omega pet ‐ ctdamaging the normal cells besides the cancer cells. various attempts have been made...

RNI Reg No : APBIL/2011/38979 Postal Registered No : HD/1151/2014-16

Date of Publication: 05.12.2014

* Conditions Apply

* Conditions Apply

Vol-4 Issue-6 Hyderabad December -2014 Pages-12 Price Rs - 1.00

d�+|�Ú{ì`4 d�+º¿£`6 �VÕ²<�s�u²<� &��d+�sY`2014 �|J\T`12 yî\ sÁÖ. 1.00

MLA Colony, Main Road, Road No. 12, Banjara Hills, Hyderabad-34, Andhra Pradesh, India.

Tel.: +91 40 2355 1034, Fax : +91 40 2355 0327. E-mail : [email protected]. For appointments +91 98480 11421

12Omega News Dec - 2014 1Omega News Dec - 2014

Positron Emission Tomography (PET) is an advanced nuclear medicine metabolic imaging technology using cyclotron produced short lived positron emi�ng isotopes like Fluorine 18 and labeled to Fluoro Deoxy Glucose. It facilitates early cancer detec�on by iden�fying abnormal increased glucose metabolism in the tumors.

PET –CT uses fusion imaging between structural imaging of CT with func�onal metabolic imaging of PET to produce comprehensive func�onal and minute details of organs and disease states like cancers, degenera�ve disorders and cardiac viability.

PET CT is extremely useful in staging of cancer, response to chemotherapy, early detec�on of recurrence and spread of cancers.

Extremely cost effec�ve, safe, non invasive, 3 D imaging modality which is a pa�ent friendly outpa�ent procedure.

OMEGA PET ‐ CT

From the Medical DeskFrom the Editor's Desk

3Omega News Dec - 20142Omega News Dec - 2014

Rapid advances in Oncological management across the world have been embraced by Omega Hospitals for

the benefit of all our cancer patients. Incorporation of these newer modalities in the management of

oncology patients has been a priority focus at our centre.

I am extremely glad to inform you that the breakthrough treatment for Cancer: HIPEC (Hyperthermic

Intraperitoneal Chemoperfusion) has been successfully performed in more than 30 patients over the past

few months with excellent results and good outcomes. Various GI and GU tract cancers have been treated

through this revolutionary approach in all the above patients which results in improving the overall

survival.

I am very happy to announce that the Cyberknife in our Neuro Oncology department has been delivered

for many of our patients with brain lesions (both benign and malignant) producing amazing results with

only 1 to 5 fractions. As you all know, Cyberknife offers a complete solution for those who require non‐

invasive, pain less, sub‐millimeter, faster treatment that can be completed in 1 to 5 days (depending on the

lesion / tumor) with a Radio Surgical precision. Cyberknife treatment is Vision (because of continuous

image tracking), Science (because it is Robotic Arm mounted with Linear Accelerator), and Artificial

Intelligence (which requires controlling by the robot). This is coupled with the art and skill of our Neuro‐

Radiation Oncologists to achieve the common goal of maximal efficacy against the disease and minimal

toxicity to the patient.

Omega Hospitals proudly stands in delivering the latest treatments to our cancer afflicted patients.

With warm personal regards,

Dr.Mohana Vamsy, Editor

MS, DNB, Mch. (Surg. Onco), FRCS (Edin),

Dip. Lap. Surg. (France)

Dear Colleagues,

Greetings of the season !

01/12/2014Hyderabad

Lapatinib is an orally active drug for breast

cancer. It is a dual tyrosine kinase inhibitor

which interrupts the HER2/neu and epidermal

growth factor receptor (EGFR) pathways. It is

used in combination therapy for HER2-positive

breast cancer. It is used for the treatment of

patients with advanced or metastatic breast

cancer whose tumors overexpress HER2

(ErbB2).

Lapatinib inhibits the tyrosine kinase activity

associated with two oncogenes, EGFR

(epidermal growth factor receptor) and

HER2/neu (Human EGFR type 2). Over

expression of HER2/neu can be responsible for

certain types of high-risk breast cancers in

women. Lapatinib is a protein kinase inhibitor

shown to decrease tumor-causing breast cancer

stem cells. Lapatinib inhibits receptor signal

processes by binding to the ATP-binding pocket

of the EGFR/HER2 protein kinase domain,

prevent ing se l f-phosphory lat ion and

subsequent activation of the signal mechanism.

Lapatinib is used as a treatment for women's

b rea s t cance r i n t r ea tment na ï ve ,

ER+EGFR+HER2+breast cancer patients (now

often called “triple positive”) and in patients

who have HER2-positive advanced breast

cancer that has progressed after previous

treatment with other chemotherapeutic

agents, such as anthracycline, taxane-derived

drugs, or trastuzumab.

A randomized clinical trial on female breast cancer

previously being treated with those agents

(anthracycline, a taxane and trastuzumab)

demonstrated that administrating Lapatinib in

combination with capecitabine delayed the time of

further cancer growth compared to regimens that

use capecitabine alone. The study also reported

that risk of disease progression was reduced by

51%, and that the combination therapy was not

associated with increases in toxic side effects. The

outcome of this study resulted in a somewhat

complex and rather specific initial indication of

Lapatinib-use only in combination with

capecitabine for HER2-positive breast cancer in

women whose cancer have progressed following

previous chemotherapy with anthracycline,

taxanes and trastuzumab.

Adverse effects like many small molecule tyrosine

kinase inhibitors, Lapatinib are regarded as well

tolerated. The most common side effects reported

are diarrhea, fatigue, nausea and rashes. In clinical

studies elevated liver enzymes have been reported.

QT-prolongation has been observed with the use

of Lapatinib ditosylate but there are no reports of

Torsades de Pointes. Caution is advised in patients

with hypokalaemia, hypomagnesaemia,

congenital long QT syndrome, or with co-

administration of medicines known to cause QT-

prolongation. In combination with capecitabine,

reversible decreased left ventricular functions are

common (2%).

ORAL TARGETED TREATMENT IN METASTATIC BREAST CANCER

Dr. Nirni S.S, MD (Internal Med), DM (Hemato Onco), Fellow (New York Medical College) USA, Fellow (Queens Elizabeth Hospital, Birmingham) UKSr. Consultant Medical Oncologist – Hematologist & BMT Physician

From the Medical Desk


STEM CELLS IN CANCER AND MEDICINE - HOPE OR HYPE

There is lot of talk regarding the 'stem-cell-

predominantly the umbilical cord' claiming it as

“universal healer/ magic potion”, with equally high

voice opposing the same. Here we tried to give a

basic concept/introduction of the stem cells,

scientific and clinical picture as on today with help

of available literature.

Stem cell- What exactly are they?

Most popular definitions will recognize them as a

population of undifferentiated cells having unique

features of, indefinite proliferating capacity and

self-renewing capacity.

Where are they located?

These cells are omni present and divide in times of

need. However, the process is quite complex. Based

on the chronology of embryogenesis, the first ones

are called Totipotent (fertilized egg), which can form

all cell lines including the placenta. The later

generations can go either ways of differentiation.

They are viz. Pluripotent (embryonic cell)—they can

form most of the cell lines except the placenta and

Multipotent (e.g., hematopoietic)—they have

limited capacity to form one committed cell line

such as blood cells, skin, neurons, myocytes, and

endothelial cells. The ability to go back and forth is

enabling us to generate neurons from skin, heart

muscles from gut etc.

What they can do

If the functional progeny can integrtate with

existing sytem, they can repair the organs with

perfection, like what happens in hematopoietic

stem cell. Howver this is not always possible.

However attempts are being continued in other

therapeutic areas such as 'neurodegenerative

disorders' though successful in transferring the cells

into the mature cells like neurons, the major

challenge is that we could not integrate with the

existing system thereby not meeting the definition of

'ideally functional progeny' despite the newly formed

neuron being able to perform its function in isolation.

Similar is the case with cardiomyopathies,

(contractility) of the heart improved partially. The

'perfect goal' of normalization is still far from reality.

What we do- Bone marrow/ hematopoeitc stem cell

transplant.

There is a great deal of success in hematopoietic stem-

cell transplant, as we have more than 4 decades of

experience and more than few million transplants

happening across the globe so far. To summarize what

we do is either put your own stem cells back after

chemotherapy, where they repair damaged normal

cells- called autologous transplant. In other cases we do

transplant stem cells from donor, called allogenic

transplant, where the donor cells help to control

disease, along with chemotherapy. It is a standard

practice across various indications in the globe.

Controversy - Testing on embryos is looked as 're-doing

the God', which is not completely wrong, lead to a

strong opposition to the stem cell. However this is not

true for the ones which we use for treatment. There are

some fixed guidelines in each country and in India too

the Indian Council of Medical Research (ICMR) came up

with guidelines to follow for the stem-cell research

w h i c h c a n b e a c c e s s e d t h r o u g h

www.icmr.nic.in/stem_cell/stem_cell_guidelines.pdf.

However it is very difficult to assume that “your own

cells will cure your disease in future”, though they may

help others.

There is definitely a good amount of hope, though the

current claims may take a longer time for possible

realization. Till then, except for bone marrow

transplant, we have to consider others as an “option”,

than “standard care”.

Chemotherapy, classically known to kill all dividing cells by various mechanisms, is associated with an unwarranted side effect of damaging the normal cells besides the cancer cells. Various attempts have been made to reduce the effect on the normal cells, mainly in the form of modified delivery mechanisms [predominantly dealing with pharmacokinetic properties]. One such mechanism is using “nano-technology” and others include liposomal preparations, pegylation and few more similar ones. The scientists believe that if the drug can be “packed in Lipid layer”, the drug can enter a cancer cell more efficiently which is the basis of “liposomal preparations”. This showed a greater deal of success in few cancers like ovary, breast, where liposomal doxorubicin is known to have better results and fewer side effects. Similarly the same technology was extrapolated to few anti-fungal and so on. Pegylation, another technology, used to make the drug available for longer periods also is a success story in that it reduced the “number and frequency of injections” so that the “comfort of patients is better”. This also had translated in few medicat ions l ike “L-Asperginase” and

“filgrastim”, etc. with others like irinotecan, which are under trails. Another technology is “NANO”, where the drug is packed in “small pocket” using nanotechnology and there by the penetrability is better. This had been proven to be success in molecules like Paclitaxel. The other approach is “targeted therapy, where we try to explore the “unique differences” of “cancer vs. normal cell” and target with monoclonal antibodies and small tablets, classically known as “magic bullets”. However the real breakthrough came when the scientist started thinking “out of box” and trying to explore the targets outside of the cancer cell – so called tumor matrix/environment”. One classic success story is “albumin bound Paclitaxel, which relies on one unique protein called “SPARC”. By biding the “Nano- Paclitaxel” with albumin, the drug concentrated multifoild around the tumor, which is predominantly due to high levels of the albumin-binding protein - SPARC (Secreted Protein Acidic Rich in Cysteine) in few of the tumors like pancreas, head and neck, where it had been associated with higher response and better tumor control. These results paved path for newer innovations and hopes for the better drugs.

We all are commonly encountering thyroid problems and hypothyroidism has become as common as diabetes and hypertension. However there is always a concern when thyroid gland enlarges(goitre) and more commonly the patient comes with cosmetic issues rather than disease symptoms as most of the nodules are clinically

asymptomatic.

DIAGNOSTIC MODALITIESThere are several diagnostic techniques such as thyroid profile , USG(ultrasonogram) of thyroid, Tc 99 scan etc. ,where the biochemist, radiologist, nuclear medicine consultant plays major role in deciding benign vs malignant / “hot “ vs “cold “


Dr. A.V.S. Suresh, MD; DM; PDCR; ECMO, Sr. Consultant Medical Oncologist

THINKING OUT OF BOX- IMPROVISING NANO TECHNOLOGY IN CANCER CHEMOTHERAPY

NODULES IN THYROID : FROM PATHOLOGIST PERSPECTIVE

Dr. P.S.Dattatreya, MBBS(Hons);MD,DNB,DM,DNB;ECMO;PDCR

Sr.Consultant-Medical Oncology, Sr.Consultant-Haemato Oncology

DR. SNEHALATHA DHAGAM

Consultant Pathologist, MD (Pathology), DNB (Pathology)



nodules.

•The role of a pathologist starts with Fine needle

aspiration cytology (FNAC) , which is a simple ,

non invasive procedure. Whenever we plan

several tests at a time, the FNAC should be the last

test to be performed on that day as some amount

of blood and collid leak within the thyroid makes

the interpretation difficult for the radiologist.

•Diagnostic dialamas are quietcommon in FNAC.

A straight forward differentiated papillary

carcinoma, or multinodular goitre may be easily

picked by characteristic cytologic features. But

solitary nodules showing repetitive follicular

pattern are always categorized in to “follicular

neoplasms”. They can be benign or malignant

and need further testing.

WHAT MORE WE CAN DO?

After the FNAreport of follicular neoplasm, both

the surgeon ,pathologist and infact even the

patient is in a dialama what to do?

•Always correlate with USG, Tc 99scan findings to

havea clue towards benign vs malignant.

•The core biopsy can be performed from a

measurable solid nodule , however still shows

follicular neoplasm and not of much use.

•Plan for hemithyroidectomy in such cases with

frozen section.

FROZEN SECTION (INTRA OPERATIVE

DIAGNOSTIC TECHNIQUE)

•Frozen section helps in better characterization of

lesions into benign or malignant

•Further tratment decisions can be made during

the surgery itself.

•However the pathologist can surely recognize

papillary carcinoma,poorly differentiated

malignancy, Hashimotos thyroiditis , nodular

hyperplasia .

•The follicular neoplasms still make pathologist and

surgeons fingers crossed. AS WE ALL KNOW FOR

ALL ENCAPSULATED ENDOCRINE NEOPLASMS

,PRESENCE OF CAPSULAR AND VASCULAR

INVASION ARE DIAGNOSIC CRITERIA OF

MALIGNANCY and will be found the time of frozen

section in occasional cases.

•The minimally invasive follicular carcinoma, follicual

variant of papillary carcinoma and follicular

adenomas are the lesions included under the blanket

term follicular neoplasm.

•Follicular neoplasms diagnosed as adenomas on

final histopathology,need no further intervention. In

case, final histopathology shows malignancy,

revision surgeryof completion thyroidectomy with

or without lymphnode dissection can be planned.

WHAT IF FROZEN SECTION NOT DONE FOR

THYROID LESIONS?

Frozen section minimises the number of revision

surgeries in thyroid , prevents unnecessary extensive

surgeries, raises the confidence levels of the surgeon

and the patient ,prepare them for further treatment

options.

OUR EXPERIENCE AT OMEGA HOSPITALS

At omega hospitals , we have state of art technology

for diagnosis and treatment of thyroid nodules. We

have equal incidence of benign and malignant

lesions and frozen section always done in all cases of

thyroid and the revision surgery rate is low.

Hence, we recommend all throid surgeries to be

done under frozen sections coverage , whenever

feasible.

Prostate Cancer is one of the most common

cancers of the males next only to head and neck

and lung cancers. It is characterised by its slow

growth, presentation in older age groups, response

to various treatment modalities and the ability to

diagnose it in the early stages. As the screening

programmes for cancer are gaining importance, we are happening to see more cancers in the early stages. Once the diagnosis of prostate cancer is made in the early stage, the treatment is with a curative intent and there are different treatments from which we can choose upon.Radiotherapy has been in the forefront as a curative option owing to ease of delivery and minimal discomfort to the patient. Various radiotherapy procedures have been proposed owing to the radiobiology of the prostate and the critical location of the gland itself. Prostate cancer radiotherapy is has many uncertainities relative to the method of delivery, fractionation, monitoring of treatment.Technological and radiobiological advances in early-stage prostate cancer treatment have led to a debate within the radiation oncology community over the optimal treatment. Long-term results from prospective and randomized dose escalation trials comparing doses of 74–81 Gy to doses <70 Gy show dose escalation with conventional fractionation (1.8–2.0 Gy per fraction) improves freedom from biochemical failure (FFBF) and disease progression with acceptable toxicity. However, despite dose escalation, improvements are needed to consistently achieve the highest outcomes.The typical treatment with dose-escalated external beam radiation therapy(EBRT) involves fractionated radiation therapy using daily doses of 1.8-2.0 Gy for eight to nine weeks. Considering logistics and life responsibilities, such prolonged treatment courses present hardship for many patients. In addition, clinical data suggest that hypofractionated radiation therapy may be radiobiologically favorable to smaller fraction sizes in prostate cancer radiotherapy due to a potentially greater sensitivity of prostate cancer to larger daily radiation fractions.Stereotactic Body Radiation Therapy (SBRT) uses the principle of stereotactic radiosurgery extracranially to provide us a curative outcome. Despite the larger dose per fraction(>5 Gy) initial results of SBRT in prostate cancer were disappointing due low total doses given mainly due poor tracking systems that were not able to track the continuous prostate motion.

CyberKnife (Accuray Incorporated, Sunnyvale, CA) delivers hundreds of individualized circular beams with a targeting error of less than 1 mm allowing the safe delivery of highly conformal treatment plans with steep dose gradients. Unlike standard image-guided radiation therapy (IGRT), the CyberKnife system incorporates a real-time tracking system that provides updated prostate position information to the robot to correct the targeting of the therapeutic beam during treatment. This feature allows for a reduction in the planning target volume (PTV) and, therefore, better limits the dose tosurrounding critical organs.Patient Selection for SBRT of prostate1)T1 and T2 tumors2)No lymph nodal involvement3)Serum PSA less than 10ng/ml4)Non-metastatic disease5)As a boost to high risk patients who completed their pelvic RTSBRT treatment planning and deliveryFour gold fiducials were placed into the prostate. Seven days after fiducial placement, patients underwent MR imaging followed shortly thereafter by a thin-cut CT scan. Fused CT and MR images were used for treatment planning. The clinical target volume (CTV) included the prostate and the proximal seminal vesicles (to the point where the seminal vesicles separate). The PTV equalled the CTV expanded 3 mm posteriorly and 5 mm in all other dimensions. The prescription dose was 35–36.25 Gy to the PTV delivered in five fractions of 7–7.25 Gy corresponds to a tumor EQD2 of approximately 85–90 Gy assuming an � /� ratio of 1.5. In general, older patients with poor baseline urinary function were treated with 35 Gy.

Cyberknife SBRT treatment plan-36.25Gy in 5 Fractions


PROSTATE CANCER - NEW INSIGHTS IN RADIOTHERAPYTREATMENT

Dr. L. Yugandhar Sarma,MD (Radiotherapy), Junior Consultant-Radiation Oncology


On the type 3 curve, there is a rapid initial rise,

followed by a drop-off with time (washout) in

the delayed phase. A lesion with this type of

curve is malignant in 29-77%.

On the type 2 curve, there is slow or rapid initial

rise followed by a plateau in the delayed phase.

The chance of a lesion with a type 2 curve being

malignant lies somewhere between the 6% of the

type 1 curve and the 29-77% of the type 3 curve.

Mammography is the only imaging study that has been shown in multiple large clinical trials to decrease the mortality associated with breast cancer. However, mammography has well known limitations. Dynamic contrast enhanced MRI (DCE-MRI) has emerged as an importat adjunctive tool. Protocols Dedicated breast coil, 1.5 Tesla magnetic strength and dynamic contrast administration are requirements for breast MR.Current Indications for MR breastResponse to neoadjuvant chemotherapy. MR has been shown to be better than mammography and USG for assessing residual disease after neoadjuvant chemotherapy.Surveillance of high-risk patientsFor the high-risk patient, there is sufficient evidence to recommend annual DCE-MRI in addition to annual mammography for screening for breast cancer. Axillary node metastases with an unknown primaryWhen axillary lymphnode metastasis is identified and mammogram is negative. Breast MR can locate primary site in 75-86 % of these cases.Contralateral breast screeningIn a recent study, DCE-MRI has been able to identify occult contralateral cancer in 3-5% cases.Invasion deep to fasciaBoth mammography and USG have limitation in the evaluation of the chest wall. MRI is able to visualize the chest wall and can clearly depict chest wall invasion, which is very important for pre-operative planning.

Patients with breast implantMammography can be difficult to interpret in the presence of breast implants. DCE-MRI is better for the evaluation of such patients. Recurrence of breast cancerConventional imaging is confusing due to post operative scarring. In such cases, negative MR is helpful in excluding recurrent disease.In addition to morphological criteria, DCE-MR shows three types of curve depending upon the enhancement of the lesion.

On type 1 curve, there is a slow rise and a continued rise with time. A lesion with a type 1 curve has a chance of 6% of being malignant.


MR MAMMOGRAPHY

Dr.Syed Safiullah, HOD & Consultant, Department of Radiology

SBRT is well-tolerated for patients with clinically localized prostate cancer. Early PSA results from our institution suggest a biochemical response similar to or even better than standard radiation therapy options. Benign PSA bounces were common. Rates of late GI and GU toxicity are

comparable to conventionally fractionated radiation therapy and brachytherapy. Urinary symptom flares are observed but the majority resolved with conservative management. A high percentage of men who were potent prior to treatment remained potent following treatment.

SENTINEL LYMPH NODE BIOPSY IN ORAL CAVITY SQUAMOUSCELL CARCINOMA AND CLINICALLY N0 NECK

Dr. Sharankumar Shetty, MS (ENT), FSOG (NIMS),M.Ch. Head & Neck Surgical Oncology (AIMS), Consultant-Head & Neck Oncology

Oral cavity carcinoma accounts for majority of

head & neck malignancy. For early stage

tumors, detection of single lymph node

metastasis upstages to Stage III requiring

multimodality treatment. Only 20 – 30% of

these early tumors have occult metastasis.

There is no diagnostic modality to detect this

occult metastasis. Hence most of these early

oral cancers undergo elective neck dissection.

Selective neck dissection is associated with

increased morbidity especially shoulder

dysfunction. Hence non invasive approach to

identify occult metastasis is of interest.

Although various non invasive modalities like

Ultrasound, CT, MRI, PET scan have better

specificity and sensitivity, but all these holds

good with nodes less than 1 cm.

Sentinel lymph node (SLN) biopsy has been

proved effective in Breast cancer and

Melanoma. Sentinel lymph node biopsy is

associated with decreased morbidity as only few

structures are at risk and requires minimal

dissection. SLN has improved swallowing, better

tactile and pain sensation, improved shoulder

constant score, less fear of disease progression,

less lymphedema, less facial nerve dysfunction.

SLN helps in identifying skip metastasis. It also

helps in better pathological handling of specimen,

effectively looks for the node at highest risk for

serial sectioning for micro-metastasis.

Various studies and meta-analysis have shown

accuracy of 100%, sensitivity ranging from 93-

95%, Specificity of 95-100%. Limitation for use of

SLN is lack of confirming multi-institutional trials,

weakness in assessing floor of mouth lesions,

surgeon proficiency and comfort.



11Omega News Dec - 201410Omega News Dec - 2014

HIPEC(Hyperthermic Intraperitoneal Chemoperfusion)

Allows for high doses of chemotherapy

Enhances and concentrates chemotherapy

within the abdomen

Minimizes the rest of the body's exposure

to the chemotherapy

Improves chemotherapy absorption and susceptibility

of cancer cells

Reduces some chemotherapy side effects

ADVANTAGES

Belmonte Hyperthermia PumpHIPEC


Every Day is Breast Cancer Awareness Day

AP's First Digital Mammography with

* Conditions Apply* Conditions Apply

omega pet ‐ ctdamaging the normal cells besides the cancer cells. various attempts have been made...

Documents