbly request all our members to partici-pate in all our activities and contribute to make this asuccessful tenure.

This issue is dedicated to Breast Cancer Aware-ness with 4 articles about the global problem. I thank allthe contributors for their articles.

This month MIMA has been sponsored by KIMSHospitals, Trivandrum & KMCH Hospitals, Coimbatore.KMCH Hospitals has been very gracious to sponsor lastmonth’s CME. We humbly request all our members tokeep MIMA in mind when the need for any advertise-ment arises.

My sincere appreciation to our CoeditorDr.Vinodhini Pradeep - a high flyer for all the coopera-tion & good work, as always for making the MIMA morecolourful. My hearty thanks to the office bearers andIMA Team 2020 for their support and involvement.

We solicit more articles, state-of-the-art contentand critical review articles for MIMA.We hope you, your families, your colleagues and yourcommunities remain safe and well.

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PRESIDENTIAL ADDRESS SECRETARY’S REPORTDear friends, It is indeed marvellous

to hear about the election of Dr.J.A.Jayalalas National IMA President. It’s a beaconof hope in these tough times. Let us jointogerher to congratulate & wish him thevery best in his journey ahead.

This entire month was dedicated to Breast CancerAwareness activities. On Sep 10th, World Breast CancerAwareness week was celebrated in AnnammalHospital. It was inaugurated by Past National IMAPresident, Dr.K.Vijaya Kumar and Dr.J.A.Jayalal. We thankthe Chairman of Annammal Nursing College, Dr.SheebaJayalal for coordinating all the arrangements. Thepatients were screened for breast cancer usingibreastexam, an unique screening tool. Entire camp wassponsored by KIMS Hospitals, Trivandrum. Around 35women were screened on that day.

World Sight Day 2020 was celebrated in Dr.JohnEye Hospital, Kaliakkavilai. Dr.John Samuel organised aunique fundraising orchestra with visually impairedpeople. At the end, we organised a free eye checkupcamp.

World Stroke Day was celebrated with anawareness video released on Youtube. Dr.Leena Jayakarspoke about risk factors of stroke and the need for rapid

It gives me immense pleasure torelease this issue of MIMA. I thank theEditor & Co-Editor for their support,leadership and vision in bringing MIMA inthe correct time.

I wish everyone a happy Pooja. My heartfelt wishes toall our members. My congratulations to our Dr.J.A.Jayalalwho has been elected as National IMA President 2021.It is a great honourable moment to all of us.

Let me thank all of you standing at the frontline duringthis COVID crisis. The work of all health professionals iscrucial to our patients and for the nation. It is thereforestrictly necessary to support the public health servicesand to adhere to all precautionary measures that havebeen put in place. The Health Service Department hascalled for list of all Medical Personnel employed in healthsector both private and public. This is for the purpose ofvaccinating all of us with COVID Vaccine. Hopefully wehave a vaccine soon enough to give us protection fromthis menace.

I wish to extende an enormous and heartfelt thaks toour Hony.Secretary, Finance Secretary, Executive boardmembers and all of you dear friends for your valuableguidance and support.

Stay safe. Stay healthy.Dr.S.Edwin Kins Raj

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FINANCE SECRETARY’S REPORT

Dr.Binish Joseph

intervention within hours. Time is brain in strokemanagement.

This month our CME, Surgery in Early Breast Cancerwas held in our Marthandam IMA hall. Dr.B.J.Sunil was thespeaker. It was a great pleasure to see all your friendlysmiling faces. We also streamed it live on ZOOM for thosemembers who couldn’t attend it in person. News clippingsof all our activities were published in daily paper. Thismonth, we have a special daughters day special photogallery in our MIMA.

We had a board meeting with our Executivecommittee members at IMA Marthandam and also acombined meeting with all the other IMA Branches of ourdistrict at Nagercoil to discuss the felicitation function ofour National IMA President Elect 2021, Dr.J.A.Jayalal.I thank all the board members of our branch and the officebearers of the other branches of our district for theircooperation and support in this regard. We Hope to havea great gala event soon.

Before winding up, I thank our President, Dr.EdwinKins Raj for his peerless leadership and our FinanceSecretary, Dr.Binish Joseph for his tireless fundraisingefforts. I am also indebted to Dr.Priya Solomon who hasbeen multitasking as both Editor of MIMA and CulturalSecretary for coordinating all the events.Thanking you, Dr.E.Pradeep Kumar

Dear friends, I am elated to reach allthrough this issue of MIMA. I express mywishes to Dr.J.A.Jayalal who has beenelected as National IMA President 2021.It is indeed a great honour to our branch.

Regarding the financial books, We have submitted all ourbooks and accounts to an auditor for the first 2 quarterswhich has never been done before. This was done as perguidance of Dr.K.Vijayakumar, Past National IMAPresident. I express my earnest gratitude to him.

Even though we were unable to conduct regular livemeetings due to the COVID situtation, we had hugeexpenses due to paying watchman salary, electricity bills,Servicing of generator, AC, installing a new sunken motor,ZOOM charges, Paying for CME credit points, MIMApublication and Postal charges. There hasn’t been anysubstancial contribution from Sponsors too. Only withyour kind benevelonce, we can continue the show. In thisregard, I record my thanks to all those who have paidthe annual subscription fees of 2000 Rupees. I alsohumbly ask the rest to pay them as early as possible.

We also solicit advertisements to publish in MIMA and .advertising stalls at our IMA Hall during the upcomingfunctions. Kindly reach out to me for the same.Thanking you,

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in 1980's and 1990's and heralded a paradigm shift away fromthe mutilating surgery.

Next landmark in Breast cancer surgery was de esca-lation of the axillary surgery. Axillary dissection was the stan-dard and it was associated with significant chance of Lymphe-dema. Halsted's theory was critical in introducing the con-cept of Sentinel lymph node biopsy- as it was understoodthat the breast cancer initially spreads to the axillary lymphnodes in a stepwise manner. Initial studies by Guiliano et alin 1994 established the safety of sentinel lymph node biopsy.If sentinel lymph nodes are found to be negative, the axillarydissection can be safely avoided.

Breast cancer surgery has gradually morphed from a fearedprocedure , to an elegant operation , delicately balancing on-cological and reconstructive principles with the quality of lifeof patients taking the forefront , as patients with early breastcancer do live a long life, almost equalling their normal lifeexpectancy

Oncoplasty is the new buzzword for the past 5 yearsin breast cancer surgery. It is the application of plastic sur-gery techniques to cancer surgery .As the word implies ,"Onco" comes before "Plastic", Oncological safety is nevercompromised for aesthetic results. There are an entire gamutof oncoplasty procedures described, but mastering a hand-ful of these procedures have resulted in achieving the goal ofoncological safety and an acceptable level of aesthetic out-come by a breast surgeon in most of the breast cancer pa-tients, with a fairly easy learning curve.

BREAST CANCER SURGERY -

LESS IS THE NEW MOREBrief history of surgery in breast

cancer and what the future holds.

Halsted's Radical Mastectomy prevailed forclose to 70 yrs. Though he was not the first surgeon who ad-vocated radical loco-regional treatment for Carcinoma Breast,he was definitely the most systematic and scientific surgeonwith a penchant for perfection. He gave a clear and concisedescription of the procedure and each and every patient's re-spective outcome. He reported a local recurrence rate of 7 %which was unheard of, during those times. He religiouslyworked to spread his procedure through journal publicationsand surgical club meetings as he absolutely believed in histheory of breast cancer as a loco-regional disease. He is cred-ited with starting the first residency program in the US andnaturally his trainees helped to spread the procedure all overthe US and eventually to Europe. Such was his influence onbreast cancer surgery- the benefit of such a radical procedurewas not questioned for close to 7 decades.

Breast Conservation surgery as standard treatmentcame about ,rather gradually, as our understanding of the tu-mour biology got better and also the role of therapeutic radia-tion in breast was slowly being realised. It took nearly 7 de-cades to even suggest that an alternative safer procedure otherthan a radical mastectomy could be performed. Breast Con-servation Surgery was established after the Veronesi's Milanand Fisher's NSABP trials.

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Radical Mastectomy is now known for its brutality, but despiteits poor reputation now , we can't deny that it did save hundredsof women's lives. Much has changed over the years. We havemoved from the "Maximum tolerated treatment" era to "Mini-mum required treatment" tailored to each patient. Worthwhilescientific progress is possible only if we realise that there is muchwe still do not know and only through constant application ofscientific research with the humane concern, putting the patient'swell being at the forefront, that we will be able to forage for adeeper understanding of the disease and to provide the best carefor our patients.Dr.Bharath Veerabadhran MConsultant Surgical OncologistKIMS HEALTH CANCER CENTRE

1.Which is known as pink citya) Jaipurb) Chandigarhc) Aligarhd) Mihir Garh2. When someone says that they are in the pink, it meansa) They are very healthy.b) They faced a huge financial loss.c) They have lost lot of blood.d) They are embarassed.

Congrats to the Winner of last month’s quiz : Dr.Venketeswaran

Whatsapp answers to 9787234321

Quiz MasterDr.Aravind Sundaraj

PINK QUIZ

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MRI

It is the most sensitive imaging modality for detection of in-vasive breast cancer. It is also the recommended screeningmodality for high risk patients like women with geneticmutation.(BRCA mutation). It may be useful in assessing theextent of insitu and invasive cancers, detection of multifocaland multicentric cancers.

PET CT

It is the imaging modality used in staging breast cancers andshould not be used to detect the breast cancer.

IMAGING IN MANAGEMENT

Imaging in addition to detection IS used in tissue sampling,Also used for presurgical localization ofsmall non-palpablebreast cancer. As more and more early breast cancersare treated with neoadjuvant chemotherapy, imaging is nowwidely used in assessment of treatment response. As the breastcancer is also treated with less morbid surgeries, imaging isalso used in marking the breast primary before neoadjuvantchemotherapy. Less extensive axillary dissection is done evenfor locally advanced breast cancer with minimal nodal involve-ment and hence nodes are also marked using image guidedmarker placement and targeted axillary dissection done withpresurgical localization of the involved nodes.

Dr.Rupa Renganathan DMRD, DNB, FRCR

Lead Consultant - Breast Imaging And Interventions

Breast Center - KMCH

IMAGING IN BREAST CANCER

Breast cancer is the one of the leading causesof mortality in Indian women. The morbidityand mortality can be significantly reduced ifit is detected at an early stage. Fortunatelyfor us, breast cancer can be diagnosed byMammogram screening.

MAMMOGRAM

Mammogram is a specialized X ray test to the breasts. It is theaccepted screening modalityfor breast cancer screening for lowrisk population. Most of the breast cancers originate from theductal epithelium which may initially start as in situ cancerscalled ductal carcinoma in situ (DCIS) and are seen asmicrocalcifications.

The breast cancers which do not produce calcifications whensmall in a dense breast may be difficult to be detected. Thislimitation to a certain extent is overcome by digital mammo-gram and to a large extent by a 3D mammogram called Digi-tal Breast Tomosynthesis.

ULTRASOUND

It is the imaging modality of choice in young, pregnant andlactating women with breast lumps. It is also used to differen-tiate solid and cystic breast lesions and evaluation of axilla.Thenon-palpable metastatic lymph nodes and the nodal burdenare best assessed with USG. Ultrasound is also the most widelyimaging used in breast intervention

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fraternity. Is it the lack of awareness or reluctance to change?I feel knowledge, attitude and practice- all play a significantrole. Most of the times, the decision is based on factors (likefinancial, social and taboo) other than the actual willingnessof the lady who holds the rights. A proper enforcement ofinformed decision making as a part of the multidisciplinarymanagement would make this scenario better.

The first mantra is that ‘every lady sitting before you wantsto conserve her breast or have it reconstructed if needed’.This is more of a rule than the exception. The second mantrais ‘cosmesis comes second only to oncological clearance’. Theassessment includes the appropriateness for breastconservation surgery in the first place and ruling out anyabsolute contra-indication. The probable size and region ofthe defect is then analysed. A defect of more than one-third toone-fourth the breast size needs some form of oncoplasty toachieve optimal results. In these scenarios, the methodscommonly used are volume displacement and volumereplacement.

Volume displacement involves moving the tissue from withinthe breast itself. Hence the importance is aimed at achievingthe shape of the breast at the cost of the size. Most of thesetechniques are relatively simpler when compared to thevolume replacement techniques which involves moving tissuefrom outside the breast in the near proximity to fill the defect.These thus aim to match both the size and the shape of thedefect. These reconstructive procedures are different form thenormal reconstruction of the defect since the planning of theseprocedures including the placement of the incision, raising

BREAST RECONSTRUCTION -A TO BE ERA OF REALITY

In Breast cancer, excellent disease control hasbeen achieved even in the advanced andmetastatic disease. In India, 90% of the stageIcancer patients live longer than 10 years. Asan oncologist, I cannot just simply exemplifyhow important it is to add ‘Quality’ to the‘Quantity’ of life these advances have achieved. Let us seehow the reconstruction of breast would achieve the ‘Qualityof Life’ that is the cynosure of the breast cancer patients.

It is sad that breast conservation is still considered to beoncologically inferior to mastectomy, even among the medicalfraternity . Needless to say, it is a task at times to pass the messageto the public. Is it the lack of awareness or reluctance to change?I feel knowledge, attitude and practice- all play a significant role.Most of the times, the decision is based on factors (like financial,social and taboo) other than the actual willingness of the lady whoholds the rights. A proper enforcement of informed decision makingas a part of the multidisciplinary management would make thisscenario better.

Knowledge about the disease biology, genetic consideration,incorporation of neo-adjuvant and adjuvant treatment becomesessential for the clinician who assess these patients beforeproviding them various surgical options. Here under I haveconcisely mentioned my approach to breast oncoplasty.

It is sad that breast conservation is still considered to beoncologically inferior to mastectomy, even among the medical

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of the flap, harvesting sentinel lymph node and mobilizationof the tissue needs knowledge of ‘onco-’ and ‘plasty-’ andrightly becomes a niche speciality - ‘oncoplasty’.

A subgroup of patients needs mastectomy due to oncologicalreasons. It is important to spot these patients especially ifthey are candidates for neo-adjuvant treatment. The durationof neo-adjuvant therapy gives time to inform about theoptions, counsel them, support them with their decision tosail through smoothly. In case of suspicion regarding geneticinheritance, this time can be used to perform genetic testingand to counsel regarding prophylactic contralateralmastectomy. Although, there are various methods of wholebreast reconstruction, autologous tissue replacement scoresbetter than implant-based reconstruction in almost allscenarios. Considerable proportion of patients who opted notto get reconstruction at the time of mastectomy wouldconsider reconstruction down their disease-free phase andsecondary reconstruction is always a viable option for them.Education and awareness would help a vast majority of breastcancer patients to come out with their desire to opt for breastconservation. Similar enthusiasm among the medicalfraternity should pave way for more surgeons undergoingbreast oncoplasty training. Times would change. The era ofreconstruction would become the reality- A rule and not anexception.

Dr. Ezhir Selvan C, MS (Gen Surg), MRCS (Edin),

M.Ch (Surgical Oncology), FRCS (Edin).,

Consultant - KMCH

BREAST CANCER RADIOTHERAPY -SHORT & SWEET

Breast cancer treatment has revolution-ised over the last decade with advancementsin surgical, radiation & systemic aspects. Asawareness gets better, self breast examination,mammography screening has become morecommon than before leading to early detect-ion of breast cancer.Breast conservation surgery

For over half a century radical mastectomy was thetreatment of choice. A group of surgeons in Italy found thatsimple tumor excision followed by radiotherapy to the entirebreast could possibly be equivalent in terms of outcomes. Thisimproved the quality of life of the patient. Since then radiationhas become an integral part of management of breast cancerboth in the early and advanced cases. Radiation is advised inall advance cancers after surgery especially in those withpositive nodes and in all patients who undergo a breastconservation surgery. Radiation is delivered traditionally over30 days which makes patients walk up and down to thehospital every weekday for about six weeks.

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Shortening treatment time

In the last five years, trials in UK and Canada haveshown that an abbreviated radiation schedule delivered over3 weeks is as good as the 5-week schedule. This has beenadopted widely in the world and it reduces the overall treat-ment by 2 weeks, hence reduced travel cost and loss of man-hours. In developing nations like India where access to Ra-diation facilities are less especially in remote rural areas thisshort Radiation schedule called as ‘Hypofractionation’ couldbe of immense benefit.

Shortening further

For patients with very early tumours (less than 2 cm),there is an option to reduce the treatment to just 5 days! Andthat too only to the tumor bed. This is termed as ‘Acceleratedpartial breast irradiation’ (APBI). In this particular techniqueradiation is delivered by ‘brachytherapy’ via multiple timesplaced in the breast during the surgery. Treatment is usuallywrapped up within 6-10 days from surgery and entire localtreatment is complete.

The partial breast irradiation concept has worked well for earlybreast tumours with favourable pathological features. Partialbreast irradiation also reduces overall breast shrinkage andpreserves cosmetic outcomes after reconstruction.

Cardiac sparing radiotherapy

Risk of cardiac events like coronary spasms, infarctionetc increases in patients receiving radiation therapy for left

sided breast cancer. Cardiac events happen late, after 10-20years of completion of radiation. Cure rates for breast can-cer has gone up steeply over the last 2 decades and there arelong term survivors. Hence it is meaningful to reduce radia-tion doses to the heart so to prevent any late cardiac toxicity.To achieve this goal, patients are trained to do a particularregular breathing while on radiation couch. Radiation is de-livered only while patient is in full inhalation thereby push-ing the heart away from chest wall / breast.

Ultra-short radiation scheduleThe year 2020, has seen tremendous changes in the

way people see about visiting a hospital. The COVID pan-demic has terrorised people especially elders from visitinghospitals for fear of contracting the dreaded infection. Thetrial results published this year from UK called the FASTFORWARD has come handy to both patients and doctorstreating breast cancer. Based on this study we can treatwomen with all stages of breast cancer with a 5-day sched-ule of radiation to the breast there by reducing treatment tojust 5 days! In countries like India this could revolutionisethe way we treat cancers and breast conservation rates couldpossibly go up.

In conclusion, ultra-short radiation schedules followingbreast conservation surgeries gives patients the advantageof time, cosmetic results and best quality of life.

Dr Madhu Sairam.R Consultant Radiation oncologistInvestigator - Hospital based cancer registry,KMCH, Coimbatore

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Dr.Vipin Venugopalan Dr.R.C PradeepGen.Medicine, Marthandam Anaesthetist, Munchirai

Dr.Stalin Joshua Dr.Rajesh Kumar P.G (M.S. Ortho) Elected as State KKMCH, Asaripallam Joint Secretary, TNGDA

WELCOME TO OUR NEW MEMBERSof

CONGRATS TO OUR MEMBERSof

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President Dr. S. EDWIN KINS RAJ Dr. E. PRADEEP KUMAR

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