The appendix is a pouch-like tube that is attached to the cecum (the first section of the large intestine or colon). The appendix averages 10 centimeters (cm) in length and is considered part of the gastrointestinal (GI) tract. Generally thought to have no significant function in the body, the appendix may be a part of the lymphatic, exocrine, or endocrine systems.
Appendix cancer occurs when cells in the appendix become abnormal and multiply without control. These cells form a growth of tissue, called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body). Another name for this type of cancer is appendiceal cancer.
Types of appendix tumors
There are a variety of tumors that can start in the appendix:
Carcinoid tumor. A carcinoid tumor starts in the hormone-producing cells that are normally present in small amounts in almost every organ in the body. A carcinoid tumor arises primarily in either the GI tract or lungs, but it also may occur in the pancreas, a man’s testicles, or a woman’s ovaries. An appendix carcinoid tumor most often occurs at the tip of the appendix. Approximately 66% of all appendix tumors are carcinoid tumors. This type of cancer usually causes no symptoms until it has spread to other organs and often goes unnoticed until it is found during an examination or procedure performed for another reason. An appendix carcinoid tumor that remains confined to the area where it started has a high chance of successful treatment with surgery.
Colonic-type adenocarcinoma. Colonic-type adenocarcinoma accounts for about 10% of appendix tumors and usually occurs at the base of the appendix. This type of tumor looks and behaves like the most common type of colorectal cancer. It often goes unnoticed, and diagnosis is frequently made during or after surgery for appendicitis (inflammation of the appendix that can cause abdominal pain or swelling, loss of appetite, nausea, vomiting, constipation or diarrhea, inability to pass gas, or a low fever that begins after other symptoms).
Signet-ring cell adenocarcinoma. Signet-ring cell adenocarcinoma (so called because, under the microscope, the cell looks like it has a signet ring inside it) is very rare and considered to be more aggressive and more difficult to treat than other types of adenocarcinomas. This type of tumor usually occurs in the stomach or colon, and it can cause appendicitis when it develops in the appendix.
Paraganglioma. Paraganglioma is a rare tumor that develops from cells of the paraganglia, a collection of cells that come from nerve tissue that persist in small deposits after fetal (pre-birth) development, and is found near the adrenal glands and some blood vessels and nerves. This type of tumor is usually considered benign and is often successfully treated with the complete surgical removal of the tumor. Paraganglioma is very rare outside of the head and neck region.
Mucinous cystadenocarcinoma. Mucinous cystadenocarcinoma is the most common non-carcinoid appendix tumor and accounts for about 20% of appendix cancer cases. This type of tumor produces a jelly-like substance called mucin that can fill the abdominal cavity and can cause abdominal pain, bloating, and changes in bowel function if the tumor breaks through the appendix or grows in the abdomen. This is called as Pseudomyxoma Peritonei or “jelly belly”.
Appendiceal tumors are often misdiagnosed as appendicitis. Alternatively, they may burst with very little symptoms and spread within the abdominal cavity to give rise to pseudomyxoma peritonei or peritoneal carcinomatosis. Fortunately, now we can treat these conditions using Cytoreductive Surgery and Hyperthermic Intra-peritoneal chemotherapy (HIPEC).
Dr. Sanket Mehta has pioneered this form of treatment in the country. He has already performed numerous such surgeries with good results.
What is Pseudomyxoma Peritonei?
A. Pseudomyxoma peritonei essentially refers to a condition where the abdomen is filled with a jelly-like mucinous material, also referred to as "jelly belly."
B. It is usually caused due to a tumor of the appendix. The classical pseudomyxoma peritonei usually refers to an appendiceal cancer of low malignant potential that has spread inside the abdominal cavity. However, there can also be an aggressive appendiceal cancer that spreads very quickly but still gives the same CT pictureand The cancer cells secrete a mucinous material that fills up the peritoneal cavity and leads to distension or bloating of the abdomen. For a long time, the patient remains symptom free, which is why it is usually diagnosed late.
What is the incidence of pseudomyxoma peritonei?
A. Pseudomyxoma peritonei is a rare disease that affects 1 per million population per year. It remains the same across the world and there are no known predisposing factors.
What are the symptoms of a patient with pseudomyxoma peritonei?
A. In the early stage of the disease there are no symptoms. However, quite a few patients may be diagnosed as acute appendicitis and may be treated for it. Some patients may undergo a laparoscopy or a laparoscopic appendicectomy and maybe diagnosed to have pseudomyxoma at the time of laparoscopy. Usually the patients are in an early stage when the presentation is such and are treatable with excellent results.
What are the treatment options?
There are 2 treatment options.
A. In the early stage of the disease there are no symptoms. However, quite a few patients may be diagnosed as acute appendicitis and may be treated for it. Some patients may undergo a laparoscopy or a laparoscopic appendicectomy and maybe diagnosed to have pseudomyxoma at the time of laparoscopy. Usually the patients are in an early stage when the presentation is such and are treatable with excellent results.
B. The other treatment option that has come in vogue in the last decade is Cytoreductive Surgery and Hyperthermic Intra-peritoneal chemotherapy (CRS and HIPEC). Cytoreductive surgery is a more comprehensive surgery than a debulking surgery because the surgeon endeavors to achieve a macroscopically complete resection of the disease (no visible disease or residual disease less than 2mm size). Typically, this may involve stripping of the involved peritoneal surfaces, removal of the greater and lesser omentum, involved organs like the appendix or the right colon, and if necessary, other organs like the rectum, uterus with the ovaries, spleen, part of stomach, etc.This is followed by administration of chemotherapy directly into the peritoneal cavity, which is delivered at a high flow rate, high temperature and high concentrations through a closed circuit system using the HIPEC machine. This Hyperthermic Intra-peritoneal chemotherapy or HIPEC takes care of the residual microscopic disease that may have been left behind after the CRS. CRS and HIPEC is currently considered to be the treatment of choice for pseudomyxoma peritonei.
Why is IV chemotherapy or debulking surgery not effective?
A. During a debulking surgery, since all of the disease is not removed, the disease that is left behind invariably starts growing back and spreading once again inside the abdomen. Although the patient may be symptom free for a reasonable amount of time, the regrowth of the disease invariably means that the patient becomes symptomatic again after an average period of 1-1½ years, requiring a repeat surgery. Each successive surgery is more difficult and less effective. This results in a poor quality of life and a significant time spent in the hospital and recuperating from the surgeries. Most importantly, there is no chance of cure and most patients invariably succumb to the disease.
B. Intravenous chemotherapy has several limitations in the case of pseudomyxoma peritonei. IV administration means that the chemotherapy circulates through all the organs of the body via the blood and hence there is a dose limitation since higher doses lead to greater side-effects. Besides, the inherent function of the peritoneum is that of a barrier and this blood-peritoneal barrier prevents the chemotherapy from reaching the peritoneal cavity in adequate concentrations to be effective for peritoneal disease. Moreover, in most cases of pseudomyxoma peritonei, the sheer volume of the disease overwhelms the dose of the chemotherapy reaching the peritoneal cavity.
Is CRS and HIPEC more effective than other treatment modalities?
A. Not only is CRS and HIPEC conceptually superior, but it has also been shown to deliver clinically superior results as well. In several large studies involving hundreds of patients from various countries, it has been shown to give markedly superior survival results, better quality of life, lesser long-term morbidity and reliably superior results compared to debulking surgery and IV chemotherapy. A recent large study collating data of 2298 patients from several specialized centers from across the world has shown that the median OS (overall survival) was almost 16 years and the 10- and 15-year survival rates were 63% and 59%, respectively. This compares favorably to the 35-40% 5-year survival achieved by just debulking surgery and IV chemotherapy. Besides, a significant proportion of the patients treated with CRS and HIPEC had a median time to relapse of the disease in excess of 8 years. This again compares favorably to the 1-1 ½ year relapse-free period achieved by debulking surgery.
B. The study also showed that when the patient is treated in specialized centers, the complication rates are much lesser and this in turn translates in longer survival. Since HIPEC surgery is a major undertaking requiring multi-disciplinary care, this surgery can only be performed in specialized centers with dedicated team focused and trained in the treatment and care of patients with peritoneal surface malignancies.
C. Often, patients of pseudomyxoma peritonei are treated with IV chemotherapy prior to being referred to specialized centers for CRS and HIPEC. However, this strategy is flawed because studies have shown that when a patient of pseudomyxoma peritonei is given chemotherapy prior to CRS and HIPEC, the survival of this patient is in fact poorer. All these results prove beyond doubt that CRS and HIPEC is the treatment of choice for pseudomyxoma peritonei.
Tags : pseudomyxoma peritonei cancer | Treatment of pseudomyxoma peritonei | polyp-like growth | Adenoma | Symptoms of pseudomyxoma peritonei cancer | Surgeries to cure Pseudomyxoma peritonei | How to Treat pseudomyxoma peritonei | debulking surgery | heated intraperitoneal chemotherapy | Dr. Sanket Mehta - Oncologist
Experts do not know exactly what causes ovarian cancer. But they do know that DNA changes play a role in many cancers.Some women are more likely than others to get this rare cancer. Women who are past menopause or who have never been pregnant are more likely to get ovarian cancer.
What are the symptoms?
In some cases, ovarian cancer may not cause early symptoms. But most women do have symptoms, even in early-stage ovarian cancer. These symptoms include recent, frequent bloating; pain in the belly or pelvis; difficulty eating or feeling full quickly; or urinary problems, such as an urgent need to urinate or urinating more often than usual.
Other symptoms that women with ovarian cancer may have include fatigue, indigestion, back pain, pain with intercourse, constipation, and changes in their menstrual cycles. But these symptoms are also common in women who don't have ovarian cancer.
How is it treated?
Surgery is the main treatment. The doctor will remove any tumors that he or she can see. This usually means taking out one or both ovaries. It may also mean taking out the fallopian tubes and uterus. After surgery, most women have several months of chemotherapy, which means taking drugs that kill cancer cells.
This cancer often comes back after treatment. So you will need regular checkups for the rest of your life. If your cancer does come back, treatment may help you feel better and live longer.
Treatment of Ovarian Cancers
The treatment of ovarian cancer is based on the stage of the disease, which is a reflection of the extent of spread of the cancer to other parts of the body. Staging is performed by the surgeon when the ovarian cancer is removed. During the surgical procedure the surgeon will obtain small pieces of tissue (biopsies) from various sites in the abdominal cavity. During this procedure, depending on the stage (extent) of the disease, the surgeon will either remove just the ovary and fallopian tube or will remove both the ovaries, fallopian tubes and uterus. In
addition, the surgeon will attempt to remove all visible cancer.
Ovarian cancer is staged as follows:
Stage I cancer is confined to one or both ovaries. The cancer is Stage II if either one or both of the ovaries is involved and has spread to the uterus and/or the fallopian tubes or other sites in the pelvis. The cancer is Stage III cancer if one or both of the ovaries is involved and has spread to lymph nodes or other sites outside of the pelvis but is still within the abdominal cavity, such as the surface of the intestine or liver. The cancer is Stage IV cancer if one or both ovaries is involved and has spread outside the abdomen or has spread to the inside of the
Treatment Options :
There are basically three forms of treatment of ovarian cancer. The primary one is surgery at which time the cancer is removed from the ovary and from all the other sites. Chemotherapy is the second important modality. This form of treatment uses drugs to kill the cancer cells. The other modality is radiation treatment, which is used in rare instances. It utilizes high energy x-rays to kill
Surgical treatment is the single most important modality determining the outcome of ovarian cancer, besides its inherent biological behavior. It is best performed by a specialist oncosurgeon who has been specially trained in the diagnosis and management of gynecologic malignancy. The treatment of ovarian cancer depends on the stage of the disease, the histologic cell type, and the patient's age and overall condition. The histologic cell type and the extent of disease based on the biopsies performed by the gynecologic oncologist during surgery (staging), are determined by the pathologist who analyzes tissues with a microscope.
Treatment of Ovarian Epithelial Cancer :
Stage I : Generally women with Stage I ovarian cancer have a total abdominal hysterectomy, removal of both ovaries and fallopian tubes, omentectomy, biopsy of lymph nodes and other tissues in the pelvis and abdomen. Young women whose disease is confined to one ovary are often treated by a unilateral salpingo-oophorectomy (removal of the affected ovary and fallopian tube) without a hysterectomy and removal of the opposite ovary being performed. Omentectomy and the other parts of the staging procedure are performed. Depending on the pathologist's interpretation of the tissue removed, there may be no further treatment if the cancer is low grade. If the tumor is high grade, the patient may receive combination chemotherapy.
Stage II : Treatment is almost always hysterectomy and bilateral salpingo-oophorectomy as well as removal of all visible tumor and sampling or removal of lymph nodes and other tissues in the pelvis and abdomen that are suspected of harboring cancer. After the surgical procedure, treatment may be one of the following: 1) combination chemotherapy with or without radiation therapy or 2) combination chemotherapy.
Stage III : Treatment is the same as for Stage II ovarian cancer, however the surgery is likely to be more extensive. Multi-organ resections may have to be performed to ensure that all disease is removed. This may not be possible in all cases and in such a situation; the patient is advised combination chemotherapy and followed up with a "Second-look Surgery with HIPEC". Following the surgical procedure, the patient may either receive combination chemotherapy.
Stage IV : Treatment will probably be surgery to remove as much of the tumor as possible followed by combination chemotherapy.
It is of prime importance that a Surgeon trained in safely performing multi-organ resections and Intra-peritoneal chemotherapy is a part of the surgical team that undertakes these surgeries, especially in stage III/IV ovarian cancers. This is to ensure that all disease is removed and the chances of long-term survival are optimized, while maintaining a low complication rate.
Recurrent Ovarian Epithelial Cancer :
Detection of Recurrent Disease : Small tumors generally respond better to treatment, therefore early detection of recurrence may be useful. However it is important to consider that the benefits of early introduction of salvage chemotherapy are limited and may intrude upon the patient's symptom and treatment-free survival. Use of frequent clinical follow-up can detect treatment failure earlier. Follow-up includes bimanual pelvic examination, serial measurement of CA125 or another tumor marker, reassessment or second-look laparotomy and occasionally one or more imaging studies. However, recurrent cancer has a large spectrum of behavior making it relatively difficult to diagnose a relapse and determine the aggressiveness of the
Second-Look Surgery :
The use of second-look surgery can help diagnose and manage ovarian cancer. The typical indication for which a Second-look is performed at our center is when an incomplete Cytoreduction has been performed at the first instance (usually by an inexperienced surgeon). Another rare instance is when an incomplete Cytoreduction was performed due to the poor general condition of the patient at the time of the first surgery, which has significantly improved after the adjuvant intra-venous chemotherapy. There is a recently published multi-centric studyref that strongly supports the role of HIPEC in this situation with more than doubling of the survival compared to historical standards. We promote the use of HIPEC in this situation and have had encouraging results for our patients.
Treatment of Recurrent Cancer :
Patients who develop recurrent cancer despite surgery and primary chemotherapy, and will be given salvage chemotherapy, may be placed into one of three groups (A-C):
Group A: are patients resistant to primary therapy and have shown tumor growth during treatment. This persisting tumor is considered to be refractory i.e. have absolute platinum-resistance. Secondary non-cross resistant chemotherapies or biological therapies should be considered.
Group B: are patients who respond well to initial chemotherapy, but develop recurrent cancer within months after the end of primary care. This group with relatively platinum resistant tumor has an intermediate prognosis.
Group C: are patients who showed a good response to primary chemotherapy, and did not develop recurrent cancer for more than 6 months after the end of primary treatment. This group with platinum-sensitive tumor shows the best responses to re-treatment with a platinum-containing regimen.
The probability of response to salvage chemotherapy is also markedly dependent upon the number of preceding chemotherapy regimens, such that
third and fourth line chemotherapies are of limited benefit. However, unique patients responding to multiple retreatments with even the same regimen of chemotherapy are sometimes observed. Tumor burden, as assessed by the size of the largest lesion and the number of disease sites and histology (serous having the best outcome) are also independent predictors of response to salvage chemotherapy.
CRS and HIPEC in Recurrent Ovarian Cancers:
Selected patients with recurrent ovarian cancers can have a remarkable response with a well-performed CRS, especially if combined with HIPEC. Recent studiesref have shown that the survival can almost equal that of patients with primary stage III disease, provided a complete CRS (removal of all visible disease) can be achieved and combined with HIPEC. Usually such a surgery needs to be undertaken after some cycles of chemotherapy to ensure that all disease is resected. It is of paramount importance that a HIPEC expert undertakes this surgery to deliver optimal results. We have been regularly performing this surgery for recurrent ovarian cancers with encouraging outcomes.
Drug Resistance :
The likelihood a patient will respond to salvage chemotherapy correlates with, for the most part, the cancer's degree of platinum drug resistance
The Gynecological Oncology Group (GOG) defines platinum resistance as meeting
any of the criteria listed below:
- 1. Disease progression while on a first-line platinum-based regimen
- 2. Tumor progression within 6 months of completion of platinum-based therapy
- 3. Persistent clinically measurable disease with best response as stable disease at the completion of planned first-line therapy
- 4. Persistent clinically measurable disease with best response as stable disease with rising CA 125 while receiving first-line non-protocol therapy. Rising CA 125 levels must be documented with two examinations where the last result being greater than or equal to 100.
The most commonly used indicator of resistance is the period of time between the end of primary chemotherapy and relapse: the longer this length of time, the better the chances of responding to salvage chemotherapy.
Cancer that relapses after primary treatment using a single platin analog will have less resistance to treatment than cancer that relapses after primary treatment using multi-agent treatment
Generally, about 25%, 33%, and 60% respond to salvage treatment when their time between last chemotherapy and relapse is 6-12 months, 12-24 months, and greater than 24 months respectively.
An integrated team approach between the surgeon and the medical oncologist is necessary to deliver good results in these complex situations. In rare instances, CRS and HIPEC can be performed even in drug-resistant recurrent ovarian cancers with encouraging results. However, these patients are selected after a thorough evaluation and counseling as not all patients will benefit from this treatment.
Tags : Ovarian Cancer | Stage III Ovarian Cancer | Recurrent Ovarian Cancer | Second-look surgery | HIPEC in Ovarian Cancer | Surgery in Ovarian Cancer | Uterus Cancer | Causes of Ovarian Cancer | Treatment of Ovarian Cancer | Symptoms of Ovarian Cancer | What are the Symptoms of Ovarian Cancer | Surgeries for Ovarian Cancer | Dr. Sanket Mehta
is a cancer of the smooth lining of the membrane enveloping the chest, lungs, heart, and abdomen. This layer is made up of mesothelial cells, hence the name mesothelioma. Mesothelioma is a diffuse but solid tumor that begins as a result of insult to the tissues caused by asbestos particles. These have penetrated into the pleural cavity of the chest or into the abdomen. Mesothelioma is either called pleural mesothelioma or peritoneal mesothelioma based on where it appears.
Because it occurs in such a small number of patients, mesothelioma is often referred to as an orphan disease. Numbers of newly affected individuals is 1/million/year. A steady rise in cases is reported in North America, Europe, Australia, and Asia.
In its early stages mesothelioma is difficult to detect as it may start with a thickening of the pleura or peritoneum, or fluid collection, which can be associated with many other conditions. In time, it begins to demonstrate progression forming a more pronounced irregular rind and nodules, which coalesce into a crust that compresses and invades into adjacent structures. In the abdominal cavity, it can invade into the liver and bowel rendering the patient inoperable. Peritoneal mesothelioma is often found coating the omentum described sometimes as a salt like sand like particles too numerous to count and impossible to remove without sacrificing the entire omentum. Involvement of the ovaries and fallopian tubes is not uncommon in women and often mesothelioma is confused with ovarian cancer. Once vital organs are involved or disease identified outside of the operative field, surgery is no longer an option and patients are referred to chemotherapy or clinical trials.
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For the vast majority of patients, as the tumor mass grows, once subtle symptoms will give way to weight loss, cough, respiratory infections, fatigue, shortness of breath, digestive and bowel problems and pain in the chest or abdomen, depending upon whether it is pleural or peritoneal. The peritoneal mesothelial cells are designed to provide lubricating secretions which allow the organs in each respective space to move freely. When the cells of the mesothelium malfunction due to the cancer's progress, an overproduction of this fluid often results. This is called ascitis and causes many of the symptoms.
The symptoms gradually become more noticeable prompting the patient to seek a medical consultation. By this time the progression of the disease may already be too advanced as the tumor may have spread to the lymph nodes and/or begun to metastasize to remote organs of the body like the brain, spleen, liver or kidneys. Metastatic mesothelioma is considered late stage and incurable, given the current state of treatments. It is of utmost importance that once the diagnosis is made, the patient should be referred to a specialist to ensure optimum outcome.
Treatments for Peritoneal Mesothelioma
The abdomen is a complex space, filled with a variety of easily damaged and extremely important organs. A cancer affecting the abdominal lining, or peritoneum is therefore a very serious and hard to treat matter.
The peritoneum is made of two parts, the visceral and parietal peritoneum. The visceral peritoneum covers the internal organs and makes up most of the outer layer of the intestinal tract while the parietal peritoneum covers the abdominal cavity.
Unique structures inside the abdomen make treating peritoneal mesothelioma both more difficult and, in some ways, easier than pleural mesothelioma. Cytoreductive surgery coupled with Hyperthermic Intraperitoneal chemotherapy (HIPEC) is now considered to be the standard of care in peritoneal mesothelioma. Extended survivals have been reported by a select group of surgeons who specialize in the treatment of peritoneal mesothelioma. The survival statistics reported in surgical series far exceed survival statistics in chemotherapy trials. Unfortunately because the number of cases is reported at 250 new cases per year, a trial to provide this information would not be able to accrue the number of patient necessary to answer the question. The treatment varies with the surgeon and research is still underway to develop the optimal treatment plan.
The initial surgery, or Cytoreductive surgery as it is referred to, will include an exploration of both the peritoneum and pelvic structures. The disease is often described as salt like sand like structures that can be found on all surfaces of the abdomen. This includes the length of bowel, which needs to be painstakingly explored, the omentum is removed, as it is usually studded with disease, and the tumor deposits are scraped off of all the visceral organs. However, the disease consists of two components �?the macroscopic or visible disease and the microscopic component which consists of microscopic cells that are not visible to the naked eye and which tend to be widely distributed all over the peritoneal surface. These microscopic cells as well as small deposits of tumors left behind are taken care of by the Hyperthermic Intraperitoneal chemotherapy (HIPEC). Like pleural mesothelioma imaging is not optimal and in many patients more disease than anticpated is found at the time of surgery.
Unlike pleural mesothelioma the typical staging system is neither applicable nor helpful in predicting survival in peritoneal mesothelioma. Dr Paul Sugarbaker is credited with the creation of the peritoneal cancer index score. This staging system takes place at the time of surgery. The abdomen and pelvis are divided into 13 sections and scores are assisgned based on the largest tumor found within each of these designated areas. A score is sometimes assigned prior to and following the surgical procedure.
The surgical procedure itself is referred to as a Cytoreduction. Long-term survival is associated with a score of CC 0 or CC1 - these are considered complete resections. Scores of CC2-CC3 predict relapse and shortened survival. Grade of tumors, extent of disease, amount of residual tumors post surgery and involvement of lymph nodes are factored together to assign a score.
The relative ease of access to the abdomen has numerous interesting benefits, however. The stomach wall can easily be entered to allow access to the abdominal space and this means that the area can support multiple debulking surgeries and inspections to keep the tumor in check. Repeated surgeries often result in the formation of scar tissue, which can result in mechanical small bowel obstructions, painful strictures and digestive problems. Repeated surgery is not a standard of care but is assessed thoroughly by surgical specialists on an individual basis. Cytoreductive surgery coupled with Hyperthermic Intraperitoneal chemotherapy (HIPEC) is now considered to be the standard of care in peritoneal mesothelioma, and all other forms of treatment like radiotherapy, immunotherapy should be offered only in the setting of a clinical trial. Intra-venous chemotherapy is used as an adjunct to Cytoreductive surgery and HIPEC, or it may be used in the palliative setting to control the symptoms and ascites.
Several treatment centers now offer peritoneal mesothelioma treatment with Cytoreductive surgery and HIPEC, with other modalities like chemotherapy, radiation etc. given either during or after the surgeries. Success with this approach has been excellent and there are now a number of long term 7+ year survivors of peritoneal mesothelioma as proof of the value of this multimodality approach. This surgery, though similar, is quite different from the debulking surgery approved for use in ovarian cancer. The doses and types of chemotherapy agents differ, as do the resulting morbidity and mortality from surgery. This surgery should only be considered if a patient is under the care of an experienced HIPEC surgeon.
Relapse patterns have been studied and interesting data has been reported that genetic mutations can also play a role in predicting poor survival and relapse in patients undergoing Cytoreductive surgery and HIPEC for peritoneal mesothelioma. In time, this will assist in determining who should be referred to surgical treatment or perhaps therapies will be developed to target these mutations prior to undergoing surgery. This is a major breakthrough in understanding the natural history of this disease.
Primary Peritoneal Cancers
Gastrointestinal & Colon Cancers
The colon is the part of the digestive system where the waste material is stored. The rectum is the end of the colon adjacent to the anus. Together, they form a long, muscular tube called the large intestine (also known as the large bowel). Tumors of the colon and rectum are growths arising from the inner wall of the large intestine. Benign tumors of the large intestine are called polyps. Malignant tumors of the large intestine are called cancers. Benign polyps do not invade nearby tissue or spread to other parts of the body. Benign polyps can be easily removed during colonoscopy and are not life-threatening. If benign polyps are not removed from the large intestine, they can become malignant (cancerous) over time. Most of the cancers of the large intestine are believed to have developed from polyps. Cancer of the colon and rectum (also referred to as colorectal cancer) can invade and damage adjacent tissues and organs. Cancer cells can also break away and spread to other parts of the body (such as liver and lung) where new tumors form. The spread of colon cancer to distant organs is called metastasis of the colon cancer. Once metastasis has occurred in colorectal cancer, a complete cure of the cancer is unlikely.
What are the causes of colon cancer?
Doctors are certain that colorectal cancer is not contagious (a person cannot catch the disease from a cancer patient). Some people are more likely to develop colorectal cancer than others. Factors that increase a person's risk of colorectal cancer include high fat intake, a family history of colorectal cancer and polyps, the presence of polyps in the large intestine, and chronic ulcerative colitis.
Diet and colon cancer
Diets high in fat are believed to predispose humans to colorectal cancer. In countries with high colorectal cancer rates, the fat intake by the population is much higher than in countries with low cancer rates. It is believed that the breakdown products of fat metabolism lead to the formation of cancer-causing chemicals (carcinogens). Diets high in vegetables and high-fiber foods such as whole-grain breads and cereals may rid the bowel of these carcinogens and help reduce the risk of cancer.
Colon polyps and colon cancer
Doctors believe that most colon cancers develop in colon polyps. Therefore, removing benign colon polyps can prevent colorectal cancer. Colon polyps develop when chromosome damage occurs in cells of the inner lining of the colon. Chromosomes contain genetic information inherited from each parent. Normally, healthy chromosomes control the growth of cells in an orderly manner. When chromosomes are damaged, cell growth becomes uncontrolled, resulting in masses of extra tissue (polyps). Colon polyps are initially benign. Over years, benign colon polyps can acquire additional chromosome damage to become cancerous.
Although colon cancer and rectal cancer share many features, there are important differences between these two diseases including, especially, the tendency for rectal cancer -- but not colon cancer -- to recur locally. Local recurrence of rectal cancer is common after standard surgery and is often catastrophic. It is difficult to cure, and the associated symptoms are debilitating. Accordingly, preventing local recurrence is one of the main treatment goals with rectal cancer.
The prognosis (outlook) with rectal cancer is clearly related to the degree of penetration of the tumor through the bowel wall and the presence or absence of lymph node involvement. These two characteristics form the basis for all staging systems developed for this disease.
The standard surgical procedure is called total mesorectal excision (TME) . Preoperative chemoradiotherapy has been found to reduce the risk of local recurrence and to cause fewer long-term toxic effects than if the chemoradiotherapy is given postoperatively. Broadly, at five years, the overall survival among patients with locally advanced rectal cancer, irrespective of whether they have had preoperative or postoperative chemoradiotherapy, is about 75%.
The treatment options for rectal cancer depend on several factors and the decision for each case is often an individualized decision for that particular patient. Certain guidelines are quite clear and if the patient falls within those criteria, the treatment is standard. For example:
- In case of early rectal cancer where the tumor is confined to the wall of the rectum and does not extend to the surrounding fat or mesorectum with no lymph node involvement, the treatment is surgery. Often this surgery will be performed laparoscopically or occassionally even through the anal canal (Transanal endoscopic surgery).
- In cases where the carcinoma is very close to the anal sphincter (the muscle controlling defecation) and/or is large in size with lymph node spread or spread into the mesorectum (the fat surrounding the rectum), the best treatment option is to go for neo-adjuvant long-course chemo-radiotherapy (which is a combination of radiotherapy for 5 weeks along with oral chemotherapy) followed by a surgery after 6 weeks of completion of radiotherapy. The advantages of performing radiation prior to surgery are:
- a. Increased rate of sphincter saving surgeries: This form of radiotherapy significantly reduces the bulk of the tumor and its extent of spread making a sphincter-saving surgery possible in several cases where otherwise an abdominoperineal resection with a permanent colostomy would be required.
- b. Decreased local recurrence rate: Giving chemoradiation prior to surgery decreases the local recurrence rate of the cancer compared to the older approach of surgery followed by radiotherapy.
- c. Lesser long-term side-effects: Since the part being irradiated is removed later during surgery, the patient suffers very few long-term side-effects, especially with the more recent methods of delivery of radiotherapy.
- d. The decrease in the tumor size also means that majority of these tumors can still be operated by laparoscopic techniques.
- In certain circumstances a neo-adjuvant short-course radiotherapy may give an equivalent effect as a long-course radiotherapy. However, these cases have to carefully selected and individualized so as to maintain the efficacy of the treatment.
- In cases where the cancer has already spread (for example to distant nodes or the liver or the lungs) but both the primary tumor and the metastatic site are operable, the surgery can still be performed with excellent outcomes. However, the surgery, chemotherapy and the radiotherapy have to be accurately timed to get the optimum outcome. In most such cases, the radiotherapy used may be short-course radiotherapy to decrease the time that the patient is off chemotherapy.
Dr. Sanket Mehta regularly performs rectal cancer surgery laparoscopically. He specializes in the treatment of loco-regionally advanced and operable metastatic rectal cancer. He has performed several major synchronous resections of the rectum with liver metastases or peritoneal metastases, along with CRS and HIPEC in case of pertitoneal disease
Pancreatic cancers are often aggressive cancers and the treatment depends on the extent of spread of the cancer and overall health of the patient. Your doctor will advice you the exact treatment plan after a thorough evaluation and adequate investigations which may include a CT scan, MRCP and even an endoscopic evaluation.
The main stay in the treatment of pancreatic cancer is surgery. Though the surgeries take long hours and involve complex procedures, with advances in anaesthesia, medical and intensive care, and better equipment; these surgeries have now become safe and involve a very low mortality rate.
The surgery required depends on the location of the tumor.
Lesions located in the head of the pancreas are treated by a surgery called the Whipple’s Surgery or Pancreatoduodenectomy. It involves removal of the pancreatic head together with the duodenum, part of the bile duct and the gall bladder. The continuity is then restored by anastomosing the remnant pancreas, the bile duct and finally the stomach to the jejunum.
Lesions located in the body and tail of pancreas are treated by a surgery called as distal pancreatectomy. It involves removal of the body and tail of the pancreas and may involve removal of the spleen as well.
Dr. Sanket Mehta not only performs these surgeries routinely, he also performs distal pancreatic surgery by the laparoscopic approach. His study on laparoscopic distal pancreatic surgery and its advantages has been published in Surgical Endoscopy, the highest rated endoscopy journal.
Liver cancer (hepatocellular carcinoma) is a cancer arising from the liver. It is also known as primary liver cancer or hepatoma. The liver is made up of different cell types (for example, bile ducts, blood vessels, and fat-storing cells). However, liver cells (hepatocytes) make up 80% of the liver tissue. Thus, the majority of primary liver cancers (over 90%-95%) arises from liver cells and is called hepatocellular cancer or carcinoma.
When patients or physicians speak of liver cancer, however, they are often referring to cancer that has spread to the liver, having originated in other organs (such as the colon, stomach, pancreas, breast, and lung). More specifically, this type of liver cancer is called metastatic liver disease (cancer) or secondary liver cancer. This is a much more common problem around the world than primary liver cancer and frequently leads to confusion, because the term liver cancer actually can refer to either metastatic liver cancer or hepatocellular cancer.
What are the Symptoms of Liver Cancer?
Most of the time liver cancer in the early stages does not cause symptoms. If symptoms are present, they may include:
unexplained weight loss
on-going lack of appetite
fullness after a small meal
a swollen liver or a mass that can be felt in the area of the liver
ongoing stomach pain extending to the back and shoulder
a swollen abdomen
yellow-green color to the skin and eyes (jaundice)
increased symptoms of illness in those who have chronic hepatitis or cirrhosis
Gall Bladder Cancers
The gall bladder is a small pouch that stores and concentrates bile. Bile is a fluid that helps us to digest food. Its main function is to break down fats in food. Bile is made by the liver and stored in the gall bladder. The gall bladder is connected to the small intestine and the liver by the bile ducts.
Causes and Risk Factors
The cause of most gall bladder cancers is unknown. There are a number of risk factors that may increase your chances of developing this type of cancer. These include:
Gall stones and inflammation Gall bladder cancer is more likely to occur in people who have a history of gallstones or in people who have inflammation of the gall bladder (cholecystitis). However, most people who have gallstones or an inflamed gall bladder won't develop gall bladder cancers.
Polyps These are non-cancerous (benign) tumours of the gall bladder that increase the risk of developing gall bladder cancer.
Abnormal bile ducts Gall bladder cancer is slightly more common in people who are born with (congenital) abnormalities of the bile ducts.
Porcelain gall bladder People who have a condition called porcelain gall bladder, in which calcium forms in the wall of the gall bladder, also have a slightly increased risk of this type of cancer.
Smoking Some evidence suggests that people who smoke cigarettes are more likely to develop gall bladder cancer.
Family history People who have a close relative (parent, brother or sister) with gall bladder cancer have a slightly higher risk of developing this type of cancer.
Obesity Being overweight increases your risk of developing gall bladder cancer.
Early gall bladder cancer often causes no symptoms and is usually discovered unexpectedly when someone has surgery to remove gallstones. About 1 in 5 gall bladder cancers are found in this way.
Most tumours are only discovered at an advanced stage. They can cause a variety of symptoms, including sickness, high temperatures, weight loss and pain in the tummy (abdomen).
If the cancer blocks the bile duct, it may stop the flow of bile from the gall bladder into the small bowel. This causes bile to flow back into the blood and body tissues, and leads to the skin and whites of the eyes becoming yellow (known as jaundice).
The urine also becomes a dark yellow colour and stools (bowel motions) are pale. The skin may become itchy.
These symptoms may be caused by other problems, such as gallstones or infection of the gall bladder, but it's important to get them checked by your doctor.
Tags : Gallbladder cancer | Gall bladder stone| Gallbladder cancer treatment
Cancer of the oesophagus is a disease in which malignant cells arise from the tissues of the oesophagus (tube leading to stomach). These eventually grow and obstruct the oesophagus, and spread to other parts of the body, such as the liver.
There are two main types of oesophageal cancer: adenocarcinoma and squamous cell carcinoma. Most adenocarcinomas are now thought to arise in Barrett's mucosa (see Barrett's Oesophagus).
The most common sign of cancer of the oesophagus is difficulty in swallowing (dysphagia). Pain in the chest may be felt when swallowing or at other times. Loss of appetite and weight loss will occur. As the oesophagus becomes obstructed, food which has not passed down the oesophagus may spill over into the lungs (aspiration), causing pneumonia.
The decision regarding treatment is complex. There are several options:
- Surgery to remove the cancer, with intent to cure
- Surgery to remove the cancer, to provide palliation (relief)
- Radiotherapy and chemotherapy (alone or combined with surgery)
- Photodynamic therapy (for very early cancers in selected patients)
- Laser therapy (mainly palliative if the cancer is large)
- Stenting (insertion of a tube to prevent the cancer obstructing the oesophagus)
The choice of treatment depends on many factors including the size of the cancer and extent of spread, age and fitness of the patient, and the patient's wishes. The chance of recovery (prognosis) depends on the stage of the cancer (whether it is in the oesophagus or if it has spread outside to other tissues) and the patient's general state of health.
Stomach cancer usually begins in cells in the inner layer of the stomach. Over time, the cancer may invade more deeply into the stomach wall. A stomach tumor can grow through the stomach's outer layer into nearby organs, such as the liver, pancreas, esophagus, or intestine.
Stomach cancer cells can spread by breaking away from the original tumor. They enter blood vessels or lymph vessels, which branch into all the tissues of the body. The cancer cells may be found in lymph nodes near the stomach. The cancer cells may attach to other tissues and grow to form new tumors that may damage those tissues.
The spread of cancer is called metastasis.
When you're told that you have stomach cancer, it's natural to wonder what may have caused the disease. But no one knows the exact causes of stomach cancer. Doctors seldom know why one person develops stomach cancer and another doesn't.
Doctors do know that people with certain risk factors are more likely than others to develop stomach cancer. A risk factor is something that may increase the chance of getting a disease.
Studies have found the following risk factors for stomach cancer:
• Helicobacter pylori infection: H. pylori is a bacterium that commonly infects the inner lining (the mucosa) of the stomach. Infection with H. pylori can cause stomach inflammation and peptic ulcers. It also increases the risk of stomach cancer, but only a small number of infected people develop stomach cancer.
• Long-term inflammation of the stomach: People who have conditions associated with long-term stomach inflammation (such as the blood disease pernicious anemia) are at increased risk of stomach cancer. Also, people who have had part of their stomach removed may have long-term stomach inflammation and increased risk of stomach cancer many years after their surgery.
• Smoking: Smokers are more likely than nonsmokers to develop stomach cancer. Heavy smokers are most at risk.
• Family history: Close relatives (parents, brothers, sisters, or children) of a person with a history of stomach cancer are somewhat more likely to develop the disease themselves. If many close relatives have a history of stomach cancer, the risk is even greater.
• Poor diet, lack of physical activity, or obesity: Studies suggest that people who eat a diet high in foods that are smoked, salted, or pickled have an increased risk for stomach cancer. On the other hand, people who eat a diet high in fresh fruits and vegetables may have a lower risk of this disease. A lack of physical activity may increase the risk of stomach cancer. Also, people who are obese may have an increased risk of cancer developing in the upper part of the stomach.
Most people who have known risk factors do not develop stomach cancer. For example, many people have an H. pylori infection but never develop cancer. On the other hand, people who do develop the disease sometimes have no known risk factors.
The causes of breast cancer are unknown. But certain things called risk factors can affect a woman’s chances of getting breast cancer. Having risk factors doesn’t necessarily mean you will get breast cancer. Some women get it while others (with the same risk factors) don’t.
Even though the exact causes of breast cancer aren’t fully known, it’s likely to be caused by a combination of different risk factors rather than just one.
The risk of breast cancer increases with age. It’s rare in women under 35, and 8 out of 10 breast cancers (80%) occur in women aged 50 or over.
Previous cancer and other breast conditions
Women who’ve had breast cancer or other breast conditions in the past may be at a higher risk of developing breast cancer. This includes women who have previously had:
breast cancer, including ductal carcinoma in situ (DCIS)
lobular carcinoma in situ (LCIS)
an over-production of slightly abnormal cells called atypical ductal hyperplasia
radiotherapy to the chest to treat Hodgkin lymphoma at a young age
dense breast tissue (when the breast is mostly made up of glandular and connective tissue with very little fatty tissue).
Exposure to the hormones oestrogen and progesterone for long, uninterrupted periods can affect your breast cancer risk. Factors that increase this risk include:
taking combined hormone replacement therapy (HRT) containing oestrogen and progesterone over several years (if you’re over 50)
not having children or having them later in life
not having breastfed or breastfeeding for less than a year
starting your periods early (under 12) or having a late menopause (after 50)
taking the contraceptive pill (but the risk reduces if you stop taking it).
The following lifestyle factors may slightly increase your risk of breast cancer:
Drinking more than two units of alcohol a day over many years can damage your liver. This increases your breast cancer risk because the liver helps to control oestrogen levels.
After the menopause, body fat is the main source of oestrogen. So if you’re overweight, the level of oestrogen in your body may be high, increasing your breast cancer risk.
Smoking heavily over many years, especially if you started smoking at a young age, increases your risk.
The increase in the number of cancer cases has been topic of worry for the world. In females, the breast cancer has been the second cause of cancer related death (first is lung cancer). Every year, there is alarming increase in newly diagnosed cases of breast cancer in females. It is one of the common cancers affecting females. According to statistics 1 out of 8 females are at risk for developing breast cancer. It is important therefore to detect the early signs of this disease and to treat it at proper time to reduce the morbidity and mortality induced by it.
To know more about the disease, we have to understand its risks, causes, prevention and treatment modalities.
Risks & Causes:
• Age: The chances of breast cancer increase as you get older.( 79 % new cases detected around 50 years of age and minimal after 80 years )
• Family history: The risk of breast cancer is higher among women who have relatives with the disease. Having a close relative with the disease (sister, mother, or daughter) doubles a woman's risk.
• Personal history: Having been diagnosed with breast cancer in one breast increases the risk of cancer in the other breast or the chance of an additional cancer in the original breast.
• Inherited genetic risks: Certain inherited genes, including BRCA-1 and BRCA-2, are associated with a significantly increased risk of breast and other cancers. Please ask the doctor for GENETIC COUNSELLING services. Only about 15%-20% of familial breast cancers are attributed to BRCA-1 and BRCA-2.
• Women diagnosed with certain benign breast conditions have an increased risk of breast cancer. These include atypical hyperplasia, a condition in which there is abnormal proliferation of breast cells but no cancer has developed.
• Having no children or the first child after age 30 increases the risk of breast cancer.
• Breast feeding 1 year or more over a woman's lifetime has been shown to lower the risk of breast cancer.
• Other contributing factors are alcohol intake, recent use of contraceptive, postmenopausal obesity.
What are the signs to be looked for?
It is important for every women to check her breast by palpate on regular basis to look for any change in size, color, shape or presence of lump.
• An area of thickened tissue in a breast
• One of the nipples has a discharge; sometimes it may contain blood
• The nipple changes in appearance; it may become sunken or inverted
• The size or the shape of the breast changes
• The nipple-skin or breast-skin may have started to peel, scale or flake
The disease when detected early has good prognosis and greater chance of cure. It is important to make accurate diagnosis which is possible now due to advanced medical diagnostic procedures which include:
Mammography: It is the gold standard for treatment planning in breast diseases. Mammography is a combination of film mammography and sono-mammography. For the film mammography, it is essential that the machine used for the mammography is of adequate quality, else fine micro calcifications and subtle lesions can be missed. For the sono-mammography, it is essential that the radiologist involved must have adequate experience in reporting breast sonography. Mammography also helps decide the kind of surgery (breast conservation vs. mastectomy) and need for intervention in the opposite breast.
Bone scan: A bone scan determines if the cancer has spread (metastasized) to the bones
CT scan or Positron emission tomography (PET-CT scan) may be required to look for spread to other organs.
The primary goal in treatment of breast cancer is to remove the tumor by surgery. There are different kinds of surgery depending upon the area of disease ranging from simple lumpectomy, breast conservation surgery (BCS) or mastectomy. With newer surgical techniques, the breast cancer treatment has become more effective and cosmetic. The advancement in plastic surgery especially for breast cancer treatment not only helps in removal of cancer tumor and affected area but also maintains the proper shape and size of breast. Depending on age at diagnosis, 20%-40% of women who undergo mastectomy elect to have breast reconstruction, either with an implant, tissue from another part of the body, or a combination of the two. The BCS and mastectomy is accompanied by removal of lymph nodes. The presence or absence of any cancer in the lymph node helps in deciding the type of treatment to be taken like chemotherapy, radiation or hormonal treatment.
Hormonal Treatment: Estrogen, a hormone produced by the ovaries, promotes the growth of many breast cancers. Women whose breast cancers test positive for estrogen or progesterone receptors can be given hormone therapy to lower estrogen levels or to block the effects of estrogen on the growth of breast cancer cells. Tamoxifen and toremifene (Fareston) are drugs that prevent estrogen from binding to breast cancer cells and are effective in both postmenopausal and premenopausal women. Treatment of ER+ breast cancer with tamoxifen for 5 years has been shown to reduce the rate of recurrence by 39% throughout the first decade, and reduces breast cancer mortality by about one-third throughout the first 15 years.
Radiation therapy is the use of high-energy beams or particles to kill cancer cells. Radiation may be used after potentially curative surgery to destroy cancer cells remaining in the breast, chest wall, or underarm area. BCS is almost always followed by radiation therapy because it has been shown to reduce the risk of cancer recurrence by about 50% and the risk of breast cancer death by about 20%. Some mastectomy patients also require radiation if their tumor is larger than 5 cm or when cancer is found in the lymph nodes. Radiation can also be used to treat the symptoms of advanced breast cancer, especially when it has spread to the central nervous system or bones.
The effect of Chemotherapy is usually dependent on number factors like size, type of tumor, amount of HER2 protein made by cancer cells, estrogen and progesterone receptors etc. Usually combination therapy helps more than single drug therapy. Depending on the combination of drugs used, chemotherapy is usually given for 3 to 6 months. Chemotherapy is most effective when the full dose and cycle of drugs are completed in a timely manner.
Approximately 15% to 20% of breast cancers overproduce the growth-promoting protein HER2. These tumors tend to grow faster and are generally more likely to recur than tumors that do not overproduce HER2. Trastuzumab (Herceptin) is a monoclonal antibody that directly targets the HER2 protein. The combined results of two large trials indicate that adding trastuzumab to standard chemotherapy for early stage HER2-positive breast cancer reduces the risk of recurrence and death by 52% and 33%, respectively, compared to chemotherapy alone.
About the endocrine system and endocrine tumors
The endocrine system consists of cells that make hormones. Hormones are chemical substances that are formed in the body and carried in the bloodstream to have a specific regulatory effect on the activity of other organs or cells in the body.
A tumor begins when normal cells begin to change and grow uncontrollably, forming a mass. A tumor can be benign or malignant. A benign tumor is not cancerous and usually can be removed without it causing much harm. A malignant tumor is cancerous and can be harmful if not found early and treated. It can spread to and damage the body’s healthy tissues and organs.
An endocrine tumor is a growth that affects the parts of the body that secrete hormones. Because an endocrine tumor arises from cells that produce hormones, the tumor itself can produce hormones and cause serious illness.
About neuroendocrine tumors
A neuroendocrine tumor begins in the hormone-producing cells of the body’s neuroendocrine system, which is made up of cells that are a cross between traditional endocrine cells (or hormone-producing cells) and nerve cells. Neuroendocrine cells are found throughout the body in organs, such as the lungs and gastrointestinal tract (such as the stomach and intestines), and perform specific functions, such as regulating the air and blood flow through the lungs and controlling the speed at which food is moved through the gastrointestinal tract.