January To April

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Issue Editor : Dr. Saurabh Mohite
Executive Editor : Dr. J. Ravindranath
PHRC
BULLETIN
Vol. 15, Issue No. 1
January-April 2014
Assistant Editor : Dr. R. Sengupta
Editorial Board
Dr. Nitin Abhyankar
Dr. Shrirang Pandit
Dr. Vijay Natarajan
Dr. Jaydeep Date
Contents
Page
Editorial
2
Breast Conserving Therapy
Dr. Saurabh Mohite
3
Breast Reconstruction
Dr. Abhishek Ghosh
6
Dr. Dattatraya Dhavale
Hospital Update
11
Dr. Mahesh Thombare
Chemo PORTS
Dr. Saurabh Mohite
19
Use of Hydroxyurea with Wheatgrass in
Thalassaemia Major / Intermedia
Dr. Vijay Ramanan
21
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23
Dr. Bharat Dikshit
Dr. P. K. Sharma
Board of Trustees
Shri. Mukundas M. Lohia
President
Shri. Hasmukhlal A. Shah
Vice President
Shri. Devichand K. Jain
Mg. Trustee
Shri. Rajkumar H. Chordia
Jt.Mg. Trustee
Shri. Rasiklal M. Dhariwal
Trustee
Shri. Chandmal M. Parmar
Trustee
Shri. Dahyabhai M. Shah
Trustee
Dr. Chensukhlal J. Munot
Trustee
Shri. Amichand K. Sanghvi
Trustee
Shri. Hemraj D. Katariya
Trustee
Shri. Kiritbhai R. Shah
Trustee
Shri. Champaklal V. SuratwalaTrustee
Shri. Mukunddas M. Kasat
Trustee
Shri. Bhabutmal P. Jain
Trustee
Shri. Purushottam M. Lohia Trustee
Shri. Prakash R. Dhariwal
Trustee
Shri. Harinarayan J. Rathi
Trustee
Shri. Nainesh M. Nandu
Trustee
Publisher, Printer & Editor :
Mr. Devichand K. Jain, Managing Trustee
Owner of Bulletin :
Rajasthani & Gujarati Charitable Foundation
through Poona Hospital & Research Centre,
Pune 411 030.
Place of Publication : 27, Sadashiv Peth, Pune - 30.
Name of Printing Press :
Typographica Press Services
2181, Sadashiv Peth, Tilak Road, Pune 30.
* Views expressed by authors are their own and not
necessarily those of the editorial board.
* For Private circulation only.
* Copyright reserved.
* Registration with Register of News Papers of India
No. - MAHBIL/2000/1809
3
Editorial
Dear Readers,
Greetings from PHRC.
This bulletin focuses on Breast conservation therapy
and the techniques of Breast Reconstruction.
Breast cancer is one of the most common cancers in
our country. Unfortunately, for a majority of our patients, for myriad
reasons, a modified radical mastectomy still remains the preferred
surgical modality by both doctors and patients alike. This is despite
the tremendous psychological trauma and the negative body image
associated with losing a breast. Several meta-analyses have proved
that the overall survival, cure rates and long term outcomes are the
same for well selected conservation surgeries as compared to radical
mastectomies.
This bulletin is an attempt to emphasize our conviction that, in this
age and time, no woman should lose her breast, unless absolutely
indicated.
We hope you enjoy this issue and provide us with inputs and
suggestions for the forthcoming ones.
Thank you !
Regards,
Dr. Saurabh Mohite
Consultant Oncosurgeon
Poona Hospital & Research Centre.
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Breast Conserving Therapy
Dr. Saurabh Mohite*
Cancer is a leading cause of death around the
world. The World Health Organization (WHO)
estimates that without intervention about 84
million people will die of cancer between 2005
and 2015.The most prevalent cancer in the world
is breast cancer and nearly one in four women
with cancer in the world has breast cancer. Half
of these are in developing countries.
HISTORY OF SURGICAL MANAGEMENT
The initial surgical treatment of breast cancer was
typically wide excision, but was associated with
a high rate of local recurrence and poor survival.
William Halsted popularized radical mastectomy
in 1894. Radical mastectomy (RM) resulted in a
significant drop in the local recurrence rate, but
the curative potential remained limited.
TREATMENT OF BREAST CANCER
For a complete and optimal therapy for breast
cancer, it should be a multidisciplinary approach
with input from the patient, the surgeon, the
diagnostic radiologist, the pathologist, the general
practitioner, the radiation oncologist, the medical
oncologist, nurses, and other health professionals.
The outcome of patients with breast and other
cancers is better if they are treated by a clinician
who has access to a full range of treatment options
in a multidisciplinary setting.
Attempts with extended radical mastectomy,
which included internal mammary node dissection,
failed to improve survival. At different times,
Modified Radical Mastectomy (MRM), Total
(Simple) Mastectomy, and more recently, Skin
sparing mastectomy (SSM) and Nipple sparing
mastectomy (NSM) were introduced.
The primary goal in the treatment of breast cancer
is to control the disease with the aim of achieving
cure. The other desirable outcomes of treatment
include: to improve survival rate, minimize the
risk of distant metastases and / or local recurrence,
cosmesis, relief of symptoms, and the return to a
quality life as close to the life before diagnosis as
possible.
The different modalities of treatment include
surgery, radiotherapy, systemic therapy (cytotoxic
drugs and hormonal manipulation) and treatment
targeted at HER2. Surgery remains an important
modality of treatment, to eradicate the primary
tumor and achieve total disease control.
Although MRM is a less morbid procedure
compared to RM, the patient will still suffer loss
of the breast. The attempt to preserve the breast
without compromising survival brought up the
use of Breast Conserving Therapy (BCT). This
includes breast conserving surgery and breast
radiotherapy. Although BCT and breast conserving
surgery (BCS) are used interchangeably, strictly
speaking BCT includes both BCS and breast
radiotherapy.
BCS is an important part of the breast-conserving
therapy, which may be defined as a combination
of conservative surgery for resection of the
primary tumor with or without surgical staging
of the axilla, followed by radiotherapy for the
eradication of the residual microscopic disease
of the breast, with or without adjuvant systemic
therapy.
*Consultant Oncosurgeon, E-mail : saurabhmohite1@gmail.com , Cell : 9220451093, 7387000081.
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BREAST CONSERVING THERAPY
The National Surgical Adjuvant Breast and
Bowel Project (NSABP) B 06 compared Total
Mastectomy to lumpectomy, with or without
radiation therapy, in the treatment of stages I and
II breast cancer. After five- and eight-year followup periods, the disease-free, distant disease-free
and overall survival rates for lumpectomy, with
or without radiation therapy, were similar to
those observed after TM. However, the incidence
of ipsilateral breast cancer recurrence (in-breast
recurrence) was higher in the lumpectomy group
that did not receive radiation therapy
PATIENT'S SELECTION FOR BCT
The four critical elements in selecting patients
for breast conserving therapy are: A history and
physical examination, breast imaging, histological
assessment of the resected breast, and assessment
of the patient's needs and expectations
CONTRAINDICATION
If an attempt to preserve the breast is likely
to be associated with high rates of in-breast
recurrence, then BCT is absolutely contraindicated
These situations are : Multicentric disease,
diffuse malignant-appearing mammographic
microcalcifications (suggesting multicentricity),
persistent positive resection margin, prior
radiotherapy to the breast or chest wall, and
pregnancy. The main reason for contraindication
in pregnancy is the need for radiotherapy, which
will be contraindicated in pregnancy. BCT can
therefore be performed in the third trimester,
deferring breast radiotherapy until after delivery.
skin or nipple retraction (not necessarily sign
of locally advanced disease), tumor location,
clinical or pathological axillary nodal metastases,
histological subtypes and the presence of an
extensive intraductal component.
SURGICAL TECHNIQUE
The essence of BCT is not only to preserve
the breast, but also to have an a aesthetically
acceptable result. The cosmetic appearance
after BCT is determined by surgical factors like:
size and placement of incision, management of
the lumpectomy cavity, and extent of axillary
dissection, if necessary. The surgical technique
can therefore make a difference. The goal at the
end is to have a cosmetically acceptable outcome
without compromising local tumor control.
In planning the incision, the surgeon had to take
into consideration the location of the lump, type
of incision, depth of mass from the skin, and
the incision had to be close to the lump to avoid
tunneling.
In order to reduce the local failure and to improve
the outcome in breast cancer, there is need to
emphasize the surgeon's role in improving patient
selection and optimizing the procedure.
The incision should be sited in such a way that
if mastectomy is eventually required, it can be
included in the mastectomy specimen. In the upper
part of the breast, incisions should be curvilinear
or transverse, while in the lower part, they should
be either curvilinear or radial.
Relative contraindications are connective tissue
disease, especially scleroderma & active systemic
lupus erythromatosis (SLE) and a large tumor in
a small breast.
An improved adequate surgical margin is crucial
and can be achieved without an excessive reexcision rate, with detailed planning, consideration
for oncoplastic resection, and intraopertive margin
analysis.
Factors thought to be associated with the risk
of breast cancer recurrence after BCT are now
known to be unfounded as long as there is a
negative margin on excision. Some of these are:
age, positive family history of breast cancer,
What constitutes an adequate margin of a grossly
normal breast tissue around the tumor in BCT is
uncertain. In one series, resection of 0.5 to 1.0 cm
of grossly normal tissue resulted in a histologically
negative margin in 95% of 239 patients.
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and it should be allowed to fill with serum and
fibrin. This will give the best cosmetic result. As
suggested by Morrow et al., reapproximation is
best avoided, as it can result in distortion of the
breast contour, which may not be apparent with
the patient supine on the operating table. In a
situation where the lumpectomy cavity is large,
latissimus dorsi reconstruction of the defect may
be appropriate
The surgical technique must ensure adequate
excision. Obtaining a tumor-free surgical margin
decreases the incidence of a local recurrence (LR)
of the primary tumor.
There are various risk factors associated with a
positive margin, among them are: the extent of
excision, age, large tumor size, multifocality,
lobular histological type, and the number of
positive lymph nodes.
The incision should be closed with a subcuticular
suture.
In 30 of 34 reviewed studies, persistent microscopic inadequate (R1) or macroscopic inadequate
(R2) surgical margins were highly significant for
LR compared to the negative margin (p = 0.0001.
Microscopic disease resulting from a positive
margin is more problematic because theoretically,
cancer in the relatively hypoxic environment
of the lumpectomy scar bed will be resistant to
radiation therapy. Furthermore, the inability to
achieve negative margins may be a marker of an
excessive tumor burden in the treated breast.
COMPLICATIONS
Seroma formation, arm morbidity (arm swelling,
arm pain, arm numbness, arm stiffness, shoulder
stiffness, shoulder pain, & nerve injury), phantom
breast syndrome, delayed cellulitis and pain
syndromes of the chest wall, axilla, and upper
extremity are known complications after breast
cancer treatment. Some of these complications,
especially arm morbidity are less common in
BCT as compared to mastectomy, and less
frequent with sentinel lymph node biopsy than
after axillary lymph node dissection.
In order to ascertain a negative margin, intraoperative margin assessment (IOMA) has been
found to be useful. This includes : gross inspection
in the operating room, with or without frozen
section analysis, cytologic touch prep (CTP)
analysis, shaved margin (SM), and intraoperative
ultrasound (IOUS). Although these assessments
are useful, they do not guarantee an absence of
microscopic tumor on permanent section.
CONCLUSION
Although getting a microscopic negative margin
is still challenging, BCT as a surgical technique
has revolutionalized the surgical treatment of
early breast cancer. BCT has not only provided
an acceptable oncological outcome, but has
diminished the psychological burden, offered
better cosmetic results, and reduced postoperative
complications.
At the completion of the excision, the surgeon
should ensure adequate hemostasis. Drainage
of the lumpectomy cavity should be avoided
q
q
q
Neha found her uncle jumping up & down on the terrace with the great vigour.
‘What’s the matter, uncle?’ She asked surprised at the sudden display of energy.
‘The doctor forgot to shake the bottle before he gave me my medicine.’
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Breast Reconstruction
Dr. Abhishek Ghosh *
Breast reconstruction is now often considered
as part of the breast cancer treatment when
mastectomy is required. There has been an
increase in the number of women undergoing
reconstruction after breast cancer surgery due
to increased patient awareness and numerous
reconstruction options.
Patients are educated at the plastic surgery
consultation regarding the need for multiple
procedures required to resect the breast cancer,
reconstruct the breast mound & create a projecting
nipple & areola. This should especially be discussed
in the context of immediate reconstruction where
avoiding any delay to adjuvant treatment is an
important consideration.
Immediate Breast Reconstruction
The previous fears that immediate breast
reconstruction might delay recurrent cancer
detection or have a negative impact on prognosis
of breast cancer, have been largely discarded.
There is no evidence that immediate reconstruction
increases the rate of local or systemic relapse.
Overall, patients benefit from the reduction
in psychological trauma experienced after
mastectomy by undergoing immediate breast
reconstruction. One of the major advantages
of immediate breast reconstruction includes a
reduction in the number of operations ultimately
necessary to create a reconstructed breast mound
following excision of the breast. Disadvantages
of immediate reconstruction include extended
surgical time and potential complications of
the mastectomy, such as skin loss or infection,
which may adversely affect the reconstruction.
Perhaps the greatest disadvantage of immediate
reconstruction is the inability to predict (in many
cases) who will need adjuvant radiation.
Delayed Breast Reconstruction
Delayed reconstruction may be performed several
days to years after mastectomy. Advantages of
delayed reconstruction include increased time
to allow for adequate skin flap healing, making
the tissues more mobile and pliable, as well as
increased time to allow for patient recovery.
Also the patient is more inclined to accept less
than perfect symmetry after she has lived with
loss of a breast. Disadvantages include multiple
procedures to obtain the same result as with
immediate reconstruction .
Chemotherapy and Reconstruction
Adjuvant systemic therapy in the form of
chemotherapy or hormonal therapy is routinely
administered to women under the age of 70 if they
are node positive & to the majority of women with
tumors > 1 cm. Chemotherapy can be delivered
to patients with implants, tissue expanders
or flaps as soon as the wound has healed and
there are no signs of underlying infection. Most
studies have shown that a delay in the initiation
of chemotherapy following immediate breast
reconstruction happens only 1% of the time.
Radiation and Reconstruction
Special consideration is given to women who will
require adjuvant radiation and women who have
*Reconstructive, Cosmetic and Microvascular Surgeon, E-mail : drabhishekghosh@gmail.com ,
Cell : 8551067257.
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received chest radiation in the past. Regardless of
timing, radiation forever compromises the quality
of the skin and underlying muscle, resulting in a
higher incidence of complications, unsatisfactory
expansion and a poorer aesthetic result. Women
with obvious radiation-induced skin changes prior
to reconstruction should undergo autogenous
tissue reconstruction.
What are the different types of breast
reconstruction procedures that are available?
The two types of breast reconstruction are
implant of a prosthetic device and the use of one's
own tissue to reconstruct the breast (autologous
reconstruction).
Implant reconstruction : This procedure
replaces the patient's tissue with a saline or
silicone implant. Depending on the patient's chest
wall characteristics, the implant can be placed
immediately at the time of the mastectomy.
However, in a majority of patients, a temporary
implant known as an “expander” is placed into
the pocket of empty space of the mastectomy.
The expander's role is to keep the pocket for
the implant open as the skin heals from the
mastectomy. Expansions will be performed to
create a breast mound that is generally smaller
than the final implant. Patients often find this
process helpful as they can progressively decide
what size of implant they may want to have.
Once the patient is fully expanded the expander
is exchanged for an implant.
Autologous reconstruction : This group includes
procedures where one's own tissue is used. The
options of tissue that can be used include tissue
from the following areas : abdomen (TRAM,
DIEP, SIEA), back (Latissimus), upper (SGAP)
or lower buttock (IGAP), and inside of the thighs
(TUG). Another type of reconstruction that has
been recently utilized is a series of procedures
that utilize the patient's own processed fat to
create a breast. This procedure is termed “fat
injection” and is sometimes used in combination
with implant-based or autologous reconstruction.
TRAM Flap Breast Reconstruction
The transverse rectus abdominis myocutaneous
(TRAM) flap is a popular technique for breast
reconstruction using autogeneous tissue from
the rectus abdominis muscle and overlying
subcutaneous fat and skin.
The TRAM flap can be harvested as either a
free or a pedicled flap. In a pedicled TRAM, the
entire length (or a large section) of the rectus
abdominis muscle along with a transverse section
of subcutaneous tissue and skin is tunneled to
the location of the mastectomy defect where it is
then molded into a breast. The pedicled TRAM
flap maintains its native blood supply from the
superior epigastric vessels.
In a free TRAM, only part of the rectus muscle is
used and the flap (which includes its attached pad
of subcutaneous fat and skin) is totally detached
from its surrounding tissues &transferred to its
new location based on the deep inferior epigastric
vessels, termed the pedicle.
The DIEP flap is a perforator based flap in which no
rectus muscle is taken which prevents herniation
in the donor site. The pedicle of the harvested
flap is then anastomosed to recipient vessels in
the axilla (thoracodorsal vessels) or chest wall
(internal mammary or intercostal vessels).
While it's the most popular autologous breast
reconstruction procedure, a TRAM flap isn't for
everyone. It's not a good choice for:
• thin women who don't have enough extra belly
tissue
• women who smoke
• women who already have had multiple
abdominal surgeries
• women who plan on getting pregnant
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Fig 1 : Woman after mastectomy, showing
(TRAM) and surrounding tissues, in preparation
for reconstruction.
A - mastectomy site
B - right rectus abdominis muscle
C - left rectus abdominal muscle
D - segment of abdominal tissues : skin and fat,
to be transferred along with muscle to create the
new breast.
Free DIEP flap harvest
Tissue Expander Breast Reconstruction
While many feel that autogenous breast
reconstruction offers superior results to alloplastic
reconstruction with tissue expansion/implants,
many patients choose this method over autogenous
options. Tissue expansion offers a faster & less
complicated operation, decreased hospitalization,
no donor site morbidity and more rapid recovery
than autogenous reconstruction.
Currently prosthetic reconstruction with expanders
is done as a two-stage technique. Stage one is the
placement of the tissue expander and stage two is
the removal of the tissue expander and exchange
with a permanent implant.
Patient intraop TRAM reconstruction.
A - lines of reconstructed breast incisions
B - right trans rectus abdominis muscle
C - left TRAM muscle is swung over to re–create
the new breast
D - incision circle of re–positioned umbilical incision
E - line of abdominal surgery
Post operative picture of free Diep flap with nipple
reconstruction(1 year followup)
Indications for Surgery
Indications for prosthetic breast reconstruction
include patients undergoing a modified radical
mastectomy or with significant congenital
deformities who desire this technique of
reconstruction for their breast deformity. It is
also indicated for patients who do not qualify for
autogenous reconstruction secondary to obesity,
scars, lack of available tissue, or co-morbidities.
Commonly, if being performed for breast cancer
reconstruction, the first stage is completed at the
time of the modified radical mastectomy.
While not an absolute contraindication, this
technique is relatively contraindicated in patients
Continued on Page 17....
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Hospital Update
CONGRATULATIONS –
l Dr. Kiran Lale & Dr. Varun Nivargi for successfully passing DNB General Medicine.
FOUNDATION DAY CELEBRATION On 8 th March 2014, Poona Hospital completed 29th year of existence in the medical service of the
city.
Like every year the celebration began a week in advance with a series of Tournaments & Matches.
Also an enormously popular Antakshari competition & various fun games were held. A large number
of staff, residents & consultants participated in these activities with great enthusiasm.
On the evening of Foundation Day a variety entertainment programme showcased the in-house
talent in singing, dancing and acting skills followed by a Live Orchestra. The hospital staff looks
forward to these events throughout the year.
Consistent good performance amongst various categories of staff was awarded. The recipients of these
awards were Mrs. Anagha Gandhi, Ms. Jobina Vergis, Ms. Sonali More & Mr. Ashok Jadhav.
The most coveted trophy of the best department went to the Cardiac Recovery Department.
The hospital congratulates all the above employees & departments once again.
As a part of the same celebration an annual get together of the Donors and Members of the Rajasthani
& Gujarati Charitable Foundation was organised on 7th March, 2014 comprising of a Musical
Entertainment Programme followed by dinner.
l
Blood Donation Camps A total of 11 Blood Donation Camps were arranged during the months from November 2013 to
February 2014 at various places the response at all these camps was very encouraging, a total of
1010 people donated blood during these camps.
CME’S, SEMINAR’S & TRAINING PROGRAMMES –
l Dr. Jayashree Todkar arranged an Obesity Patients Meet on 15 th December 2013.
l
l
l
l
l
Indian Society of Anaesthesiologists, organized a CME on ‘Myths and Facts of Anticogulation’ on
24th December 2013.
Dr. Jayashree Todkar organized An ‘Advanced Laparoscopic Surgery Workshop’ with the theme‘Laparoscopic Surgery Simplified for GI and Solid Organs’ on 19th January 2014.
A 3 days Certificate Course of ‘Advanced Cardiovascular Life Support & Basic Life Support’ was
organized in joint collaboration with Symbiosis Institute of Health Sciences, comprising of lectures,
presentations & examinations on 27 th - 28 th February 2014 & 1st March 2014.
Diabetic Association of India, Pune Branch arranged a lecture on ‘Prevention of Heart Disease’ on
02nd March 2014.
Department of Medicine, Poona Hospital & Research Centre organized the following CME’s on
1. ‘Polymerase Chain Reaction’, ‘ELISA’ & ‘Adult Vaccination’ on 22nd January 2014.
2. ‘Iron Deficiency Anaemia’, ‘Megaloblastic Anaemia’ & ‘Myelodysplastic Syndrome’ on 11th
February 2014.
3. ‘Hemolytic Anaemia’, ‘Polycythemia’ & ‘Aplastic Anaemia’ on 19th March 2014.
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DEPARTMENT
MONDAY
TUESDAY
WEDNESDAY
Dr. V. GUNDECHA
DR. A. BAHULIKAR
MORNING 10 A.M. TO 12.30 P.M.
P
O
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N
A
H
O
S
P
I
T
A
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MEDICINE
DR. N. M. BEKE
SURGERY
DR. R. S. DUMBRE
DR. D. JAIN
DR. A. PORWAL
GYNAE & OBSTETRICS
DR. (MS) S ANPAT
DR. (MS) S. KAKATKAR
DR. A. SHAH
PAEDIATRICS
DR. P. V. ALATE
----
DR. L. RAWAL
ORTHOPAEDICS
DR. R. KOTHARI
DR. A. DESAI
DR. R. ARORA
E.N.T. (10.30a.m.-1.30p.m.)
DR. A. M. ATHANIKAR
DR. (MS) V. SHIRVEKAR
DR. (MS) V. JOSHI
----
OPTHALMOLOGY
DR. (MS) V. RAWAL
DR. P. GORANE
PSYCHIATRY
DR. V. G. WATVE
DR. D. M. DHAWALE
DR. S. CHAUGULE
DERMATOLOGY
DR. H. S. CHOPADE
DR. S. TOLAT
DR. H. S. CHOPADE
CHEST DISEASES
DR. N. ABHYANKAR
----
DR. N. ABHYANKAR
ONCOLOGY
DR. S. M. KARANDIKAR
DR. S. M. KARANDIKAR
----
ONCOSURGERY
----
----
DR. S. MOHITE
11.30 A.M. TO 12.30 P.M.
CARDIOLOGY
DR. M. ASAWA
DR. S. SATHE
DR. S. HARDAS
CARDIAC SURGERY
DR. V. NATARAJAN (10.00a.m.to
DR. V. KARMARKAR 12.30p.m.)
DR. M. BAFANA
DR. V. NATARAJAN
DR. SHIV GUPTA *
DR. V. NATARAJAN
NEUROLOGY
DR. N. BHANDARI
DR. S. KOTHARI
DR. (MS) A. BINIWALE
NEURO-SURGERY
DR. P. BAFNA
DR. S. PATKAR
DR. N. LONDHE
NEPHROLOGY
DR. N. C. AMBEKAR
DR. S. V. UKIDVE (10-12 p.m.)
DR. N. C. AMBEKAR
URO-SURGERY
DR. S. BHAVE
----
DR. J. DATE
&
R
E
S
E
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C
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E
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O
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PLASTIC SURGERY
DR. R. GANDHI
DR. S. PANDIT
DR. R. GANDHI
GASTROENTEROLOGY (MED.)
DR. V. THORAT
DR. N. DUBALE
DR. V. THORAT
GASTROENTEROLOGY (SURG)
----
DR. R. TANDULWADKAR
----
ENDOCRINOLOGY
DR. M. MAGDUM
----
----
HAND SURGERY
DR. A. WAHEGAONKAR
DR. A. GHOSH
----
AFTERNOON 1 P.M. TO 3.30 P.M.
MEDICINE
DR. C. G. SHETTY
DR. (MS) A. SHAHADE
DR. (MS) G. DAMLE
SURGERY
DR. P. PRADHAN
DR. B. DIKSHIT
----
GYNAE & OBSTETRICS
----
DR. (MS) M. CHIPLONKAR
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VASCULAR SURGERY
OPHTHALMOLOGY
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DR. D. R. KAMERKAR
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CARDIOLOGY---NEUROLOGY
---DR. D. SASTE (2 to 4 p.m.)
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---DR. N. BHANDARI
SURGERY3.00 p.m. to 5 p.m.
DR. (MS) S. KELKAR
DR. (MS) S. KELKAR
DR. (MS) S. KELKAR
DR. H. PATKAR
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DR. S. SONAWANE
DR. A. RANADE / DR. A. BHAT
----
ORTHOPAEDICS 3.00 - 5.00 p.m. DR. S. SONAWANE
ONCOLOGY 2.00 p.m. - 3.00 p.m. ----
SPECIALITY CLINICS
HERNIA CLINIC 12.30 p.m. - 1.30 p.m.
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DIABETOLOGY 8.30 a.m - 9.30 a.m.
DR. (MS.) G. DAMLE
DR. B. B. HARSHE
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HEMATOLOGY 9.00 a.m.-11.00 a.m. ----
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PROCTOLOGY12.00 p.m. to 2.00 p.m. ----
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TT
THURSDAY
DR. V. G. SHAH
FRIDAY
DR. M. TULPULE
SATURDAY
DR. K. P. RUNWAL
SUNDAY
DR. A. TAMBOLKAR
DR. A. FERNANDES
DR. B. DIKSHIT
DR. S. SHAH
DR. A. FERNANDES
DR (MS) N. DESAI
DR. A. SHAH
DR. (MS) N. DESAI
----
DR. P. V. ALATE
----
DR. L. RAWAL
----
DR. R. KOTHARI
DR. A. DESAI
DR. N. NAHAR
----
DR. A. M. ATHANIKAR
DR. S. PABALKAR
DR. (MS) V. JOSHI
----
DR. R. BHANGE
DR. (MS) V. RAWAL
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DR. V. G. WATVE
DR. D. M. DHAWALE
DR. S. CHAUGULE
DR. M. DIXIT / DR. H. KULKARNI
DR. H. S. CHOPADE
DR. H. S. CHOPADE
DR. H. S. CHOPADE
----
DR. AJIT KULKARNI
DR. N. ABHYANKAR
DR. (MS) V. KHADKE
DR. J. JAIN
----
DR. S. M. KARANDIKAR
----
----
DR. S. MOHITE
----
DR. S. MOHITE
----
DR. H. GUJAR / DR. I. ZANWAR
DR. P. SHAH
DR. C. CHAVAN
----
DR. R. JAGTAP *
DR. V. NATARAJAN
DR. R. JAGTAP *
* By Appointment Only
DR. P. K. SHARMA
DR. S. KOTHARI
DR. P. K. SHARMA
----
DR. S. PATKAR
DR. P. BAFNA
DR. S. PATKAR
----
DR. S. V. UKIDVE (10 - 12 p.m.) DR. N. C. AMBEKAR
DR. S. V. UKIDVE (10-12 p.m.)
DR. S. BHAVE
DR. J. DATE
----
DR. S. PANDIT
DR. S. PANDIT
DR. R. GANDHI
----
----
DR. S. JAIN
DR. N. DUBALE
----
----
DR. R. TANDULWADKAR
DR. M. THOMBARE
----
----
----
DR. M. MAGDUM
----
----
DR. A. WAHEGAONKAR
DR. A. GHOSH
----
----
DR. S.V. NAGARKAR
DR. A. CHOPDAWALA
DR. A. CHOPDAWALA
----
DR. A. FERNANDES
----
----
----
----
----
DR. (MS) M. CHIPLONKAR
----
-------
-------
---DR. (MS) V. RAWAL
-------
-------
-------
-------
DR. (MS) S. KELKAR
DR. (MS) S. KELKAR
DR. (MS) S. KELKAR
DR. H. PATKAR
----
DR. S. SONAWANE
DR. A. RANADE / DR. A. BHATT
DR. H. PATKAR
----
-------------
DR. M. P. DESARDA
----
----
----
----
DR. B. B. HARSHE
----
DR. V. RAMANAN
----
----
----
----
----
DR. ASHWIN PORWAL
----
15
15
Rajasthani & Gujarati Charitable Foundation’s
POONA HOSPITAL & RESEARCH CENTRE
27, Sadashiv Peth, Pune 411 030.
Tel. : 24331706, 66096000, Fax : 24338477
DEPARTMENT OF DENTAL SURGERY
Timings
Monday
Tuesday
Wednesday
09.30 to
Dr. Paresh
11.30 a.m. Gandhi
Dr. Anjali
Gandhi
Dr. Shashikant Dr. Charudatta
Bamb
Naik
12.30 to
Dr. Mukund
02.30 p.m. Kothawade
Dr. Paresh
Gandhi
Dr. Mukund
Kothawale
03.30 to
5.30 p.m.
Dr. Surendra
Rathi
Dr. Shashikant
Bamb
---
Thursday
Friday
---
Saturday
Dr. Surendra
Rathi
Dr. Paresh
Gandhi
Dr. Mukund
Kothawade
Dr. Charudatta
Naik
Dr. Shashikant
Bamb
Dr. Surendra Dr. Anjali
Rathi
Gandhi
CASHLESS FACILITIES
TPAs : The following TPAs (Third Party Administrators) have a tie up with Poona Hospital
for their members to avail of the treatment facilities provided by the hospital.
* Medi Assist India Pvt. Ltd.
* Genins India Ltd.
* Medicare TPA Services (I) Ltd.
* Park Mediclaim.
* MD India Health Care Services Pvt. Ltd.
* Raksha TPA Services.
* Paramount Healthcare Services Ltd.
* Dedicated Health Care Services.
* Health India (Bhaichand Amoluk Ins.)
INSURANCE COMPANIES : Poona Hospital also provides cashless facilities to
policy holders of the following Insurance Companies
* ICICI Prudential,
* MAX BUPA Health Insurance
* Bajaj Allianz Gen. Insurance Co. Ltd.
* Cholamandalam MS Gen. Ins.
* Future General Total Insurance Solutions
* Religare Insurance Co. Ltd.
* Star Health & Allied Insurance Co. Ltd.
* Apollo Munich
* IFFco Tokio General Insurance
* Reliance General Insurance
* ICICI Lombard General Insurance (I Health Care),
1616
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Continued from Page 8....
who will receive perioperative radiation therapy.
In general, thesepatients should undergo an
autogenous or delayed reconstruction.
Side view of breast area with unfilled tissue
expander in place.
A - tissue expander–unfilled
B - port
C - catheter
D - syringe
E - ribs
F - pectoralis major muscle
G - Other muscles of the chest wall.
Side view of breast area with filled tissue expander
in place.
A - tissue expander–filled
B - port
C - catheter
D - syringe
E - ribs
F - pectoralis major muscle
G - Other muscles of the chest wall.
Latissimus Flap Breast Reconstruction
The latissimus dorsi musculocutaneous flap was
originally described almost a century ago as a
method to cover radical mastectomy defects which
included a wide skin excision. In recent years,
there has been a resurgence of the latissimus flap.
Improvements in tissue expansion and implant
design, as well as the ability to perform complete
autologous reconstruction in selected patients has,
once again, put the latissimus flap in the forefront
of breast reconstruction.
Indications
The latissimus dorsi flap is a good option for
women with small - to - medium sized breasts
because there's usually not much fat on this part
of the back.
Post mastectomy defect
Pre operative patient with LD muscle
LD muscle swung anteriorly to
reconstruct the breast mound
19
Reconstruction with Pedicled LD muscle
flap with nipple/areola graft
Nipple reconstruction with skate flap
Nipple Reconstruction and Tattooing
The final stage in breast reconstruction is creation
of the nipple-areolar complex (NAC), which
carries aesthetic and psychological importance
to patients. The current trend is the use of local
dermal flaps along with tattooing. These methods
have proven to be cost-effective and carry low
morbidity.
3-6 months after breast reconstruction in order to
achieve stable breast volume, overlying skin and
contour.
Conclusion :
The wide variety of choices in breast
reconstruction and increasing expertise has made
breast reconstruction a feasible option to offer
to our patients. The increase in awareness and
patient demands have resulted in an increase in
the number of reconstructions. Further awareness
is needed to educate the patients so that breast
reconstruction becomes a part and parcel of the
breast cancer management protocol.
Indications and Timing
A patient undergoing NAR can have nipple
creation and tattooing performed simultaneously
or as two separate procedures.
It is recommended to delay NAR for approximately
q
q
q
One afternoon, a man went to his doctor and told him that he hadn’t been keeping well lately.
The doctor examined the man, left the room and came back with three different bottles of pills.
Then he gave the patient the following instructions: ‘Take the green pill with a big glass of water
after you wake up. Take the blue pill with a big glass of water after you eat lunch. Then just
before going to bed, take red pill with another big glass of water.’ Startled at being put on so
many medicines, the man stammered, ‘My God, Doctor, what exactly is the problem with me?’
The doctor replied solemnly, ‘You’re not drinking enough water.’
20
Chemo PORTS
Dr. Saurabh Mohite *
Chemotherapy is now an integral part in the
treatment of breast cancer. As a rule, almost all
cases of breast cancer, regardless of the stage of
disease, benefit from chemotherapy. It is used in
the neoadjuvant and adjuvant settings, and with
curative and palliative intents.
How Is a Port Inserted ?
A major problem in the administration of
chemotherapy; and also a cause of significant
morbidity, is securing intravenous access. The
veins on the operated side cannot be accessed
due to risk of thrombosis. Besides, almost all
chemotherapeutic agents are cytotoxic &can cause
significant thromophlebitis & tissue reactions on
extravasation. The veins may not be accessible
in the obese or in children. Patients who have
undergone bilateral breast surgery obviously
cannot be administered chemotherapy through
peripheral lines.
During insertion, a small round metal or plastic
disc is placed under the skin through an inch-ortwo-long incision. This may be located on the
upper chest or occasionally the upper arm. This
port is then attached to a catheter tube that is
threaded into one of the large veins near the neck,
such as the subclavian vein or jugular vein.
Usually a day care procedure, PORTs are
usually placed at least a week before the start of
chemotherapy. They can also be safely placed at
the time of primary surgery for the cancer, thereby
reducing costs and hospital stay.
A Chemo PORT is strongly recommended in all
of the above.
What Is a Port for Chemotherapy ?
A chemotherapy port (also known as a port-a-cath)
is a small device that is implanted under the skin
to allow easy access to the bloodstream. A port
can be used to draw blood, infuse chemotherapy
drugs and for transfusion of blood products.
*Consultant Oncosurgeon, E-mail : saurabhmohite1@gmail.com , Cell : 9220451093, 7387000081. 21
After the port is placed, a slight protrusion is
noticed over the chamber site. During blood draws
or chemotherapy infusions, a needle is inserted
into an area called the "septum," a resealing
rubber/silicon center on the Port. Since the port is
completely under the skin, the patient can bathe
and swim without being concerned about getting
an infection.
• Rare (less than 1%) complications of insertion
can include bleeding (such as if the subclavian
vein is punctured) and pneumothorax (collapse
of the lung)
Benefits
• Greater comfort – A single needle stick through
the skin is usually all that is needed to access
the port. With IV therapy and traditional blood
draws, sometimes many needle sticks are
needed to find a good vein, especially if the
veins have been damaged from repeated blood
draws and infusions.
• Thrombosis – A clot may form in the port or
catheter, causing it to stop working. Between
12 and 64% of people who have a port placed
for chemotherapy will develop a thrombosis
(clot) in the catheter (often causing a need for
the port to be replaced.)
• Avoiding delays and multiple needle pricks in
attempts to secure a good peripheral IV access
• Lowering the risk of "extravasation" – When
an IV is used, medications are more likely to
leak (extravasate) into the tissues surrounding
the hand or arm. Since many chemotherapy
medications are caustic to tissues, a port can
reduce the risk of inflammation related to
leakage of these medications.
• Easier bathing and swimming – Since a port
is completely under the skin one can usually
bathe and even swim without being concerned
about the risk of infection.
Possible Drawbacks
• Infection – The risk of infection varies in
studies but isn’t uncommon. If a port becomes
infected, it will often need to be removed and
replaced.
• Mechanical problems that cause the port to
stop working – In some cases mechanical
problems, such as movement of the catheter or
separation of the port from the skin, can cause
a port to stop working.
• Limitations in activity – Though activities such
as bathing and swimming are usually okay, the
oncologist may recommend holding off on
exercises to strengthen the upper body or arms
until the port is removed.
• Scarring–Given the gravity of cancer treatment,
a scar from the port is a relatively minor
drawback. But some people may find a scar
on their upper chest disturbing for cosmetic
reasons or because it is a symbol that they once
went through chemotherapy.
Possible risks include :
• The risk of the surgical procedure to install the
port.
q
q
q
Having recovered from a serious illness, Nikhil had gone for a final checkup to the doctor.
Smiling brightly the doctor said, ‘Young man, you owe your fine recovery to your wife’s tender care.’
With a twinkle in his eyes Nikhil replied, ‘Thanks doctor. I will make out the cheque to my wife.’
22
Use of Hydroxyurea with Wheatgrass in
Thalassaemia Major / Intermedia
Dr. Vijay Ramanan *
Introduction
B-thalassaemia is caused by mutations in the
β-globin locus resulting in loss of or reduced
hemoglobin A (HbA, α2β2) production.
institutional resources. In economically challenged
nations, basic management (red cell transfusions,
iron chelation) is a distant dream for the majority,
who, consequently, endure a poor quality of life.
Hydroxyurea, an antimetabolite, is a potent
inducer of HbF production.
Aims and Objectives :
To study the effect of hydroxyurea and wheatgrass
in reducing the frequency of blood transfusion.
Mechanisms :
1. A cytotoxic effect resulting in stress erythropoiesis, with increased HbF levels occurring as
a result, is most commonly proposed.
2. More complex effects involving the production
of nitric oxide and the soluble guanylyl
cyclase and cyclic guanosine monophosphate–
dependent protein kinase pathway gene have
been proposed as being responsible for this
activity.
Hydroxyurea therapy is not associated with
considerable or steady effects on erythrocyte
deformability in β- thalassemia, which may
explain the reduced response to the drug in some
patients.
Wheatgrass contains Chlorophyll which makes
up >70% of the solid content of wheat grass juice.
Both chlorophyll and hemoglobin share a similar
atom structure. Hemoglobin consists of iron, while
in chlorophyll the metallic atom is magnesium.
The believers of alternative system of medicine
claim that as chlorophyll and hemoglobin are
alike in atom structure, intake of wheat grass
juice enhances hemoglobin production.
The treatment of transfusion dependent b-thalassemia
imposes a considerable burden on the family and
Materials and Methods
The study was carried out between January
2008 and June 2013 on 74 patients diagnosed as
Betathalassaemia by HPLC.
Randomly selected 74 patients with transfusion
dependent B-thalassemia, were recruited for the
study.
Patients were enrolled irrespective of whether
they were receiving chelation therapy with
defiriperone /desferrioxamine or not.
A medical doctor exclusively on the roll of
thalassemia center maintained records of the
study subjects.
Exclusion criteria :
1. Indiscipline in intake of wheat grass and
hydrxyurea tablets. This included interruption
in intake exceeding 3-days/week or more than
7-days month.
2. Hydroxyurea was not administered below 2
years of age.
Methodology
• Our index case gave me insight into follow up
in these cases. He had been transfused for over
30 years but first transfusion was after 1 year
of age.
*Consultant Haematologist, E-mail : mvijayr@gmail.com , Cell : 9325315471.
23
• I realised the real effect of Hydroxyurea +/Wheatgrass can only be judged by allowing
the hemoglobin to fall upto 5 to 6 gm% with
pulse rate never crossing 120/min.
• This level allows the inherent hemoglobin
synthesis to start i.e HbF synthesis. If a patient
doesn’t receive transfusion for over 3 months
then it translates into
TRANSFUSION INDEPENDENCE
Patients have better energy levels in general. They
don't become unenergetic close to their previous
transfusion period.
Patients without palpable spleen, those who
underwent splenectomy as well as those who
required first transfusion after 1 year of age could
become transfusion independent to great extent.
There are 3 children who presented at age of 5 to 7
months, who have received wheatgrass and have
not been transfused for 12 to 14 months. Meaning
a Thalassaemia Major can probably be converted
to Thalassaemia Intermedia with Wheatgrass
alone or with Hydroxyurea.
bmtpune@gmail.com
09923693304 / 09890661341 / 09325315471
www.vijayramanan.com
Download - Anemia Diagnosis App
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Doctor : What’s your problem?
Sardarji : I keep forgetting things.
Doctor : Since when you had this problem?
Sardarji : What problem?
24
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*Consultant Oncosurgeon, E-mail : saurabhmohite1@gmail.com , Cell : 9220451093, 7387000081. 25
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