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Choosing the right oncosurgeon

Choosing the right oncosurgeon

 Fear, anger, disbelief, rejection… these are just some of the emotions that a person goes through when they hear a diagnosis of cancer.

This is true for almost all cancer patients, but equally true is the fact that they all come to terms with it… some sooner, some a bit later. And the sooner you make peace with the reality, the faster you can start taking proactive steps to wage a battle against cancer.

There are different cancers and different stages which call for different treatment modalities. Some may require chemotherapy, some radiation therapy, some may require surgery, and some may require a combination of two or more of the above interventions.

In this article we are focusing primarily on choosing an oncosurgeon, (if you have been advised surgery) since getting operated is always a scary thought and choosing a surgeon is the hardest part. unless you have full faith and confidence in the competence and credibility of your oncosurgeon, you will always have second thoughts. So choose wisely.

Let us try and understand how we can make this choice, a well informed and a well researched one:

  1. Referring Physician: This would most probably be your family doctor or physician. They are the ones who are most familiar with your medical history and also the ones you have the most faith in. They have, in all probability, referred you to an oncosurgeon, who is best suited to treat your particular type of cancer. They would also be the ones who would be closely involved with you and the operating doctor throughout the course of your treatment. So your best bet would be to consult with the specialist, they have referred to.
  2. Second opinion: Whatever your stage of cancer, there is always time for a second opinion. A second opinion is important as it helps you to compare treatment protocols. Check whether the recommendations of the 2 doctors match each other or there is a difference of opinion. Also helps to compare other things such as facilities offered, choice of hospital, techniques of surgery, cost of treatment, etc. It helps you make a more informed decision. Remember, in the end its your choice.
  3. Background search: It wouldn’t hurt to do some background research about the doctor you have been referred to on your own, either on the internet or through your friends and family who have had some direct or indirect experience about that cancer specialist. This research should typically be focused on:
    1. The credentials of the oncosurgeon. What is his/her degree? Is it from a reputed institution and/or national or state board? Have they done any specialisation in the field of oncosurgery?
    2. Do they focus on any specific organ or do they perform multi-organ surgeries.
    3. Are there any advanced techniques which they are skilled in such as robotic surgery, minimally invasive surgery, or any technique which they have patented or pioneered in?
    4. Have they received any special training in treating your specific type of cancer?
    5. What is their ability to handle complicated cases as well as what is the percentage of complications expected and encountered by them specific to your type of cancer?If you don’t find answers to any of the questioned mentioned above or have any other questions in mind, you can always ask them to the doctor, without being embarrassed about it. Its your right to know.
  4.  Experience of the oncosurgeon: experience both in terms of number of years in practice as well as the number of surgeries performed. A doctor who has more experience in operating on a certain type or types of cancers, has more experience in dealing with intraoperative complications and resolving them and consequently has more likelihood of giving better results.
  5. Personality: Many would argue that the personality of a doctor or their approach towards the patient has nothing to do with his/her skills in the operation theater, but there is an important component of any doctor-patient relationship and that is “the comfort level.” Unless you are comfortable sharing your doubts and queries with the doctor and get the feeling that the doctor is genuinely interested in hearing your problems and always has your best interest at their heart, you would not like to get operated from such a doctor, however competent or reputed. So the most important thing to look for in a doctor is approachability. He/she should have a pleasant personality, make you feel important, be willing to clear all your doubts, however silly, and most importantly take your preferences and wishes into consideration.
  6. Additional facilities: A cancer surgery is not a walk-in, walk- out procedure. The entire process may take anywhere from a few days to a few weeks. So, many other factors should be taken into consideration while selecting an oncosurgeon:
    1. Is he/she going to operate in a multispeciality hospital with state of the art latest equipments and a large ICU setup with round the clock monitoring
    2. what are the types of accommodation facilities at the hospital for you and your attendant, relative or friend.
    3.  Does he/she have a team of doctors which can handle other related aspects of the disease such as, your medicine or surgical side effects like pain, nausea, vomiting, infections, etc.
    4. Does he/she have a team of support staff such as an on-call secretary through whom you can be in constant touch with your surgeon, a billing assistant, a mental health counsellor, a follow- up counsellor, a diet counsellor, a physical therapist etc.
    5. what are the modes of payment accepted by your surgeon and the hospital. Do they have cashless mediclaim facility, do they have medical loan facility, do they have installment facilities etc.
  7. Patient testimonials and reviews: Nothing puts a troubled mind to ease more than knowing that someone else has gone through what you are going through right now and come out victorious. So reading testimonials of other patients who have been treated by the doctor of your choice is the best way to judge the competence of your doctor. You should be able to find patient testimonials at your oncosurgeons office either in written form or as a video. Alternatively you can ask for contact number of patients who are willing to share their story. You would be surprised, that most of the times, you will find answers to questions you had never even thought of. You can also read reviews on social media and the internet, but beware, along with genuine reviews, there are a lot of negative comments posted by people with mala fide interests. Use your better judgement.
  8. Be informed, but not influenced: Information is never a bad thing. But knowing the difference between the right and the wrong kind of information is of paramount importance, especially when it relates to something as serious as cancer. For every 1 piece of well researched, well documented, scientifically and  medically proven treatment modality, there are hundreds of baseless claims, unresearched, unproven alternative treatments offered with the promise of a sureshot cure. Please don’t believe in it. Not only do they give you false hope, they end up creating more confusion and chaos, which delays your treatment and reduces your chances of a quick recovery. It is a good idea to learn more about your disease, the kind of treatment options available, the latest developments and research in the field. It helps you frame your questions, more accurately for your doctor. And if you have read or heard about any such alternative treatment option, place it in front your oncosurgeon during your consultation. They will be more than willing to clear your doubts.  Finally, just like there are no guarantees in life, so too, no cancer surgeon can guarantee that you would be totally cured or that there wont be any complications during or after your surgery. But if you have taken the efforts to do due-diligence while selecting your surgeon, it will stack the odds highly in your favour.
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CAR T cells

CAR T cells

 Chimeric antigen receptor (CAR) T cell therapy is a new form of cancer therapy and is showing a lot of promise.

T cells are a part of body’s immune system. They are a type of white blood cells. T cells have proteins on their surface which act as receptors. Any foreign substance that enter the body like bacteria and virus also have proteins on their surface. Whenever T cell receptors come across the protein antigen of the foreign substance, the latch onto it and destroy the foreign substance. But Not every T cell receptor can bind to every protein antigen since both the receptors as well as antigen on foreign bodies are differently shaped. Only those that fit their receptors can be destroyed.

This forms the basis of CAR T cell therapy in cancer therapy. Since cancer cells also have antigens and can bind to T cells receptors but it is rarely a perfect fit, scientists have developed a novel method of help the T cells bind more accurately to a particular type of cancer cell.

The process:

  1. Firstly patients are evaluated thoroughly via a series of tests to assess if CAR T cell therapy would be useful in their case or not

  2. Secondly blood is drawn patients into a machine where white blood cells are removed along with the T cells and remaining blood is sent back into the patients body.

  3.  Next, T cells are separated from the rest of the white cells. They are sent to the laboratory where Chimeric antigen receptors CARs are added to the T cells, creating CAR T cells which can recognize antigen on the targeted tumor or cancerous cells.

  4. These reengineered T cells are then allowed to multiply in the lab until there are millions of them. This process can takes weeks.

  5. These millions of CAR T cells are then frozen and sent back to the hospital to be infused back into the patient. This is done via an IV line just like blood transfusion. Patients may receive chemotherapy prior to infusion of Car T cells, to prepare the immune system to receive the CAR T cells.

  6. Once inside the patients body, the CAR T cells start binding with the specific cancer cells against which they have receptors and once attached they increase in number and can destroy the cancer cells.

At present CAR T cells have been approved some few types of leukemias and lymphomas as well as multiple myelomas. However multiple clinical trails are underway across the world to check its effectiveness in various other types of cancers.

Side effects: Most of the complications are generally temporary and not quite severe, yet sometimes the therapy can cause some serious side effects.

The main amongst these are:

  1. Cytokine release syndrome CRS: When CAR T cells multiply, they release a huge amount of a chemical called cytokine which triggers an inflammatory condition called CRS. The symptoms of this can cause:

    High fever

    Chills

    Breathing difficulty Nausea, vomiting diarrhoea Fatigue

    Low blood pressure Rapid heartbeat Cardiac arrest

    Heart failure

    Multiple organ failure

  2.  There may also be neurological side effects such as Confusion

    Dizziness Delirium Seizures

    Loss of balance Trouble speaking

    Other symptoms also include allergic reaction during infusion Weakened immune system making one susceptible to other infections

This is why, the patient has to be kept in the hospital for a few weeks under strict observation and periodically evaluated for the next 2-3 months post treatment to check for side effects and treatment response.

In India, Tata memorial hospital (TMH) recently conducted the first CAR T cell therapy at the Bone Marrow Transplant unit at ACTREC in Mumbai in association with the Bioscience and Bioengineering (BSBE) department of IIT Bombay who designed and manufactured the CAR T cells.

A sum of Rs 19.15 crores has been approved by the National Biopharma Mission and BIRAC to the team to conduct the first- in-human phase-1/2 clinical trial of CAR T cells.

The clinical trials are being conducted byDr. Gaurav Narula, Professor of Paediatric Oncology and Health Sciences and his team from TMC (TATA MEMORIAL CENTER) mumbai. And the CAR T cells were manufactured by prof. Rahul Purwar of the BSBE department and his team from IIT-B.

Although this therapy is a great breakthrough in the field of cancer treatment, yet the cost is highly prohibitive and can run into crores of rupees per therapy.

The team of IIT-B along with the team from TMH are working relentlessly to make the trial a success and more importantly trying to make the treatment more affordable to the patients. And if the trials are successful, it could help save millions of lives. We at Specialty Surgical Oncology, are proud of these achievements and congratulate the team of TMH as well as IIT-B. Kudos to them!!!

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What is Survival rate?

What is Survival rate?

What is Survival rate: Survival rate is a statistics that tells you, what percentage of people, with a certain type of cancer, survive for a specific amount of time.

Survival rates are usually represented in percentages and are usually described in a given length of time. For eg.,

1 year survival rate 5 year survival rate 10 year survival.

The most commonly used length of time is the 5-year survival rate.

A 5-year survival rate is the number of people who are alive 5 years after they were diagnosed with a certain type of cancer or started treatment for that cancer.

In other words, If the 5-year survival rate for a specific type of cancer is, say cervical cancer in women is about 66%, it would mean that around 66 of every 100 women with cervical cancer will be alive 5 years after the initial diagnosis of the cancer. Conversely it would also mean that around 34 of those 100 women will not live beyond 5 years.

The 5- year survival rate is also calculated according to the stages of a specific cancer.

For eg, the 5- year survival rate for early stage lung cancer is around 56%, whereas the 5- year survival rate for late stage lung cancer is just 5%.

Other types of Survival rates which give a specific information are:

after cancer treatment without any signs or symptoms of the cancer

  • Progression free survival: This shows the number of people who still have cancer, but the disease is not progressing.
  • Median survival: Median survival is the length of time after which 50% of the people have died and 50% have survived. Relative survival rate: This gives the percentage of people who have not died of a particular cancer after a certain length of time. It does not include people who have died of other diseases or other causes.
  • Disease free survival rate: The length of time, people live
    What can Survival rates tell you and what it cant…
    Each and everybody is different and survival rates can in no way paint an accurate picture of your future. At best a survival rate is an educated guess and a prediction, it is by no means a definite figure. It is an estimate of how your disease may progress, and predict the chances of your getting cured as well as recurrence. Also it can help your doctor select the best treatment option for you in terms of choosing better quality of life treatment option with lower side effects is your survival rate is low vs aggressive treatment at the cost of more side effects if your chances of survival are more.
    Your actual Survival depends on a lot of different factors such as
    For eg, if you are relatively young and in good overall health, your chances of survival and subsequent cure are far more than someone who is old and in poor health.
    Also since survival rates such as 5 or 10 year survival rates, take years to collect, they do not include the latest treatments. Cancer treatment is getting better and more effective with each passing day. Hence your chance of beating the survival rate percentages are much better now as compared to few years ago.
    Its your choice: In the end, its completely your decision whether you want to the completely ignore survival rate statistics or just use it as a guideline to get an idea about possible future course. But even if you do want to know about it, remember one thing – don’t read too much into it and get scared. Everybody is capable of beating the worst of odds and emerging victorious. You are much more than a statistics.
    your overall health
    your age
    Your comorbidities
    your cancer type
    Your response to treatment
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Liquid biopsy

Liquid biopsy

Liquid biopsy: A liquid biopsy is blood test that detects tumor DNA that are freely circulating in the blood when cancerous tumor cells die. Elevated levels of these freely circulating tumor cells can be identified in the peripheral blood of the patient as compared to healthy individuals. Its is a non invasive biopsy, in that, it only requires a sample of blood drawn with a syringe instead of the conventional core biopsy which often requires surgery.

The quantity of free circulating DNA has been shown to correlate with tumor burden and determine tumor heterogeneity.

Advantages of Liquid biopsy

  1.  It is quicker, easier and less painful. 

  2.  It is less traumatic for the patient compared to surgical biopsy.

  3. Since it involves drawing blood, it can be repeated multiple times as and when needed.

  4. It helps in early detection of cancer.

  5. It helps to determine whether the patient is responding to the current treatment protocol.

  6. It helps predict the chances of recurrence.

  7. It helps identify treatment resistance.

Role of Liquid biopsy colorectal cancer.

Colorectal cancers (CRC) usually have wide heterogeneity with general genomic instability. Liquid biopsy in CRC helps in analysing circulating tumor cells (CTCs) and genomic material including cell-free DNA (cf DNA) which acts as a complementary tool to solid tumor tissue.

Liquid biopsy detect mutated DNA in the blood and compare then with DNA mutations measured in primary tumor obtained during initial surgery.

It helps measure amount of markers in the blood which could help detect residual disease after surgery, measure response to treatment, disease progression, etc.

Liquid biopsy helps determine tumor genotype to better design treatment effective for the patient. For eg., if the liquid biopsy indicates that a patient responded well to the early chemotherapy, there is a possibility that surgery could potentially cure the disease. But if they did not respond well, its likely the cancer is too widespread and cant be eradicated with surgery and so those patients should receive more chemotherapy to control their disease.

Studies suggest that residual disease detected in liquid biopsies was predictive of outcomes. In addition, it can potentially help identify patient who would be candidates for targeted therapy and immunotherapy, etc.

A new study from Washington School of Medicine in St. Louis, demonstrates that a liquid biopsy examining blood or urine can help gauge the effectiveness of therapy for CRC that has just begun to spread beyond the original tumor.

The study appears online in the Journal of Clinical Oncology Precision Oncology, a journal of the American Society of Clinical Oncology.

Although Liquid biopsy is still in nascent stage, and core biopsy and colonoscopy still remains the gold standard in CRC, several ongoing studies and more and more approvals are in the pipeline and pretty soon, liquid biopsy may have the potential to become a primary diagnostic tool in detecting early stage CRC, determine first, second -and third line treatment based on circulating tumor DNA and offer non invasive and cheaper alternative to surgical biopsy.

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IOUS guided liver surgery

IOUS guided liver surgery

Pushing the Limits of cancer surgery - challenging dogmas and treading the thin line

As young and eager type A surgical residents, we were all told this story to rein in our horses. Most surgical oncologists must have heard some or the other version of it. Here’s the version I heard – there was this young surgical registrar who was performing a total esophagectomy and realised that the oesophageal lesion was locally advanced and probably inoperable. He called in his lecturer who after a long battle managed to remove the tumour and left the OT with a swagger, believing he had done a good job. The next time, this lecturer was in trouble and the Assistant professor had to step in to rescue him and remove the tumour.

This same incident repeated with the Assistant professor and the HOD had to step in. The resident felt that he had a long way to go, which he did, but at the end of one year – all the patients were dead from a recurrence.

 Moral of the story:

  1. The lighter version which, as a resident I liked was that “the Resident is always right about inoperability”.

  2. The real lesson that was intended for the residents was –  “There is no role of surgical bravado in the treatment of cancer”. This was perhaps taught to us so that we would follow protocols and ensure standardized outcomes for patients in a teaching institute.

But as you grow older and wiser, you realize that this philosophy is regressive and deters evolution of surgical techniques. Take the case of Liver surgery for colorectal liver metastases (CRLM). In the 1980s and 90s, there were stringent selection criteria for consideration for a liver resection – <4 lesions, confined to one lobe, <5cm size and absence of extra-hepatic disease. But this was in the era before doublet chemotherapies like FOLFOX or FOLFIRI, which we now know are far superior to then existent chemotherapy options. Then came the era of biological therapy, which in combination with optimal chemotherapy gives responses that even converted initially inoperable CRLM to operable in 20% cases. And this changed the landscape of surgery for CRLM.

But was it only the chemotherapy and biological therapy that made the difference? Had it not been for curious and adventurous surgeons who wanted to push the envelope this wouldn’t have been possible. We now have surgical strategies like 2-stage liver resection in combination with portal vein embolisation, liver-first approach, ALPPS, intra-operative ultrasound (IOUS) guided liver surgery, and indeed liver transplantation for inoperable liver metastases. And all ancillary modalities have developed around these adventurous surgeons. Which is why we now have better and safer anaesthesia, highly accomplished interventional radiologists, better energy devices, sophisticated intra-operative imaging techniques and better post-operative care units.

Of course, these surgeons who think differently and challenge dogmas need the support of their colleagues, medical oncologists, interventional and conventional radiologists; and indeed their institutions to do the research, develop protocols, get ethics committee approval, perform these challenging surgeries, and ensure good outcomes. Over the last 3 decades, treatment of CRLM has become a sub-specialty in itself and more and more studies have pointed out the importance of concentrating these cases in highly specialized units to ensure better outcomes.

Our own experience has shown a trend towards shorter hospital stay and better post-operative outcomes with the adoption of IOUS and parenchyma-sparing liver surgery. In this treatment strategy, we use the latest devices in intra-operative imaging (HITACHI ALOKA ARRIETA 70 with the micro-convex echo probe for open surgeries and 4-directional Laparoscopic probe for laparoscopic surgeries) to mark out the anatomical landmarks and the exact locations of the liver lesions in relation to these structures. Based on pre-operative imaging and volumetric studies along with intra-operative IOUS findings, a 3D map of the liver to be resected can be envisaged and a highly precise resection is performed to remove all the CRLM while preserving as much of the normal liver parenchyma as possible along with its portal supply and venous drainage. Often, the challenge in extensive liver metastases is the preservation of adequate venous drainage; IOUS guided flow analysis helps in the detection of collateral communications among hepatic veins that helps tailor the hepatic  resections beyond the standard segmentectomies, sectionectomies and hemihepatectomies.

Fig 1 A

Fig 1 B

Fig. 1A and 1B – Lesion in seg 6 and another non-palpable lesion in segment 5. In the absence of IOUS, it would involve a formal set 5 resection but with IOUS, a contiguous resection can be performed with adequate margins without sacrificing additional normal liver parenchyma

Fig 2A – IOUS identifying 3 lesions straddling segments 7,8 above the plane of the hepatic veins

Fig 2B – Resection performed under IOUS guidance to resect segments 7 and 8 above the plane of the hepatic veins to encompass the 3 liver metastases. An additional small liver metastasis identified in segment 6 was removed separately

Fig 2C – Final specimens

Fig 2 A

Fig 2 B

Fig 2 C

Fig 3 - A precise resection of seg 4B, 5, 8p done under IOUS guidance to resect large CRLM in close relation to the right portal pedicle

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Appendix Tumors

Appendix Tumors

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

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
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.
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Gastrointestinal & Colon 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.
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Peritoneal Mesothelioma

Peritoneal Mesothelioma

Malignant mesothelioma is a rare form of cancer that affects the thin cell wall lining of the body’s internal organs and structures. This lining is known as the mesothelium.

It is of three varieties:

  1. Pleural Mesothelioma (covering of the lungs)

  2. Peritoneal Mesothelioma (covering of abdomen)

  3. Pericardial Mesothelioma ( covering of heart)

 

Risks Factors:

Asbestos exposure is a known risk factor for development of malignant mesothelioma. Asbestos is a natural, yet toxic, mineral that was frequently used across a wide variety of industries. Microscopic asbestos fibers enter the body via the lungs or by means of ingestion. Once inside the human body, the durable asbestos fibers are unable to be broken down or expelled, resulting in a harmful inflammation and scarring of the mesothelium. This scarring lays the groundwork for malignant mesothelioma.

No other genetic, dietary or geographic factors or variation have been reported.

Signs and Symptoms:

Trouble breathing, pain under the rib cage, distension of abdomen due to ascitis, lumps in the abdomen, unexplained weight loss. The symptoms depend on the extent of involvement. Nowadays, a common mode of diagnosis is incidental finding on laparoscopy for infertility or other procedures.

How is it diagnosed?

  1. Imaging Scan: CT Scan, MRI, PET CT usually picks up the disease.

  2. Biopsy: Cytology cannot diagnose a mesothelioma. A biopsy is essential and the goal standard for the diagnosis of mesothelioma. A staging laparoscopy is ideal since it helps get adequate biopsy sample and assess the extent of peritoneal disease.

  3. Blood Tests: Tumor marker levels like Ca 125, Ca 19-9 and CEA are advisable but not diagnostic.

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Ovarian Cancer

Ovarian Cancer

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 Overian Cancer
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.
Overian 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 liver.
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 cancer cells. 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.
Recurrent Overian 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 tumor.
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: Disease progression while on a first-line platinum-based regimen Tumor progression within 6 months of completion of platinum-based therapy Persistent clinically measurable disease with best response as stable disease at the completion of planned first-line therapy 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.
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Rectum Cancer

Rectum Cancer

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 Stomach Cancer

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:

  • 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.
  • 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
  • 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.

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