Considering the lifestyle change in Bangalore, has there been a rise in the number of cases with liver diseases?
There is a rising incidence of liver disease for the following reasons: metabolic syndrome among large number of patients, non-alcoholic steatohepatitis and alcoholism. Hepatitis C takes about 15 to 20 years to convert to cirrhosis. This virus was screened in blood donors routinely only from the mid 1990’s, so those infected by this virus are only being diagnosed as cirrhotic now – and will continue to do so at least till 2020. Young people are more likely to be affected by alcoholic liver disease and as a consequence of metabolic syndrome.

What is the impact of obesity and sedentary lifestyle on liver? Can it lead to liver failure?
Yes, it can. Obesity leads to fatty infiltration of the liver. In some people who develop fatty infiltration, this process is accompanied by inflammation and scarring of the liver that may lead to cirrhosis over time. The only treatment is a change in lifestyle.

Who are the candidates for liver transplant? Who can donate liver? Can there be cadaver donors too? Are there enough donors?
Liver transplants are performed for decompensated chronic liver disease, acute liver failure, certain liver cancers and for certain metabolic diseases. Cadaveric liver donation is the best and safest form of liver transplant whenever possible, but its drawbacks are that patients need to wait long periods to get an organ and many die on the waiting list. Also, certain indications for transplant – particularly acute liver failure or liver cancer need transplant to be done quickly so that there may not be time to wait for a cadaveric liver. In such instances live donors are necessary. A live donor needs to be a close relative with a compatible blood group, who is fit and healthy. The risk to the donor is only about 0.5%.

What are the possible risk factors associated with liver transplant?
The overall risk to life from undergoing a liver transplant is about 10%. However it is important to remember that this is in patients, who would survive less than a year without transplant. The risks are related most commonly to either rejection or infection – although there are good drugs to control these problems in the majority of affected patients. Rarely there may be complications related to technical issues during operation. Finally there are certain diseases that can recur in the new liver that need to be identified and treated.

How is the quality of life post liver transplant? Does the recipient need to be on medication for rest of life?
The quality of life is excellent in most cases and patients can lead a normal life. They need to be on immunosuppressive drugs for rest of life and so need to avoid infection by drinking clean water and eating healthy food

Currently, the world is moving from evidence-based generalised medicine to evidence-based personalised medicine. In order to get the right treatment, opinion from a specialist is important. The world is seeing a shift where patients are taking opinions from a team of specialists. This is ideally a combination of medical, radiation and surgical oncology. Hence, the world is moving forward towards combination therapies to manage cancer.

Now, with super sensitive DNA testing, doctors can detect the defective genetic code in a cancer cell. The day isn’t too far when doctors can correct all genetic defects related to cancer. There is an overwhelming progress in radiotherapy innovations. Researchers say that DNA testing will reach greater heights and the defective gene in a cancer cell can be identified accurately and targeted. Here are some of the state-of-the-art treatment methods, by which doctors can destroy cancer cells and nip the disease in the bud.

3D CRT: Three-dimensional Conformal Radiation Therapy, which is specially used to detect tumours in the brain, abnormally shaped tumours and tumours surrounded by tissue that is highly sensitive to radiation.

IMRT: Intensity Modulated Radiation Therapy, which has a specific and streamlined approach to targeting tumours. It is designed to attack tumours by protecting soft and sensitive tissue.

IGRT: Image Guided Radiation Therapy, makes use of high-resolution image mapping of tissue to zero in on the exact location of the tumour. Two robotically-controlled arms capture CT, fluoroscopic and X-ray images of the tumour

Proton Beam: A type of particle therapy which uses a high-power beam to remove diseased cancer tissue.

What are the recent advances in cancer care?
Until now the treatment of cancer was based on stage of the disease and a particular histological (that is based on study of biopsy tissue) type. Now we are beginning to understand that a same histological type responds differently in
different patients. Stage IV may get cured and stage I may come back, although probability of cure is much higher in the latter. For that matter, a good responding tumour has a tendency to stay in earlier stage for longer time making for the difference in survival for the different stages.

How does radiation therapy help?
Coming to radiation therapy, similar stage, similar size and similar histology responds differently in different patients. However, generally it is known that invisible cancer cells respond to radiotherapy best, a size up to 2-4 cms responds moderately and a size greater than 4 cms responds not to the level of expectation. We generally add chemotherapy along with radiation, in lesser dose, to improve the effect of radiation. Recently there is entry of biological agents and oral tablets called small molecules, which penetrate the cancer cells and sensitise them only to radiation damage. However, we are still far from a satisfactory strategy.

What is boost therapy and how does it work?
There are basically two types of cancer cells, group of them who respond to our treatment and a group who mange to survive our attack. The latter is termed as resistant cells and is responsible for recurrence of cancer.
In radiation therapy, to handle these resistant cells, long time practice has been to deliver higher dose to the visible portion of cancer. This technique is the boost therapy – i.e. boosting the basic dose with higher dose to the particular portion of cancer. This technique is also used when the disease comes back (recurrence) in the earlier radiation area. Recently, by studying various biological models, we understand that it is not only total dose, but also amount of dose per treatment that matters in killing cancer cells. That is how a new technique of radiation has emerged, known as radiosurgery.

How is radiosurgery different from radiotherapy?
In radiosurgery high dose of radiation per sitting is given, focused on tumour only, to cause ablation (that is laser like destruction), unlike in radiotherapy where smaller dose per session is given, killing some cells and hoping that subsequent doses will completely kill surviving cells. With the radiation, cancer can be eliminated and cure can happen.
However, in selected patients when this does not happen or when the disease comes back in the same area, radiosurgery is an option.

Why is the boost with cyberknife technology in cancer care considered to be so very valuable?
CyberKnife being the product of robotic technology is the only stereotactic machine, as of now, which tracks the tumour during the treatment and automatically corrects the patient position. This has several cascading benefits. Hence, the boost with the cyberknife is very valuable after conventional radiotherapy. It is also ideal technique to deliver good dose of radiation to the tumour, when it is large in size or if the tumour persists after radiotherapy or in cases of recurrence following earlier radiation.

he company at present has around 24 centres across India and one each in Uganda and Nairobi. It plans to open around four to five centres in metro cities, while around 10 would be set up in tier II, tier III cities, by 2014, said Dinesh Madhavan, director – marketing, HCG.

The investment in each centres may vary according to the model we choose including tie up with oncologists to setting up a full-fledged centre. We are planning to invest Rs 50 crore from internal accruals and to raise another around Rs 50 crore from private equity for this,” he said. A full- fledged centre could cost Rs 20 crore for the company, owing to the higher cost of sophisticated equipment and technology that such a facility requires.

Already, Premji Invest, the private equity fund of Azimji Premji, Milestone Religare and Evolvence India Life Sciences Fund have together invested an aggregate amount of around Rs 150 crore in the company.

“We have different options to raise funds, from private equity players, from our technology partners or oncology experts who are in partnership with us,” said Madhavan.

The company would also go in for an initial public offer (IPO), by 2014, and according to the present estimates, we will raise funds to the tune of around Rs 500 crore through an IPO. However, plans are yet to be finalised.

It is also exploring owning and managing opportunity in tie-ups with major hospitals; to own an oncology division in the hospital or to manage the hospitals’ oncology division with its expertise. Various measures including an EMI scheme are designed by the company to provide cancer care at affordable cost. Its tie-up with technology developers and equipment manufacturers also help it to reduce cost of treatment, he said.

Established almost five years back, the company present has around Rs 350 crore revenue at present. It envisages the revenue to grow to Rs 500 crore by 2014, by the time it would launch IPO. However, limited number of oncology specialists along with lack of skilled manpower in clinical and paramedical staff, are the challenges the company faces at present.

But fortunately there are certain measures that can be taken to prevent it.

Most studies have found that being overweight or obese increases the risk of colorectal cancer. Having more belly fat (that is, a larger waistline) has also been linked to colorectal cancer.

The World Health Organization has determined that dietary factors account for at least 20 percent in developing countries. Cancer researchers have found that people who avoided meat were much less likely to develop the disease. There are several reasons for this. First, meat is devoid of fiber and other nutrients that have a protective effect. Meat also contains animal protein, saturated fat, and, in some cases, carcinogenic compounds such as heterocyclic amines (HCA) and polycyclic aromatic hydrocarbons (PAH) formed during the processing or cooking of meat. HCAs, formed as meat is cooked at high temperatures, and PAHs, formed during the burning of organic substances, are believed to increase cancer risk.Overall, diets that are high in vegetables, fruits, and whole grains (and low in red and processed meats) have been linked with lower colorectal cancer risk. There is a lower risk of colorectal cancer and polyps with increasing levels of physical activity. Moderate activity on a regular basis lowers the risk, but vigorous activity may have an even greater benefit.

High fiber intake, especially from whole grains, may lower colorectal cancer risk. Heavy alcohol consumption also increases the risk of this cancer.

Lifestyle Recommendation for prevention of colorectal cancer

• 30 minutes of physical activity a day (at least 5 days a week)
• Less consumption of alcohol
• No smoking
• Waist size less than 88 cm for women and 102 cm for men
• Healthy diet including around 600 g fruit and vegetables a day, under 500 g of red and processed meat a week, under 30% total energy from fat and 3 g dietary fibre

In general the response to treatment depends on size of the cancer and invisible cancer cells respond best and large cancer respond least. Invisible cells can be eliminated with lesser dose and larger cancers require higher dose. The way of delivering the higher radiation dose to the area of disease visible on CT/PET-CT scan or MRI is considered as “Radiation Boost”. In case of disease recurs in the earlier treated area of radiation, it is important to deliver the highest possible dose to disease visible in CT/PET CT or MRI scan and least possible dose to the normal tissue in the previously irradiated area.

Why CyberKnife Radiosurgery Boost / Reirradiation / Repeat Radiation?

Conventional radiation works by the principle of small doses every day and allow recovery of normal cells in between doses. However, this allows the partial repair of malignant cells also. Therefore, in radiotherapy not only the total dose given but also dose per treatment can affect the tumour control.

When the patient is on the couch during the radiation treatment there will be natural movement of the patient and also that of tumour (due to either breathing or surrounding organ filling with fluid or gas). This may be in terms of few millimetres to few centimetres.

To account for this and not to miss the tumour, wider area of normal tissue is purposefully included. As we include larger normal tissue volume lesser the dose that can be tolerated. Therefore, in conventional radiation therapy focus is more on giving lesser dose to avoid toxicity rather than delivering the required dose to control the tumor.

Additionally, cancers like glioblastomas, renal cell carcinomas, sarcomas and melanomas are considered traditionally difficult to respond to conventional radiation doses.

CyberKnife is the only stereotactic machine, as of now, which tracks the tumour during the treatment and automatically corrects the patient position. This one point has several cascading effects.

Hence, the boost with the Cyberknife is very valuable after conventional radiotherapy. It is also ideal technique to deliver good dose to the tumour in cases of recurrence following earlier radiation.

How CyberKnife radiosurgery (SBRT) does overcome tough cancer cells?

Dose per treatment is higher than the regular radiation and is given in 1 to 5 sittings increasing the probability of killing cancer cells which are no longer responding to regular radiation.

When is CyberKnife boost given?

» After initial radiation therapy of 5 weeks duration.
» After the completion of regular radiotherapy treatment and when the disease is still persisting.
» 3 months after completion of radiotherapy if active disease is still present.
» When the disease comes back in the area treated earlier with radiation.

Sites of cancer that require Cyberknife boost

The common cancer sites that require Cyberknife boost:
» Glioblastoma multioforme and other brain cancers
» Ca. Nasopharynx
» Ca pancreas
» Ca lung
» Cancer in the Head and Neck region
» Others e.g. sarcomas, cancers in the pelvis, including Ca prostate.

Radiotherapy is one of the cornerstones in the management of cancer for almost 100 years now. Stereotactic Body Radiotherapy (SBRT) is the most advanced form of radiotherapy currently and is indicated for specific situations. It is a sophisticated method involving precise 3 dimensional, high dose radiations to the tumour, with minimum possible radiation to the normal tissue. Cyberknife, is the best available SBRT machine today because of its robotic approach. The technique of SBRT with CyberKnife is also known as Robotic Radiosurgery. It is offered when surgery is indicated but is not possible or when the patient is totally unwilling for the surgery. It is also indicated when the tumour persists or recurs after the conventional therapies.

In cancer management it’s not just the sophisticated treatment that helps. It is the body immunity that kills the remaining few cancer cells with the standard treatment. The routine treatment helps in bringing down the cancer cell burden to a level where body can fight effectively. Hence immunity of body plays a crucial role in getting rid of cancer. Autologous (patient’s own) Dendritic cell therapy is a type of cancer vaccine, which enhances the body’s own immunity against cancer cells. Dendritic cells are normally present but become deficient in cancer. Dendritic cells carry cancer peptides (proteins secreted by the cancer cells) and helps in delivering cancer peptides to the lymph nodes which in turn induces an anticancer T cell response in the body. Following an encounter with either tumour derived peptides or tumour cells in circulation, these sensitized T cells kill the cancer cells. Also, it is very logical to combine the conventional therapies with the methods which improve body immunity. Studies have confirmed the safety and efficacy of Autologous Dendritic cell vaccine and have also demonstrated increase in the median survival of patients.

Combination therapy in cancer treatment has been the best way in handling cancer. Multimodality treatment approach results in a more desirable disease control. High end radiotherapy like Cyberknife results in considerable reduction of tumour burden. Detection and killing of the invisible cancer cells distributed in the body is invariably relied on the body’s immune system. Therefore, combining Cyberknife with Autologous immunotherapy offers an effective approach to combat cancer.

We are offering the combination of Cyberknife radiosurgery and Autologous Dendritic Cell vaccine to cancer patients. During Cyberknife radiosurgery, large numbers of cancer cells are broken down and tumour derived proteins and peptides are released. Administration of patient’s own dendritic cells along with cyberknife radiosurgery might help in improving the control rate. This might be of particular benefit in immunogenic cancers such as renal cell carcinoma and melanoma.

For more details please click the link below http://www.hcgoncology.com/combined_cyberknife

Dr. Raghunath, K S, Consultant, Uro Oncologist, HCG, said, “The incidence of prostate cancer is on the rise, because of changes in lifestyle. By modifying lifestyle and diet one can cut down the risk of developing prostate cancer. In the initial stages prostate cancer is asymptomatic and in most cases the patients present with symptoms where usually it is locally advanced or metastatic. This is potentially curable cancer if detected early. Through effective screening, we can detect early. After 50 years of age, yearly PSA test (Prostate Specific Antigen – Test) is recommended and if anyone with a family history of this disease, they should start screening as early as from 35 years.”

Dr. K S Gopinath, Senior Consultant, Surgical Oncologist, HCG, said, “The treatment for cancer has advanced over the last decade. Multi disciplinary team approach is the way forward now. New treatment methods and advanced technologies have become more effective with better medical outcomes. This has improved the survival rates of the patients and also the quality of life. When in doubt about treatment in cancer care, it’s always better to seek a second opinion from the specialists.”

What is testicular cancer?
When germ cells of one or both testicles become malignant (cancerous), it is called germ cell tumour of the testicles. The testicles (also called testes or gonads) are a pair of male sex glands, which produce and store sperm and are the main source of testosterone in men. These hormones control the development of the reproductive organs and other male physical characteristics. Testicular cancer can spread to other parts of the body, mainly lymph nodes in the abdomen, lungs and bones. Risk factors include genetic influences.

How to diagnose it?
Testicular cancer is diagnosed by entirely removing the testicle and sending it for the histological diagnosis in a laboratory. The blood tests, including tumour markers support the diagnosis. The tumour markers help in monitoring response to treatment. The CT scan is done for staging of the disease i.e. to know extent to which the disease has spread. Although the incidence of testicular cancer has risen over the years, more than 80 per cent of cases are curable with chemotherapy.

How to treat testicular cancer?
Treatment of testicular cancer depends on the type of tumour, the stage, the amount of certain substances called tumour markers in the blood, and the man’s overall health. Testicular cancer is almost always curable if found early and is often curable even at later stages. The three main treatment options are surgery, chemotherapy, and radiation therapy. Treatment usually starts with surgery to remove the affected testicle. Then active surveillance (watchful waiting) to closely monitor an early-stage cancer is recommended. Some men may also have surgery to remove lymph nodes from the back of the abdomen. Chemotherapy may be given to lower the risk of the cancer returning or to treat cancer that has spread or come back after treatment. Surgery may be done after chemotherapy to remove any remaining tumors. Radiation therapy is used in specific settings for seminoma.

Cancer, more so breast cancer has entered India without knocking. Over 100,000 women develop breast cancer in India every year. One in 26 women is at a lifetime risk of developing breast cancer. The incidence is more in urban areas and in a decade younger (40-50 years age group) than in western countries, thus affecting women in their prime of life. The loss of the organ is associated with significant personal, social and sexual overtones.

In the context of these facts, we have made various improvisations in the surgical treatment.

1). Modified Radical Mastectomy: The size of the scar has reduced from a traditional 10-12 inches to 6-7 inches. The orientation of the incision makes it cosmetically acceptable. Skin and nipple sparing mastectomy are performed in selected patients, who are potential candidates for breast reconstruction. Complications like flap necrosis and infection are less than 3%.

2). Axillary dissection: Refinement in techniques has reduced the morbidity of axillary dissection Lymphedema (swelling of the arm) is uncommon though seroma (fluid accumulation in the armpit) is not. Patients with non palpable axillary lymphnodes undergo SENTINEL LYMPHNODE BIOPSY (Use of a radioactive and / or blue dye to accurately stage the axilla), thus avoiding a conventional axillary dissection.

3). Breast conservation surgery: Long term results of numerous randomized trials have demonstrated that Breast Conservation Surgery (Wide Excision and Axillary Dissection) is as effective as Modified Radical Mastectomy in loco-regional control. In patients with appropriate tumor to breast ratio and in the absence of other contraindications this surgery promises excellent cancer control and cosmesis.

4). Breast Reconstruction: All patients undergoing a unilateral or bilateral breast surgery should be seen by a reconstructive plastic surgeon to discuss options for breast reconstruction. Selection of reconstructive method depends on
a. Patient expectations: No reconstruction Perfect Breast

b. Physical appearance: Breast size / shape, weight, scars, skin quality.

c. Cancer treatment: Chemotherapy, Radiotherapy, Unilateral Vs Bilateral

Options for breast reconstruction

Implant Based Reconstruction

Saline – filled implant
Silicon – filled implant

Autologous Tissue Reconstruction

Latissimus Dorsi Myocutaneous Flap with or without implant

Abdominal wall flaps:
Pedicled TRAM (Trans Rectus Abdominus Myocutaneous Flap)
Free TRAM Flap
Muscle-sparing free TRAM Flap
DIEP (Deep Inferior Epigastric Perforator) Flap
SIEA (Superficial Inferior Epigastric Artery) Flap

SGAP (Superior Gluteal Artery Perforator) Flap
ALT (Anterolateral Thigh) Flap
Gracilis Myocutaneous Flap

Even the nipple areola complex can be reconstructed.

Thus the traditional mutilating potentially devastating Halstedian surgery has been replaced by refined and cosmetically more acceptable surgery.