vol - 5 | issue - 2 | hyderabad | august - 2015 | pages ... · production further work up was done...
TRANSCRIPT
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Every Day is Breast Cancer Awareness Day
AP's First Digital Mammography with
Aug - 2015 Aug - 201512
Date of Publication: 05.08.2015Date of Posting: 15.08.2015
Vol - 5 Issue - 2 Hyderabad August - 2015 Pages - 12 Prices Rs - 1. 00| | | | |
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HIPEC (Hyperthermic Intraperitoneal Chemoperfusion)
Allows for high doses of chemotherapy
Enhances and concentrates chemotherapy within the abdomen
Minimizes the rest of the body's exposure to the chemotherapy
Improves chemotherapy absorption and susceptibility of cancer cells
Reduces some chemotherapy side effects
ADVANTAGES
Belmonte Hyperthermia PumpHIPEC
* Conditions Apply
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Aug - 2015
Dual role of F 18 positron emission
t o m o g r a p h y - c o m p u t e r i z e d
tomography in diagnosis and radio
therapy treatment planning in
critical oncological conditions.
Authors
§ Dr.V.V.S.Prabhakar Rao, MD(Radio Diag), DNB (
Radio Diag ),DNB(Nucl Med), DRM, PG
Dip(Geriatric Med). HOD Nuclear medicine &
PET CT Department, OMEGA Hospitals.
§ Dr.Koustubh Sharma, Medical Officer, Nuclear
medicine Department, OMEGA Hospitals.
Introduction
F 1 8 Po s i t r o n E m i s s i o n To m o g r a p h y -
Computer ized Tomography (PET-CT) has
established itself in the field of oncology as an
inva luable d iagnost ic armamentar ium by
identification and localization of early cancer by
the metabolic component of mitotic disease,
which precedes anatomical changes. In a
revealed malignancy PET-CT often upstages and
down stages disease thus altering therapeutic
regimes and options. However it has a vital role in
precision planning of gross tumor volume and
planning tumor volumes in radio therapy while
irradiating vital structures and saving vital
adjoining structures , delivering precise dose
exclusively to the organ or areas of interest
sparing adjacent critical areas .
Illustrative Case
A 44 year old male presented with a mass in the
right side of the neck of two years duration with a
history of increase in size from past one month
associated with pain.
Physical examination revealed a nodule of 5 x 4
cms in the right lobe of the thyroid gland
moving with deglutition with enlargement of level
III cervical lymph nodes on left side. FNAC of the
thyroid nodule showed features of anaplastic
carcinoma, Patient underwent total thyroidectomy
with removal of enlarged cervical lymph nodes.
Histopathology revealed polygonal to spindle
cells, showing organized pattern with clumped
chromatin, moderate to abundant cytoplasm with
areas of necrosis, focal hemorrhage, abundant
extracellular brownish black (HMB 45 positive,
Perl’s negative) melanin pigment , Sections from left
lobe of thyroid showed features of medullary
carcinoma of thyroid with amyloid production
without melanin.
In view of the medullary carcinoma and melanin
production further work up was done by whole body
iodine 131 Meta Iodo Benzyl Guanidine (MIBG)
scan to outline any residual or metastatic foci with
high dose of Iodine 131 MIBG therapeutic intent.
However there was no MIBG localization in the neck
or elsewhere. Thus due to non therapeutic options
with MIBG and known radio resistance to radio
therapy of melanotic medullary carcinoma thyroid
patient was kept on close follow up. One year later patient presented with diffuse boggy
swelling in right side of neck associated with severe
Aug - 20153
08
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impending SVC obstruction diagnosed and
managed by timely radio therapy using PET based
diagnostic and RT Planning technique with gratifying
outcome high lights the vital role of PET CT in clinical
oncology.
Legends
Fig 1
F 18 FDG PET-CT showing an intensely hyper
metabolic hypo dense intra luminal tumor thrombus
in the right IJV , EJV, subclavian vein, innominate vein
up to SVC.
Fig 2
F18 FDG PET CT after radiotherapy showing
complete metabolic regression in the intra vascular
tumor and significant reduction in the tumor
thrombus load (Fig 2).
pain radiating to the right ear, however there was no
puffiness of face, no engorgement of veins in the
neck or chest wall. Clinical examination revealed a
firm diffuse fixed mass along the right jugular region.
A F 18 PET-CT was performed which revealed an
intensely hyper metabolic hypo dense intra luminal
filling defect in the internal jugular vein (IJV), and also
in the external jugular vein (EJV) right subclavian vein
confluencing at the right innominate vein with inferior
extension into the superior vena cava (SVC) falling
just short of the right atrium suggestive of tumoral
thrombus with no residual mass in the thyroid bed
(Fig 1). With limited therapeutic options and
impending cardio vascular catastrophe and large
tumor thrombus load in major veins of the neck like
right IJV,EJV, and SVC, an immediate blunderbuss
salvage radio therapy was considered with F18 PET
CT image based IMRT planning sparing the carotid
vessels to prevent carotid artery blow out and
adjoining trachea . Patient tolerated the entire course
without any complications and became symptom
free by the end of the radiation course. Patient was
kept on clinical follow with a metabolic assessment
with F18 PET CT after three months which revealed
complete metabolic regression in the intra vascular
tumor and significant reduction in the tumor
thrombus load (Fig 2). Follow up at 6 months patient
continues to be symptom free and free of tumor
thrombus.
Conclusion
A rare case of Melanotic Medullary carcinoma with
tumoral thrombosis into internal jugular, external
jugular veins and superior vena cava presenting with
Aug - 20154
Advances in rad io the rapy i n
management of spine metastasis
Spine metastases are a common complication of
cancer. While similar to other bone metastases in
terms of vertebral bone involvement, spine
metastases have unique clinical considerations.
One is spinal bone pain, which is the most common
initial presenting symptom. The other is that these
metastases can present with a soft tissue mass at
the paraspinal area or as an epidural compression.
Therefore, patients with spinal metastases
invariably have severe back pain, often with
associated neurological problems, which can
further compromise their performance status.
The main presenting symptom of spine metastases
is back pain. Therefore, the primary goal of
radiosurgery for spinal metastases is pain control
(relief). The treatment of spine metastases has
largely been with conventional fractionated
radiotherapy. Although the most common regimen
of radiotherapy has been 30 Gy in 10 fractions, the
radiation dose-pain response has not been well
settled. Early RTOG study for bone metastasis
reported that low-dose short course radiotherapy
was as effective as a high dose protracted regimen.
However, the duration and rate of pain control of
bone metastases was limited by the conventional
method of radiotherapy. In a subgroup of patients
with spine metastases, only 61% of patients
experienced partial or complete pain relief at 1 month
post-treatment. Recently, there has been an
increasing trend of diagnosing more localized spine
metastases (i.e., oligometastases), although the true
incidence of solitary spine metastasis is not known.
These patients may have a prolonged survival time.
Therefore, there is pressing need to improve the pain
control of patients with spine metastases, which may
be connected to an improvement in quality of life and
probably a cure in the setting of solitary spine
secondary.
It is evident from the studies that a single dose of
radiotherapy is as effective as 10 fractions of
radiotherapy. This suggests that a further increase in
the single dose of radiation may improve the rate of
pain control. The difficulty is that there is a dose
limiting organ, the spinal cord, within close proximity
to the vertebral body, and spine metastases often
are present with epidural tumor masses. Therefore,
accurate targeting and radiation intensity-
modulation will be required to minimize the spinal
cord dose.
In this effort, radiosurgery or stereotactic body
radiotherapy (SBRT) has emerged as an innovative
and accurate treatment option for spinal
metastases. While the spine region does have the
benefit of minimal breathing-related organ
movement and easy imaging, safely delivering a
more intensive dose of radiation requires not only
precise targeting due to the proximity of the spinal
cord, but also accurate treatment planning and
delivery.
Aug - 20155
Dr. L. YUGANDHAR SARMAMD (Radiotherapy), Junior Consultant-Radiation Oncology
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Preclinical physical and dosimetric studies have
demonstrated the applicability of patient
positioning, immobilization, and dosimetric
characteristics of spinal radiosurgery for spine
metastases. The first approach to establish clinical
feasibility was to determine the accuracy and
precision of radiosurgery to treat the spine and
epidural/paraspinal tumors that are adjacent to the
spinal cord. SBRT on Cyberknife offers a perfect
solution in planning and delivery of treatment.
Advantages of SBRT with Image
Guidance using Cyberknife
Ÿ Rapid and durable pain relief
Ÿ Treating with extreme accuracy helps in sparing
of the spinal cord which is very close to the target
which in turn helps in rapid recovery of
neurological function.
Ÿ Only the involved vertebra is treated—this results
in sparing of bone marrow and no discontinuation
of systemic treatment is needed which is very
important in these cases.
Ÿ Treatment can be completed in one to three days
as opposed to 10-15 days of conventional
therapy—rapid institution of systemic therapy
especially in oligometastatic setting.
Ÿ SBRT is a non-invasive treatment and it can
potentially reduce the need for open surgery.
Spine Image Guidance in Cyberknife
The tracking of spine treatments in Cyberknife is done
using X-Sight spine tracking system. This system is
capable of monitoring the patient movement to a sub-
millimetre level ss that treatment is delivered
accurately.
CARCINOMA BREAST WHERE ARE WE NOW?
Aug - 20156
We all know the fact that the breast cancer is the most common cancer among the women in urban areas, where as carcinoma cervix is the most common in rural women. There are changing trends in the genetics, environment, causing tumor heterogeneity, ….. in the same manner there are change in trends in diagnostic and therapeutic modalities.
Those were the days when women used to come
with big palpable lumps sometimes with skin, chest
wall, axillary nodal involvement, eventually go for
radical / modified radical mastectomy. The present
trend is to diagnose as early as possible using
imaging techniques such as 2D/ 3D mammography,
MRI scan, PET scan; have confirmation by FNAC/
needle biopsy and go for conservative surgeries i.e.
wide local excision. Wherever the facility for frozen
section and adjuvant radiotherapy are available,
the choice of surgery is conservative; which is
universally acceptable according to standard
guidelines (ASCO –CAP; ST GALEN etc).
In the good o lden days, h is topatho logy
examinations for tumor type, axillary nodal
involvement were only available to medical
oncologist. Later came up the hormone receptor
studies for estrogen and progesterone receptors,
helpful for adding anti- estrogens. With the
invention of targeted therapy for HER2 positive
patients by trastuzumab, about one and half decade
ago , a lot many changes happened and now the
adjuvant therapy is based on molecular
classification (luminal A, luminal B, HER 2, Triple
negative), hence there is rapid development in
diagnostic modalities as we started looking for
genetic signatures of tumors.
Aug - 2015
Some of the genomic testing options available
are:
ONCOTYPE DX
This test includes analysis of 16- genes and 5
controls, done by RT-PCR technique on formalin
fixed ,paraffin embedded tissues , in both pre and
postmenopausal women having stage1&2 breast
cancer (node negative/ or 1-3 nodes positive; ER &
PR positive). This analysis gives recurrence
scores, risk stratification (low, intermediate, high),
which helps to make a choice in chemotherapeutic
options.
MAMMAPRINT
This test includes analysis of 70 – gene expression
signature focused on proliferation, done by Micro-
array , can be done only on fresh tissue only, in
both pre and post menopausal women having
stage 1&2 breast cancer (node negative / positive,
up to 3 nodes; ER positive / negative). This analysis
gives two risk groups (low, high), helps to make a
choice in chemotherapeutic options.
PROSIGNA
PAM 50 based genetic signature which includes
analysis of 50 genes and 8 controls. It can be done
on formalin fixed, paraffin embedded tissues, in
post menopausal women only, having stage 1 & 2
breast cancer (node negative / positive, 1-3
nodes; ER/PR positive). The analysis gives a
prosigna score for risk stratification (node
7
DR. SNEHALATHA DHAGAM
Consultant Pathologist, MD (Pathology), DNB (Pathology)
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negative-3 risk groups- low, intermediate, high:
node positive – 2 risk groups –low, high), helps to
make a choice in chemotherapeutic options.
SMOKING CESSATION
INTRODUCTION
It has been estimated that at least 70 percent of
smokers see a physician each year; 70 percent
also report a desire to quit and make at least one
serious attempt to do so. A physician's advice to
quit as an important motivating factor for
attempting to quit; brief advice from a physician
leads to a spontaneous quit rate of 2 to 4 percent.
BACKGROUND
Despite the benefits of smoking cessation,
clinicians are not adequately screening and
treating patients who smoke. One study, for
example, found that only 50 percent of smokers
seeing a primary care physician in the past year
were asked about their smoking or urged to quit.
An even smaller proportion was counseled to quit. The American Psychiatric Association (APA) also released nearly identical guidelines. Clinicians now have available a clearly defined standard of screening and intervention to use with their patients.
The AHCPR has proposed the model of "5 R’s" in promoting motivation to quit smoking:
l Relevance — Motivational information to a patient is more effective if it is relevant to a patient's circumstances (such as prior quitting experience, disease status, or health concerns).
l Risks — The acute and long-term risks of smoking should be stressed. It is most effective if smoking can be tied to the patient's current health or illnesses. For the healthy patient, environmental risks, such as exposing spouses and children to smoking and thereby increasing their risk of ill-health should be included. Smokers should also be made aware that children of smokers are more likely to smoke.
l Rewards — Encourage the patient to identify potential benefits of smoking (such as saving money, performing better in sports, improving the health of children and other household members, etc).
l Roadblocks — Ask the patient to identify barriers or impediments to quitting and note elements of treatment (problem solving, pharmacotherapy) that could address barriers.
l Repet i t ion — Repeat the mot i va t iona l intervention each time an unmotivated smoker visits the clinic setting.
TREATMENT STRATEGIES
Patients should also be encouraged to make the following preparations for quitting:
Ÿ Inform family, friends, and coworkers of the plan to quit, and explicitly ask for support.
Ÿ Avoid smoking in the home, car, and other places where a lot of time is spent.
Aug - 20158 Aug - 20159
Ÿ Review prior quit attempts. What worked? What didn't work and may have contributed to relapse?
Ÿ Anticipate nicotine withdrawal symptoms, cues to smoking, and "danger situations."
Three elements of successful smoking cessation
treatment strategies have been identified:
Ÿ Social support
Ÿ Pharmacologic therapy
Ÿ Skills training or problem-solving techniques
Several medical centers now have patient resources or learning centers in
which patients can access additional self-help materials. Web site resources include the following:
Ÿ — The web site for the www.lungusa.orgAmerican Lung Association, sponsor of the American Smoke-out Day, includes an online guide for smoking cessation
Ÿ — www.cancer.gov/cancertopics/tobacco The National Cancer Institute web site contains information on smoking cessation , as well as general information on the health effects of tobacco
Ÿ — A n e x c e l l e n t , w w w. q u i t n e t . c o mcomprehensive resource for patients
Ÿ www.ahrq.gov/consumer/index.htm?l# smoking — A good source for pat ient pamphlets on smoking cessation.
LOCALIZATION OF NON PALPABLE BREAST MASSES
Suspicious clinically occult breast lesions are found frequently as a result of widespread mammograph ic sc reen ing p rograms o f asymptomatic women .Some 15–20% of these lesions are malignant, and their removal should be preceded by a rad iograph ica l l y gu ided localization procedure to assure an accurate and low tissue volume biopsy.
Several techniques have been developed as a
diagnostic and therapeutic tool. Wire-guided
local izat ion (WGL) is present ly the most
commonly used localization method for non-
palpable breast lesions. However, the ideal
technique should involve precise localization,
avoid the excessive surgical resection of healthy
breast tissue, improve the rate of free margin, not
discomfort the patient and decrease operative
time. Although WGL has been shown to accurately
localize the lesions, the technique has some
disadvantages. The placement of the wire is
difficult in dense breast tissue. The wire may be displaced during surgery. For surgical
excision with free margins, the surgeon must
follow the wire through healthy tissue until the
lesion is found, and this can cause removal of
healthy breast tissue. Furthermore, migration or
rupture of the wire leads to a small risk of
Dr.Syed SafiullahHOD & Consultant, Department of Radiology
Dr. Md. Hidayath HussainMBBS, DTCD, DNB ( Pulmonology), MNAMS
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Aug - 201510 Aug - 201511
pneumothorax, and the discomfort of the patient
and injuries for both the surgical team and the pathologist are other
restrictions of the procedure.Radioguided occult lesion localization (ROLL) is a
new method for the localization and resection of
non-palpable breast lesions. The approach involves
the intratumoral injection of a small amount of
n u c l e a r r a d i o t r a c e r u n d e r g u i d a n c e b y
ultrasonography or stereotactic mammography.
Radioactivity allows for the radiolabeling of the
lesion and subsequent surgical excision guided by
a handheld gamma ray detection probe. During the
last decade, ROLL has gained popularity on
account of several advantages associated with a
reduced excision volume, more accurate centricity
of a lesion within the surgical specimen, better
cosmetic results and a higher percentage of tumor-
free margins.