Dr. Mandar Nadkarni

AREA(S) OF INTEREST:

Breast Oncology & G I Oncology

TREATMENTS/PROCEDURES OFFERED:

• Breast Cancer
• Mastectomy
• Gastrointestinal cancer

We established the Kokilaben Hospital Breast Care Unit in 2009 - it was based on the guidelines set by the European Society of Mastology (EUSOMA) - it included all fields from screening to diagnosis to multimodal care and even palliative care and pain clinic - over the last 17 years we have performed over 9500 breast cancer related procedures varying from simple surgeries like Modified Radical Mastectomies and Breast conservation to very advanced Oncoplastic procedures that have now become standard of care .

We also set up a Port clinic to enable patients needing systemic chemotherapy to have access to central venous access devices like chemo ports or PICCs.

Very early after starting the unit we adopted Oncoplastic surgery techniques as standard of care for our patients starting with basic level I Oncoplastic surgical procedures such as Benelli technique, Hemi round block technique, parallelogram Oncoplasties, batwing technique and E3 Grisotti flaps for central quadrant lesions to allow excellent cosmetic outcomes for our patients without affecting oncological safety.

We then moved on to reduction mastopexy techniques that permitted breast volume reduction and mastopexy as cosmetic additives to oncological resection with good effect - the last 5 years the unit has trained and adopted advanced Oncoplastic surgery which includes performance of extensive breast resections including mastectomies and immaculate reconstruction using chest wall perforator flaps (a new concept for the last few years) .

We regularly perform Lateral Intercostal artery perforator (LICAP), anterior Intercostal artery perforator flaps (AICAP), Medial Intercostal artery perforator flaps (MICAP) and lateral thoracic artery perforator (LTAP) flaps . We have also devised our own modified technique of LICAP to minimise scars and improve cosmetic outcomes - these flaps have enabled breast surgeons to carry out extensive (>30%) breast volume resections with ease and superlative cosmetic outcomes.

For patients needing or choosing mastectomies over conservative procedures we established a whole breast reconstruction program very early on. Since inception of the unit we have been performing performing Nipple areola sparing mastectomies and subcutaneous mastectomies with assistance of a well trained reconstructive surgery department skilled in implants, pedicled flaps and free tissue transfer with excellent results - we have data with over 600 such patients . We also have the highest number of series of cases with prophylactic bilateral mastectomies and reconstruction in patients unfortunate to have hereditary breast cancer owing to pathogenic mutations in BRCA 1 and 2 genes

In 2009 we established the first sentinel node biopsy program in Mumbai with dual technique (using methylene blue dye and Tc99 radioactive isotope) for detection of the first echelon node to where the cancer may have spread - this enables surgeons to identify patients without axillary nodal spread thereby avoiding unnecessary axillary nodal dissection and preventing Lymphedema - 8 years later we moved on to dual technique using the latest Indocyanine green technique using the SpY-phi system that is known to give better identification of sentinel nodes- this technique is the present standard of care- we were again the first to adopt evidence based management of the axilla in single sentinel node positive patients adopting the results of Amaros trial to radiate the axilla and avoid Lymphedema to good effect.

In patients undergoing neoadjuvant chemotherapy we use Sentinel Biopsy dual technique in all patient with uninvolved nodes - in patients with involved nodes that turn disease free after upfront chemotherapy we have adopted the gold standard (from MD Anderson CC) technique of targeted axillary dissection using markers to identify the sentinel nodes along with dual technique . This technique raises safety of axillary sentinel node detection by reducing false negative rates below 10% - all of the above enabling limited axillary surgery and reducing Lymphedema rates - translates into excellent quality of life

In patients who need axillary lymph node dissection (unavoidable in patients with a heavy nodal disease burden) we have a standard policy of performing Slympha and micro vascular lympha technique (by our microvascular team) to identify affected lymphatics of the arm following a complete axillary lymph node dissection using reverse axillary mapping and reconnecting them back to the tributaries of the axillary vein using microvasular techniques with superfine sutures. This technique has been shown to reduce lymhpedema rates to 10-14% - again translating into better quality of life for our patients

Management of impalpable lesions -

With a thriving executive health check up programme in our institution we encounter a sizeable number of screen detected cancers seen on mammography that are yet not clinically evident.

With the advent of neoadjuvant chemo in triple negative and her2neu positive patients- as many as 65% patients will show near complete to complete response and the surgery involves removal of impalpable lesions using stereotactic mammo-localizations and hook wire techniques - we have used intraoperative ultrasound to guide us in the excision of impalpable solid lesions since inception - a technique that improves accuracy and is fail safe. Over the last many years we have data of over 1500 patients treated by this technique successfully.

Awareness programmes - as part of our commitment to society the breast unit has been a part of various conferences, forums, social gatherings etc in raising awareness about breast health helping to disperse knowledge about breast cancer screening, prevention, early detection, recent advances to help generate a consciousness among the common people about how one should be breast aware.

Academics/Research/Awards

Visiting observership to Centre Oscar Lambret where he trained himself in oncoplastic surgery and implant reconstructions

Invited faculty for the Breast Health Global Initiative (BHGI is run by the Fred Hutchinson Research Centre, Washington) as an invited representative from India to brainstorm and formulate guidelines for breast cancer management in the developing world.

World Health Organisation panel - In 2007 he coordinated the Indian panel for development of guidelines for treatment of breast cancer in India depending upon different levels of available infrastructure at different oncology centres across the country.

Over 21 publications

Landmark publications

• Breast conservation surgery without pre-operative mammography–A definite feasibility (published in Breast 2006)
  - The original paper attracted an editorial by Dr Benjamin Anderson - The results is the paper were included as a guideline to increase breast conservation in developing countries worldwide (in Cancer 2008 and World Journal of Surgery 2010)
• Single-Injection Depot Progesterone Before Surgery and Survival in Women With Operable Breast Cancer: A Randomized Controlled Trial
  - A simple inexpensive intervention in selected patients to reduce risks of recurrence after breast cancer treatment.
• Influence of surgical technique on axillary seroma formation: a randomized study. ANZ Journal of surgery 2007
  - Original research paper to reduce the incidence of postoperative seroma formation

Conferences

• Organisation of the Tata Memorial Hospital-Women's Cancer Initiative conference on breast cancer
• Coordination and Organization of the World Health Organization panel for development of treatment guidelines for early and advanced breast cancer in India
• Invited for surgical demonstration including
• National Surgical Conferences- Oncosurg at Tata Memorial
• Surgical faculty for the onco plastic masterclass at Pune in 2015
• NorthEast chapter of ASI conference on common cancers
• Regional surgical conferences - MASICON conferences (Asso. of surgeons, Maharashtra Chapter)