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Breast Conservation Surgery

Oct 18 | 2:00 PM

The rapid growth of breast conservation therapy has significantly changed the management of early breast cancer with outcomes shown to be equivalent to mastectomy when combined with radiation. Surgical management remains the standard of care for non-invasive and localized invasive breast cancer, which may get combined with systemic endocrine therapy, chemotherapy, and/or radiation. Identified advantages to breast conservation therapy include reduced operative time, diminished psychological burden when compared with mastectomy, improved cosmetic outcomes, and limited side effects. Lets get some interesting insights on breast conservation surgery with Dr. Sandeep Nayak.

[Music] good evening everyone i'm dr niveda from netflix and on behalf of netflix i welcome you all to today's session on breast conservation surgery today we have with us a very well known or surgical oncologist from bangalore dr sandeep naik he is the director and hrd of surgical oncology at photos hospital he is known as the pioneer uh in advanced laparoscopic uh surgeries uh like the minimally invasive neck dissection in india and he's also introduced a robotic assisted breast taxillo in suffic insufflated thyroidectomy in india as well along with that he is also associated with ngos unlike the connect to heal and indian cancer society and he conducts regular awareness camps where he spreads the message of early detection and cure thank you thank you [Music] nice like i i don't know you know the type of gathering here would be the resurgence and predominantly uh general surgical students as well i guess so what i have done in my presentation is there are key points which are essential for everybody to know about you know oncoplastics basically breast conservation surgery and the congo plastic techniques which are required in giving sufficient cosmesis so overall my presentation will be hovering around or rather the learning objectives of this presentation are the history and the science behind the breast conservation surgery how to plan a breast conservation surgery what are the key points and how to manage the axilla because axilla is a very important part of breast conservation surgery so ah as we are managing the malignancies very it's very important and at the end of the day uh cosmetic outcome is very important and as i told you this presentation would be focusing on general surgeons in mind so [Music] sorry so why is breast cancer so important it is important because we because of the numbers that we are seeing in fact in india as of today breast cancer is the most common cancer among indian women so if you this is a southeast asian data it is you know as such about it's constituting about 25 of cancers among women and if you look at overall also it is one of the most common cancers in the society today so it's very important that you know all everybody knows how to manage it so manage it satisfactorily now there are two clear aspects of managing a breast cancer and these are the management of the primary disease and the management of the axilla so there are two different aspects and we need to understand the two separately because if uh if the results you know results depend on the way you manage these two satisfactorily it's very important so we will be first dealing with the primary tumor and towards the end of my talk i will talk about the lymph nodes so dealing with these two constitutes the complete surgical aspects so uh so how has you know before doing that i would be discussing as to how the breast cancer scenario has you know evolved over the years see in actually radical mastectomy started was actually started by william halstead in the year 9 18 1894 that's when the first radical mastectomy was performed so from then on the in fact initially there were some surgeons who did an extended mastectomy also because they wanted to remove portion of chest wall and a lot of other things thought processes came up and over time uh you know people started realizing that those extensive surgeries are not going to help the results are similar if you do less and it took nearly 60 years somewhere around 1948 is when parties that modified the radical mastectomy to modified radical mastectomy so there are various modifications there are three main modifications and most batteries is one of the most commonly used modification that we all use so modified radical mastectomy came into existence in 1948 now that you know when the results started popping up and people realize that you know not much has changed for the patient the outcomes are similar then the thought process started evolving towards you know can we do less because the results seem to be similar so they started doing less and less with similar results and that's when you know a further trial started in the 1970s i'll show you another slide which is showing you the uh trials this slide will tell you about the various trials which finally constituted starting from the 1970s the nsa bp the b04 this is a trial which tried out whether mastectomy it compared the breast conservation surgery with radical mastectomy so the uh the you know overall result uh sorry you know radical mastectomy uh with less extensive surgery was nsfvp04 which actually established the modified radical mastectomy and then further studies came up 1976 nsa bpp06 which studied breast conservation surgery again the result said it is good you know it is good to go it was published in 1985 actually but results categorically told that there is no uh inferiority of for breast conservation surgery again breast conservation surgery was always accompanied by radiation so it was essential to add radiotherapy in all these cases so then on multiple trials came and it went on establishing the equivalence of breast conservation surgery and uh you know then people started thinking until till uh you know say about 1990s we were always thinking that you know breast can be saved but we need to completely remove the axilla but over time the evidence started favoring even sparing axilla in fact they started looking at the data of nsa bpp06 trial and saw that when in some cases the you know radiation sorry then lumpectomy alone was performed without axillary dissection uh the results the survival was similar for all the patients you know even when the axilla was not addressed the patients did not have a reduced survival they had if they returned they had their axilla had to be treated so that is what they realized and and that's when they started thinking do we really need to treat axilla aggressively so the thought processes started changing and a lot of trials came up to reduce the axillary dissection which were like the you know almanac trial zero one one trial and all those trials started coming up and then the further reveal evidence uh came up completely eliminating axillary infrared sections when the lymph nodes are negative even up to the patients where one to two lymph nodes are positive on central biopsy also there are places there are there are centers today who do not do any further uh axial lymph node dissection so and finally there are you know thought processes wherein you know a lot of more things are coming up wherein the question of can we totally avoid you know exactly for dissection is being tried out by some centers and also there are places the thought process to avoid surgery altogether in patients who are you know complete responders to chemotherapy are also there so these are all various thought processes because we are looking to do less and less with similar results as of today but as of today the standard of care for breast cancer remains surgery now what exactly constitutes you know breast conservation surgery as far as the milan guidelines are concerned melancholic guidelines are considered the standard for breast conservation surgery so what is it defined as it is a complete removal of the breast issue with the concentric margin of surrounding healthy tissue performed in cosmetically acceptable manner usually followed by radiotherapy basically they are talking about the normal sorry abnormal breast tissue along with a healthy margin and as of today remember you know in the histopathological report if the margins are negative negative inked margin of the breast lump that is considered adequate surgery for the breast lump we are not talking about the electron dissection here we are only talking about the breast surgery alone okay so that is the important you know that is the point here now what are the uh but you know it is not just removal of the lump which is more important over here you know at the end of removing the lump if the results look like this with the cut rest it is better to do a mastectomy like what is shown on the uh you know the picture on the right side so so finally it is very important that you you are cosmetically depressed these things should not happen and that is where your planning comes into a play so this is a very important thing uh to remember this is you know the this is a consensus definition and classification system for oncoplastic surgery like american society of breasts americans because know loss of by weight like you know 200 gram 100 gram loss of weight but the thing is every breast is not the same so if you try to classify it based on the volume by weight it is not going to uh make sense because you can't make your decision so this is a good way of classifying based on the volume loss so it goes from you know level one oncoplastic surgery is 20 uh breast tissue removal and level 2 is 20 to 50 percent and these two that is level 1 and level 2 are treated by level sorry volume displacement they do not require a volume replacement anything above 50 50 percent of breast loss we need to do a volume replacement we have to get volume from somewhere else to replace it so that is the that is the key thing here so we look at the our main discussion will be about the volume displacement which is a very easy thing to do for most of you so we will not be i won't focus too much on the other aspect that is volume replacement which will require a specialized unit so how is it again this is the same thing which is being reiterated but you see most of the what is important here is you know when there is up to 20 percent breast tissue wide local excision with the closure of the cavity is usually adequate and it is 20 to 50 percent white local exhibition with immediate reconstruction with or without various things whereas techniques are required and third one is about mastectomy wherein we have to do a reconstruction if the patient is wishing to do for go for it now let's first discuss the level one types of incisions this is how you have to place remember level one surgeries you don't need to remove much of you know lose the skin uh because you know skin the tumor is not very large your volume is very small so primary closure is enough so in these cases you don't need to remove much of the skin paddle along with the tumor when you are doing a level one section in a uh i'm sorry level two we are losing some bit of the skin as well so these are various incisions which you can place the donut incision lollipop incision anchor crescent shaped incision so these are the various incisions which can be best to give a good cosmetic appearance there are other incisions like the radial incision or the circum areolar incision so any of these incisions are good enough to give you quality scar and give a good results so but always remember around the breast you know other way to put this is to look for the uh you know the you know skin threes lines so that you know you don't cause any much of a scar issue now how are these level one you know resections performed this is very uh very important to know this this picture picture tells you know how it is done first once you put a wound it is important that you raise the flap on either side of the tumor so you look at this first part of the first picture the the skin flap is raised and once the skin flap is raised then in the picture too we remove the tumor it is removed like a cake if you saw the previous picture you can see the picture here in this you can see how the tumor is removed like a cake it is not removed like uh just the you know there are no very fat you know around everywhere it is taken out in a block single block so that is very important so once that is done you remove the cake of tissue with a good healthy issue all around our em when we are resecting is usually one centimeter margin the pathologist may say it is only one millimeter because there is tumor infiltration but our aim is usually to get around surrounding one centimeter once that is you know see once the lump is removed you go under the breast tissue and mobilize the tissue under along the chest wall so that the breast tissue can be moved easily and once that is done you put sutures to close that cavity so that is how you get a cosmetically acceptable appearance otherwise there will be a shrinkage of tissue once the once radiation is given because seroma is going to shrink in okay so these are some of the incisions you saw this is the lollipop or sorry this anchor incision and for a tumor above it can be circumvent aerial or incision also or an incision along the tumor it is an option which is there either of the two is good enough now yeah can you show the video is it possible is it playing well yes [Music] so you know elliptical incision i am taking out some bit of a skin over here in fact it may or may not be required many times but there was a scar probably that's why i have taken that once that is done the skin flaps are raised on either side that is very very important because if you don't just materials don't come out very well so even in a small tumor it is very important that the breast mobilization breast tissue mobilization happens okay so that is the mobilization all around it is done upper flap as well as the lower flap laterally as well so so that gives a good mobility to the breast tissue so once this is done as i told you you uh you know you look look for the margin keep your fingers on the tumor so that you know you know that you know you are giving sufficient margin so with with with keeping your finger on top of it you go and cut the uh breast till the chest wall or the pectoral not chest wall sorry pectoral pectoralis major pectoral fascia not just wall sorry so now you can see i'm going to the chest in a pectoral muscle so all the while feeling that you know the tumor is complete so that is a pectoral fascia so now it is just taking the entire tissues all around giving a healthy tissue margin all around so that is the so that is the tumor so once this is removed we can perform uh the axial infrared section if indicated this can go for a specimen mammography or it can go for a frozen section if margins are doubtful in this case i don't think i needed it this is a very old video i think more than 10 year old video [Music] i think you would have just followed it a little i think you know we won't be talking about the axial lymph node dissection uh does anybody want me to discuss the agile infrared section here can the audience you know give any feedback or anything in this system so they can put it in their comments actually so if you all want so to talk about it please put it in the comments and then we can continue with it i don't know whether they can see the video very nicely or not because yeah so that is the completion you can see the pectoral muscle at the bottom over there so you can see that's a pectoralis major so this is the tumor cavity so this is as such an upper outer quadrant tumor in many upper outer quadrant humans it's possible to yeah see very important to mark the specimen specimen marking is very important usually what we do is a short superior and long lateral is what we do and this is an accessory dissection video not the central node biopsy today we are doing most of the patients we do we perform the central node biopsy central node biopsy i'll show you a video later on so in many patients where we do you know lumpectomy sometimes nipple repositioning may be required but more than in this type of uh smaller lungs in a larger lump it is very important to perform so now coming to the uh you know in the incision placements which we discussed for benign tumor benign tumors as well even the multiple life is scattered across instead of giving multiple incisions it's a good idea to do a round block kind of a incision around the nipple and this is what we generally do we don't place multiple incisions if it's uh multiple fibroadenomas large fibrones that have to be exercised we go in a round block kind of a thing or a donut kind of an incision so it gives good results now coming to the uh that was a level one uh you know reconstruction wherein less than 20 volume was lost this is a level two whenever there is level two resection that is required uh we have to remember a few important points so uh the easiest to reconstruct in this area are the lateral especially the up outer upper outer quadrant tumors are very favorable to you know cosmetic result but the less favorable are the lower inner lower half itself sorry inner half of the breast itself is more difficult but it gets more difficult when we go further down um so what are the skip you know what are the options that are available to us so there are various options which we will look at as we go on because each area see lateral upper outer quadrant has a good amount of breast tissue so the glands are better over there so it is it gives a better uh thickness for the tube you know for us to resect and reconstruct but when it comes to the inner half of the breast the breast volume is thin so it becomes difficult to reconstruct so it tends we don't tend to get a good a good volume of tissue in this those areas so that is why the difference comes so we can look at you know first we will start with a lower pole put marked over here lower core tumors means the center tumors so the central lower for tumors what are the options we have the superior medical mammoplasty and inverted or vertical scar mammoplasty these are the two options we remove the central portion of this area create the two flaps we get the flaps together and we reconstruct whenever actually whenever we do a level 2 there is a significant volume loss so ideally we should reconstruct the opposite breast also but what we generally do is we wait for the radiation to come complete so that the scar tissues formation is okay and then we do the reconstruction or reduction mammoplasty for the opposite rest we don't do it at the same city in our practice so this is how it is superior medical mammoplasty is performed like this okay so i'll show you a picture of real kids see this is how it is the tumor is located in the lower midline over here so incision is placed all around the nipple over here you can see in the incision as the one once the tumor is resected this area is resected what is done around the nipple is it is called uh it is epithelialization which we perform we don't really remove the full thickness of the skin it is up to the dermis and once a dm realization is done only we place the stitches all around it to close the you know dermis to the sorry the epithelium to epithelium so that tissue the dermis goes inside and as the uh we get a cosmetically acceptable result you can see the result over here so then see this difference in the placement of the nipple can be adjusted later on by doing a reduction normoplasty of the opposite breast just the adequate change we can we have to plan so okay so for in other situations where the tumor is you know we want to hide the scar all together there is an option to put an infra memory crease incision go and reset and reconstruct mobilize the entire breast tissue reconstruct and close the entire breast tissue that is feasible and it gives a fairly good result for the inferior quadrant or inferior pole tumor so that is these are two main approaches you see i am only showing you what we practice here so there are many other things which can be done for lower inner quadrant tumors which are again a difficult area to reconstruct what we do is a superior medical so this is the area we are talking about so how is this planned uh see you can see it's a lower inner quadrant so we incision is similar but the latin scar is longer so we have to reposition the nipple laterally because the entire breast issue moves medially so this is how you plan it and the results are you know cosmetically usually acceptable see with this small production in the society so it is uh concept you can see it here so it's later this is called a j mammoplasty because it looks at the end of the surgery the incision looks like j this is the jmr plasti you can see we have done actually we can we need to put an incision sometimes under the intra memory crease also but many times we can do without that so this is the j shape which we are seeing so the results are cosmetically acceptable see this here if you see in the first picture we have done the lumpectomy and we have removed the uh you know epidermis it's the epithelialization of the tissue all around when we close that entire tissue closes we get a good approximation so that is the idea this is again a rash mammoplasty for the absolutely you know lateral too much so you can see it's a racket in this racket shape so this also gives a good cosmetic appearance for a patient so there are times when we do a specialized different kind of a flap which is again a local flap in fact this is a general surgeons means you know as our surgical oncologist can fashion this plant this is a facial continuous flap from the infra memory crease so this flap can give a very good cosmetic result you can see you know it's an intra memory uh tissue which we are removed for an outer lower outer quadrant tumor and it gives a cosmetically acceptable result in fact the results are sometimes better than doing a mammoplasty so for the upper outer quadrant tumors this is an easy area to recuster comparatively there are multiple flaps we generally use a rasher flap in these moisture most basically we use what is called as a round block technique again here we are losing we'll remove some bit of skin around the nipple so that you know we get a you know we reduce the entire breast volume so that we need to come compensate for that we go all around the breast and exercise the skin you can see in this marking i don't have other pictures i think in this or maybe in another picture later on i'll show you uh yeah so this is again a rashy incision you can see it's an upper outer quadrant tumor and we put a racket on and when you close this is the result so when this car means one scar will be there so this is a typical incision [Music] so this for upper outer quadrant is same you know uh for upper you know we can also use what is called as a batwing mammoplasty in fact i have a better picture of this than this so you can see the marking is bad so any tumor in this region either this coil of upper outer midline or upper ear we can use this battery plus to show you another picture little later so upper pole and upper inner tumors so main reconstruction is usually using battering mammoplasty so these these upper inner and upper uh midline are again little tricky tumors to reconstruct but see this is a good picture of the what is called as the uh round block technique so we have if you zoom in you can see we are gone all around the nipple the primary tumor is removed with the incision so this bit of epithelium is removed and when we close this is the only scar that will be left around you know there is no evidence that any surgery has been done for the patient you can see this scar over here the final result so there is hardly any evidence that any surgery has been done it will be just a small scar around the breast tissue around the nipple areolar complex so so when it comes to again a bad wing mammoplasty this is the batwing thermoplastic we remove the same concept we there's some midline tumor we remove the breast tissue from the midline you can see we have b ap theorize the tissue around the nse nipple areolar complex and this you know two wings of the bat compensate for that tissue which has been removed and this is the result of the final result of the reconstruction here you know whenever we de-epithelialize we have to be very careful to not to damage the sub dermal venous plexus because you may compromise the blood supply of the nipple areolar complex so it should always be you know deep realization should be at the level of uh you know dermis so you know this is not a part of our present today's discussion because i am only talking about oncoplastic because breast itself is a very huge topic so but whenever the defects are larger and the surgeon is not satisfied that you know we can give cosmetically good results latissimus dorsi flap is a very good option uh along with uh prosthesis or without processes can be used very often we'll you know we perform this on regular basis but many will require plastic surgery involvement and apart from this whenever we have to perform a total mastectomy or skin sparing mastectomy or nipple area or aspiring mastectomy a reconstruction is very ah becomes very important and this generally as of today we prefer to use what the procedure i know we prefer to use a free flap which is a diep flap that is a deep inferior epigastric perforator flap which is a free flap which is you know taken the tissue is taken from the lower part of the anterior of down wall and the breast reconstruction construction is performed using that you can see the first picture is mar has marked the diep perforators and the skin you know whatever we are going to lose has been marked then finally this is the result but this can be this will be remodeled as we go on and we can even tattoo the nipple areola complex so finally very another very common question which comes you know larger tumor and presentation is it okay to go give new adjoint chemotherapy and perform breast conservation surgery as per most of the guidelines it is acceptable to do that especially for larger tumors where the patient wants to go for breast conservation it is acceptable to go for neoadjuvant chemotherapy and vss afterwards but very important thing to remember for you is to that you should always place a fiducial or a clip what we call and the clip placement usually is we always perform we put a clip in the center of the tumor not at the periphery as of today that is the standard place it in the center one or two clips and finally you in when we do a resection we should do a this is a resection specimen we do a specimen mammography to prove that the tumor has been removed remember very often many of the tumors in in today's chemotherapy nearly 40 percent of the tumor the cancers will have no palpable tumor at the end of chemotherapy so it becomes essential that you uh you know keep a clip because clips can be identified even with ultrasound on table during surgery so ultrasound becomes important on table identify the area and then do a removal of that particular area so otherwise you know you can't palpate so this is how the hip placement is done we do it the surgeons ourselves we do it during when we put for the you know we put a chemo board for new joint chemotherapy at that time we play secrets so very once we have learnt what is to be done it is very important to remember that there are some contra indications which you should remember so it's mainly because of the requirement of radiotherapy uh for every conserved breast that we have to think about whether this patient is suitable for radiotherapy or not so uh so in a pregnant lady it becomes a big no whenever we see definitive micro calcification across the breast again it is a high risk for multiple primary so that becomes a contraindication so there are these are very standard guidelines okay so white flood disease is a different contraindication for pcs they are all absolute contraindication diffuse pathological you know margins becoming positive repeatedly during surgery so those cases are also a contraindication uh some heterogeneous mutations of some genes like p53 atm g these genes are also a contraindication because in these patients if you radiate they develop second malignancy so others are all relative contraindications prior to small radiation for some other cause active connective tissue disorder like in scleroderma lupus sle all these things are a contract relative contraindications so you can always consider so there are so many others which are available online you can always you can find this in this is from nccn guidelines so you can find it easily so [Music] so apart from this what is very important is to how do you treat axilla because axilla is very important because if you do complete lymph node dissection level one two three four dissection nearly forty to fifty percent of the patients end up with uh you know upper lip edema sometime during their uh life so it can be gradually increasing over time you know see it can be from a stage one to stage four edema wherein the elephant tiatic limb becomes a useless limb so this is the you know to in order to prevent this the best way to prevent which gets one to two percent is to perform sentinel node biopsy uh central node biopsy i have a video which i can show but i think you know because they are showing it through a camera it is may not be very clear let us try it out but there are two aspects of it whenever a complete lymph node dissection is required actually in front of the section we perform what is called as a reverse mapping so reverse mapping is we give it in a central load biopsy we give a injection in the near the tumor or in the nipple areolar complex and trace the lymphatics coming from the breast to the axilla whereas in reverse factoring we inject the dye in the arm and look for the lymphatics coming from the arm in order to share the arm lymphatics and remove rest of it so that is the difference between the two uh see you can show the uh will you be able to show the video this is central important it's a double die technique [Music] the standardized guideline today is to inject in the uh you know subcutaneously in the nipple areola complex we for methylene blue generally we give it at the four spots around the nipple area complex so you can see this and we do not use a radio collide before it used to be radio collide today we use what is called as endocytin green we have this technique technology available widely so indo-cyanine green is used indoor sign in green very small quantity about you know one nimble is only required so half an ml in the at two locations only we don't give it too much because the dye in fact will impair your see this is how indoor signing is green is seen on a specialized camera you can see the dye flowing towards the axilla once you have given it see now this is through the surgery you can see that you know that blue or blue dye now once that is senior this is the endocyting green you can see a strained node so that is a central lymph node so that central lymph node is isolated and removed you can see you know whereas the different color settings are there so that lymph node is removed and it is sent for we generally as of today we are sending it for central you know you know biopsy or frozen section and there are centers in the world where they don't do it they simply you know remove the central node and proceed across the you know axilla also because they believe that you know it does not matter if it is positive the outcomes are same so that is the positive node not so sorry the lymph node or what is called as hot lymph node or central new node so this lymph node is sent for testing a histopathology are sent in a bottle marked and sent in a bottle and after that we continue with our rest of the procedure now how do we do reverse mapping this is it doesn't show the next go to the next video so this is for reverse mapping which we are performing a complete lymph node section so this is the technique which we follow we inject into web spaces in the arm sorry hand and then as we perform the lymph node dissection in the axilla we look at this lymphatics coming from the upper limb into the axilla see endocyting grid travels very fast it's not like the medium block so we need to we can't give too much time between the injection and this one so sometimes we are in fact this is not a perfected technique till date in fact there is not much of evidence but we have been doing it so we do inject in two areas we have been trying to inject into areas and see how the results are that as of now we are not going to discuss here so we can see the flow of the dye towards the axilla so once we see the in fact this is become camera all over camera so like it will be difficult to see so as we as the dye moves into the axilla yeah you can see the lymphatics above the axillary vein you can identify the axillary vein over there you can see the green color dye above it which is going towards the this one so that is the lymphatic coming from the upper limb so we have spared it very uh convincingly in this case so this patient is less likely to develop a upper lip edema because of axial lymph node dissection let's move to the slides so after any breast conservation surgery it is important that the patient undergoes radiotherapy so uh today external before beam radiotherapy is a standard of care so when this comes this this radiation can be performed in a single sitting patient does not have to come back because radiotherapy in the least number of days it will take is two weeks and up to you know five weeks it can go on so with in fact many patients refuse breast conservation because of that reason alone so in those good risk patients where it looks good to go ahead so there is a possibility of intraoperative single sitting radiotherapy and completing the completing the complete course of treatment in single sitting so it's possible today we are looking forward to this is a different technology in fact we will be getting it in fact it's something new in india this is the first time so uh so this is the last slide at the end of the day the final message is that you know what we are doing was the purpose of saving breast is to give the normalcy to the patient who is suffering so finally it is the quality of life at the end of it so the cosmesis becomes very important because many of these patients whom we are treating the breast has no other purpose other than cosmesis because they are all older patients in the patient also it becomes very very important to give a good quality of reconstruction whenever they come so thank you very much thank you so much for that presentation um so if you all want to ask questions to sir y'all can use the raised hand options we have one question here it is uh what should be the maximum size of the breast tumor to do a breast conservation surgery it all depends on the you know the breast to tumor ratio it's you know you you don't have an absolute uh size so breast tube breast tumor to the breast volume ratio is what matters if it is adequate you know if you are able to leave a liquid you can go ahead there is no upper limit like that okay is it possible to remove the breast clump without removing the skin flap is the whole question i guess it is possible if it is a smaller less than 20 volume loss it is possible to do without removing the pattern it's all in the volume so if it is less than 20 percent of the breast volume you can easily do it without any problem i hope that answers your question hello so myself dr vijay lakshmi from karnataka actually i'm a ba ms doctor uh so for lump removal i think we can use cytokine tablet we have cytokine tablets that controls our cancer and mitosis and meiosis can be controlled from that medicine so without surgery i have absolutely no idea never heard of it like in cancer there is a more cell division so during cancer we have we have learned in pathology that cancer will uh cause more cell division so i think cytokine tablet can be used with our okay i have no idea about psychopaths speciality medicines like homeopathy or any other things we cannot really know what they do but at least in one thing i know about this you know in ayurveda the standard of care for any tumors was surgery because sushruta and all those people practice excellent results so and most of the medicines standard medicines which is which are there the standard of care is surgery so only any alternative medicines which come up it is only for patients who are not able to go for any kind of therapy alternative medicines may be an option because the concept of modern medicine is today to accept everything and you know start giving results because many of the you know horrible remedies have been further researched and we have incorporated for example what what is what is called as tax scenes are today actually uh [Music] so you should remember that you know nothing is you know it's only alternative person to my opinion in my opinion is only useful when nothing unknown or standardized statement does not work okay um so we have another question here in a village setup is there any option for mapping of lymph nodes [Music] you can if you are able to invest and put the setups it's possible but single day whatever what we call as blue dye technique methylene glue is freely available it can be procured and it can be used um i think uh that's it those were the end of the questions and uh thank you so much sir for coming on our platform and uh giving this uh talk which was uh really good very informative and i'm sure our audience have taken back a lot of uh have got a lot of message to take back um and we hope you do come back uh to the session to our platform for another session [Music] okay thank you thanks for having me

BEING ATTENDED BY

Dr. Dr Venkatachalapathy Anur & 431 others

SPEAKERS

dr. Sandeep Nayak

Dr. Sandeep Nayak

Chief of Surgical Oncology, MACS Clinic & Director, Department of Surgical Oncology, Fortis Cancer Institute, Bangalore | Known as the pioneer of robotic thyroidectomy and Minimally Invasive Neck Dis...

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dr. Sandeep Nayak

Dr. Sandeep Nayak

Chief of Surgical Oncology, MACS Clinic & Dir...

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