Decoding PET CT

The PET CT Scan is one of the sought after diagnostic tests. Lets find out more on what is a PET CT and why is it preferred over other diagnostic tests, such as an MRI, CT Scan or an ultrasound.

What is a PET Scan ?

A PET Scan is a nuclear medicine technique which produces images of the human body at a molecular level.

A PET CT, uses radioactive tracers in conjugation with isotopes such as oxygen, nitrogen, carbon etc. These radio isotopes act at a molecular level and work as probes which seek out disease, cancer in the body while giving out radio signals which are captures to produce an image.

PR

PET CT Scan
PET CT

This can help in diagnosis of even the tiniest lesions, thus increasing the accuracy of investigation, subsequent diagnosis and hence cancer treatment.

A PET CT Scan, therefore reveals a lot more about the body than standard diagnostic tests such as MRI, CT Scan or an ultrasound.

What happens during a PET Scan ?

A PET CT Scan, is always on a price appointment basis as the radio isotopes, having a a very short half life need to be brought in just before the scan.

A PET CT, is usually carried out empty stomach on overnight or ateast 6 hrs fasting.

The creatinine levels, need to checked prior to conducting the PET CT by a simple blood tests called KFT or Kidney function test

If the creatinine levels are in order, the patient is  tested for blood sugar and if found in order , the patient is given an injection of glucose with a radioactive tracer.

After the injection, the patient is made to rest for about 90 mins and then taken for the actual scan which takes about 30 mins to 45 mins depending upon the imaging required.

During the scan, the patient is made to lie on a comfortable table that moves slowly through the ring like PET scanner.

After the scan, the patient can leave immediately. However close contact with others especially children and pregnant women is best avoided for the next 4-6 hrs.

It is also good to drink a lot of water, to flush out the radio active tracer from the body.

The imaging can be seen by the doctors and the nuclear medicine specialists almost immediately for evaluation, though a formal written report takes a day to be handed over to the patient.

Are there any side effects or discomfort due to the scan ?

There are no sid effects or discomfort due to the PET  CT Scan, except the minor prick while injecting the tracer.

The PET CT scanner, also does not make any sounds while the scan is going on unlike a few other diagnostics tests.

What are the diseases for which a PET CT Scan can be used ?

The most common use case for a PET CT Scan is for detecting and treating cancer. However other applications, include diagnosing cardiac or heart problems and also neurology.

Cancer/Oncology :

During the initial stages of the disease, a PET CT helps distinguish between benign and malignant disease and also cancer staging, that is knowing  and determining the stage of the disease and also its characteristics, which further helps oncologists decide the best treatment option for the patient.

During course of treatment, it helps determine response to therapy or cancer treatment and if the metabolic activity decreases on the PET CT Scan, the oncologists know that the drugs being administered are working.

On the other hand, if the metabolic activity on the scan increases, it indicates that the treatment option is losing its efficacy or is not working and helps oncologists change the line of treatment to benefit the patient.

Cardiac Care: Post a heart attack, a PET CT Scan can be used to determine myopathy , need for CABG or open heart surgery and if there would be any benefit from CABG or would a heart transplant or an LVAD be a better treatment option.

Neurology: Alzeheimer’s at an early stage can be diagnosed using a PET Scan leading to early intervention.

A PET CT Scan helps locate tumours, distinguish between benign and malignant tumours and also scar tissue for brain surgery.

A PET CT  is also useful for treatment of epileptic seizures. It can help locate the origin and focus of seizures and assess sites for intervention if any is required.

What is the difference between a PET CT and an MRI or a CT ?

A CT or an MRI works on the physical level and can give the size and location of the tumour with accuracy.

However since both tests donot work on the molecular level, they cannot indicate metabolic activity of the tumour which only a PET CT Scan can indicate, thereby making a PET CT, a diagnostic test of choice for oncologists, cardiologists, cardiac or heart surgeons and interventional neurologists.

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Are Childhood cancers different from Adult Cancers?

Cancer
Childhood Cancer

Childhood cancers or Paediatric cancers are biologically different from adult cancers.
They grow faster than most adult cancers.

Factors which trigger cancer or cause childhood cancers are different from those causing adult cancers for example smoking a leading cause of adult lung cancer is not a cause for childhood lung cancer.

Most Paediatric cancers are non hereditary and happen due genetic mutations of growing up cells, though pollution, exposure to radiation, chemicals are also contributory factors in a few cases.

Common cancers in children:

The most common childhood cancer is Leukemia or Blood Cancer. Of all types of blood cancers, ALL is the most common one. It affects children in the age group of 2-6 years.
Other common paediatric cancers are tumours of the brain, retinoblastoma, neuroblastoma, lymphoma, tumours of the kidney, tumours of the adrenal gland, sarcomas , bone tumours etc.

Symptoms of Childhood Cancers:

  • Unusually High Fever
  • Bruise marks or blue marks on the body
  • Prolonged fever with no established cause
  • Unusual weight loss
  • Nose bleed, gum bleed
  • Swelling in the abdomen
  • Joint pains
  • Pale palor, accompanied with fever, body ache
  • Swelling in the neck or axilla.
  • Increase in size of lymph nodes, along with cough, fever, weight loss
  • Persistent headache
  • Unusual Redness in the eye
  • Early morning vomiting, loss of appetite
    If you notice any of these, it may be a good idea to plan a visit to the doctor.

Are Childhood cancers curable ?

As childhood cancers grow faster than adult cancers, they are also more responsive to chemotherapy and other forms of treatment.

Depending on the stage of cancer and the spread of cancer, a combination of surgery, chemotherapy and radiation may be advised.

With advances in medical treatment, it is now possible to save limbs in bone cancers, eyes in retinoblastoma depending upon stage of cancer and response to treatment options.

Most blood cancers in children respond extremely well to chemotherapy and get cured.

Over 70% of childhood cancers get cured. 5 year survival rates for brain tumour are more than 90%, for Hodgkins lymphoma are over 90% and for ALL or acute lymphoblastic leukaemia survival rates are over 80%.

Even after complete cure, regular followups with paediatric oncologists are required for the next couple of years.

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PRRT and the promise it holds for cancer treatment

As we continue our conversation on Precision Medicine for cancer, a popular therapy used to treat NET tumours or Neuro Endocrine Tumours is PRRT or Peptide Receptor Radionuclide therapy.
Neuroendocrine tumours are a rare form of cancer and originate from Neuro endocrine cells in the body and hence the name.They are different from adenocarcinoma’s and often do not do not respond well to chemotherapy, the 1st line of treatment for most cancers.

By administering radioactive protein lutetium octreotate, it is possible to treat NET tumours or neuro endocrine carcinoma with precision and offset progression of disease.

PRRT for neuroendocrine tumour
PRRT treatment for metastatic cancer cells spreading and growing. Tailor-made precision medicine based on genetic profile and molecular structure of the tumour.

In PRRT a peptide or a cell targeting protein is combined with a small amount of radio active nuclide creating what is called as a radio peptide. The radio peptide when injected into the patients blood stream travels and binds to a neuro endocrine tumour, delivering a high dose of radiation to the tumours. This also limits damage to the nearby healthy tissue and hence lesser and milder side effects than chemotherapy.

What kind of cancers can be treated by PRRT?

Along with Neuroendocrine tumours, carcinoids, islet cell carcinoma of the pancreas, small cell carcinoma of the lung a form of lung cancer, pheochromocytoma (a rare tumor that forms in the adrenal glands), gastro-enteropancreatic (stomach cancer , intestine cancer and pancreas) neuroendocrine tumors, and rare thyroid cancers that are unresponsive to treatment with radio iodine are often treated with PRRT.

Role of PRRT is also being explored for treatment of prostate cancer.

When is a patient a candidate for PRRT ?

Patients with following conditions are often proposed for PRRT

  • When neuro endocrine tumours are not responsive to other lines of cancer treatment
  • When surgical removal of tumours is not possible at current stage, PRRT may be used to reduce size of the tumours.
  • PRRT is also a treatment option for last stage inoperable cancers when metastasis has set in.
    The main aim of PRRT is then to slow down progression of disease, offer relief and prolong life.

However, not all neuroendocrine tumours respond to PRRT. First an OctreoScan is done. If the patient is found to have a positive OctreoScan and meets other requirements, PRRT is proposed.

What happens during PRRT ?

For patients having a positive octreoscan, to start with an amino acid solution is delivered to protect the kidneys.

As most net tumours have a lot of a specific type of surface receptor, a protein called somatostatin. Octreotide, is a lab version of somastostatin. During PRRT, a dose of radio nuclides such as Lutetium, Yttrium are often combined with octreotide and injected into the blood stream.

Molecular imaging and scans follow to see whether the radio peptide has latched on of the tumour sites correctly.

The entire session usually lasts for about 4 hrs and is often done as an out patient procedure.

The main goals of PRRT hence are to provide symptom relief, to stop or slow tumor progression and to improve overall survival.

Advantages of PRRT ?

PRRT along with other molecular therapies or targeted therapies offer excellent results as they are tailor made keeping in mind molecular properties of the tumour and also biologic characteristics of the patient.

PRRT is offered in Germany , USA, UK and other developed countries at a significant cost, In India, a single session of PRRT costs approx USD 6300.

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Understanding Precision Medicine for Cancer.

We often hear of Precision Medicine for Cancer, but what is Precision Medicine, how is it different from standard treatment protocols and what can be the benefits for choosing Precision Medication over standard protocols?

The diagnosis and treatment of cancer at a cellular or molecular level is known as Precision Medicine.

Cancer
Precision medicine : Tailored medication for cancer based on specific patients, genetic profile .

Cancer is a heterogenous disease, with different genetic profile not only between patients with different cancers but also differences in genetic , molecular and cellular profile even within the same type of cancer.

All cancers are genetic by nature and with cellular profile changing over time even in the same patient, till now no single drug is known to cure even a single type of cancer let alone different types of cancer’s.

Standard chemotherapy protocols focus of administering standard chemotherapy drugs ( one size fits all) without taking into account cellular or genetic profile of the patient.

Precision medicine on the other hand focuses on accurate and effective treatment to each patient based on the genetic profile, the proteins feeding the tumours or the cancers.

There are sufficient number of detractors even amongst the best doctors but precision medicine or administering drugs based not a specific tailored patient profile not being the best option is a pre mature conclusion.

This week being Breast Cancer week, let’s shed some light on Precision medicine for breast cancer.

Breast cancer treatment in India beyond surgical options of lumpectomy, mastectomy involves administering chemotherapy and radiotherapy, with chemotherapy being the first line of treatment.

Difference in outcomes depends upon whether the patient has been tested for HER2(human epidermal growth factor receptor 2), ER, PR or not.

For patients testing positive for HER 2, addition of trastuzumab to chemotherapy slows down disease progression. Lapatinib plus chemotherapy (i.e., capecitabine) achieved a longer median time to disease progression compared with chemotherapy alone.

A combination of pertuzumab, trastuzumab, and chemotherapy further improved the median overall survival time to a median of almost 5 years compared with a combination of only trastuzumab and chemotherapy for a median of 3 and half years.

Similarly treatment with ado-trastuzumab emtansine, a conjugate of a HER2 monoclonal antibody and a cytotoxic drug, significantly improved the length of progression-free survival and overall survival with lower adverse effects when compared with lapatinib and chemotherapy

The above examples clearly show how genetic profiling, identification of key mutations like the Bcr-Ablfusion or HER2 can benefit a large number of breast cancer patients.

Genetic profiling also enables identification of molecular targets for intervention.Cell death is caused by a combination of deficiencies in the expression of two or more genes, whereas deficiency in only one of these genes can increase viability or enhance multiplication of mutant cells. For example, BRCA (mutant gene responsible for particularly aggressive breast cancers( and poly ADP ribose polymerase (PARP) genes were found to have a synthetic lethal relationship.

For example, by using olaparib, a PARP inhibitor, to treat BRCA-mutant ovarian cancer patients, the progression-free survival of BRCA-mutant ovarian cancer patients was significantly prolonged by olaparib compared with standard chemotherapy protocols.

This methodology focusses on identifying cancer vulnerabilities and subsequent tailored treatment based on patient profile.

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Decoding CyberKnife, for cancer treatment and benign tumours

We often get queries on CyberKnife and what is CyberKnife used for ?

CyberKnife is an excellent treatment option for treating cancer’s such as prostate cancer, gliomas ,brain cancer, kidney cancer, lung cancer, spine cancer, cancer of the pancreas, head and neck cancer, liver cancer, early stage -localised breast cancer and several types of malignant tumours, benign tumours and several other medical conditions.
CyberKnife delivers stereostatic radiation( SBRT) with extreme precision and a tissue margin of 1-5mm

Non invasive, CybeKnife vaporises a brain tumour

Cyber knife is totally non invasive and offers hope for inoperable localised cancers such as small cell lung cancer,for inoperable lesions where there is no other alternative for the patient to be treated.
CyberKnife can spot the exact size, shape and location of the tumor and delivers highly concentrated beams of radiation with precision ranging from 1 to 5 mm and this leads to minimal damage and bleeding.

Since CyberKnife treatment is totally non invasive, it is used for treatment of inoperable cancers as an alternate to surgery or as an alternative to surgery to minimise trauma, avoid complications and reduce risk.

Most patients can be treated several times with the CyberKnife and even treated again or retreated with minimal side effects leading to a better quality of life.For example for prostate cancer, even for a repeat surgery, CyberKnife can be used very successfully.

CyberKnife treatment is FDA approved and can spot patient movement even while breathing. The radiation beams can be aimed from several directions, thereby never losing the precision which is hall mark of a CyberKnife treatment.

CyberKnife treatment usually gets completed in 3 to 5 sessions spread over a week. Most patients can lead normal lives post CyberKnife treatment Most CyberKnife treatments are covered by insurance providers all over the world.

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Since the treatment involves a high degree of expertise, CyberKnife treatment is not offered by most hospitals.

The stage, location and size of the tumour or the cancer plays an important role, hence multiple teams of doctors and oncologists need to be involved before a decision on  use of CyberKnife as treatment option can be arrived.
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Bowel Cancer- Are there a few red flags to watch out for ?

Bowel cancer is defined as cancer of the bowel or parts of bowel. Depending upon where the cancer is based, it is also known as colon cancer, rectal cancer or colorectal cancer.

Colon cancer is cancer of the rectum. Rectal cancer is cancer of the rectum.

Colorectal cancer is cancer affecting the colon and the rectum.

Most colon cancers are lethal simply because they are diagnosed at a very late stage. Most patients present themselves with symptoms and often visit doctors but symptoms are often missed .

A short guide on awareness of possible symptoms, which are red flags but are often missed during doctor visits.

ColonCancer
Bowel, colon and rectal colorectal cancer symptoms causes risk factors diagnosis
  • Blood in the stool which shows rectal Bleeding
  • Change in Bowel Habits
  • Diarrhoea
  • Abdominal Pain

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Stomach Cancer- Why does it catch us unawares ?

Stomach cancer is defined as the growth of cancerous cells in the stomach lining.
According to the National Cancer Institute (NCI), there will be approximately 24,590 new cases of stomach cancer every year.

Stomach cancer
Clinical stages of stomach cancer. How stomach cancer spreads?

Stomach cancer is often left undiagnosed because it doesn’t have many early symptoms – it is diagnosed when cancer spreads to other parts of the human body.

A few early signs are:
Nausea and Vomiting: Nausea is defined as a feeling of queasiness at the back of your throat or stomach. Vomiting, on the other hand, is defined as the contraction of your stomach muscles that push the digested food back through your oesophagus. Both nausea and vomiting may be early symptoms of stomach cancer especially if one’s blood shows in the vomit.
Bloating: If one faces bloating, which doesn’t ease up and persistent, it calls for a visit to the doctor and an ultrasound at least to start with.

H. Pylori Infection: If one suffers from frequent indigestion, bloating,one must get tested for bacterial Infection with H pylori, as it is the most prominent indication of people developing stomach cancer later.

Research has shown that people suffering from H.Pylori infections have a much incidence of stomach cancers.

Weight loss: Stomach tumours cause blockages, preventing food from passing into the stomach or into the intestines causing loss of appetite. Similarly, stomach cancer causes energy from food to be burned at a faster rate which combined with nutritional loss causes weight loss.

Stomach Pain: Unexplained stomach pain , the kind which persists is also a warning sign that something may be wrong.

Frequent HeartBurns:  Frequent heartburns could be because of ulcers and may also indicate that everything is not ok.

Inability to eat: As the tumour progresses, it blocks various parts of the digestive system. Coupled with body’s inability to digest food,  there is a reduced appetite, which at a later stage is often total inability to eat and digest food.

As the symptoms are so generic, they are often missed leading to diagnosis at a much later stage when the cancer has spread or metastatised to other parts of the body.

Is there a co-relation between our habits and stomach cancer?
Food: Food and stomach cancer have a direct relationship. The right dietary intake can lower the risk of stomach cancer. Storage of food through refrigeration instead of by smoking, salting and pickling also reduces the risk because the nitrates and nitrites in smoked food increase the risk of stomach cancer.
Smoking: The use of tobacco increases the risk of stomach cancer. It is said that the rate of risk of stomach cancer is doubled in smokers as compared to non-smokers. This is because smoking reduces the production of natural substances that protect the stomach and duodenum from tissue damage. Additionally, smoking promotes the duodenum reflux and increases the acidity of the duodenum making it vulnerable to H. Pylori bacteria. Smoking also constricts the blood vessels in the stomach reducing the blood flow in the stomach. All these mechanisms strengthen the link between stomach cancer and smoking.

Treatment of stomach cancer involves, surgery if detected at an early stage, followed by chemotherapy as the 1st line of treatment.

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Cancer Treatment in India, Colon Cancer

colon cancer
colon cancer

Colon Cancer Treatment:

Colon Cancer occurs when there is uncontrolled cell growth in the large intestine. Mostly it grows out of tumors known as adenomatous polyps that occur in the walls of the large intestine.

Major causes of colon cancer include polyps, genes, traits, habits, diet and other medical factors. Cancer Treatment in India involves diagnosis and starting of the treatment process.

Types of Colon Cancer:

The types of colon cancer include:

1. Primary colorectal lymphomas
2. Gastrointestinal stromal tumors
3. Lecomyosarcomas
4. Carcinold tumors
5. Melanomas

Colon Cancer Symptoms:

  • Weight loss Anemia
  • Abdominal pain
  • Blood in the stool
  • Stool consistency change
  • Diarrhea or constipation maybe experienced
  • Stools maybe narrow
  • Bowel movement pain
  • Fatigue

Diagnosis of Colon Cancer

For a diagnosis full physical examination and also personal examination and family medical histories may be examined. The diagnosis is done after an endoscopy is conducted.

Endoscopy is a procedure for examining a person’s digestive tract using an endoscope. In the case for diagnosing colon cancer an endoscopy known as sigmoidoscopy or colonoscopy is done.

It involves inserting a long flexible tube with a camera on one end into the rectum for inspecting the colon inside. When polyps are found inside the colon are removed and further examined under a microscope so as to detect any cancerous cells.

The process of endoscopy begins with the patient staying without food or drinks for a number of hours before the procedure.

Through the rectum a liquid containing the element barium is injected to the colon to line the intestine then an X-ray is done of both the colon and the rectum.

The element will show white color on X-ray tumors and it will show dark outlines on polyps. To know how far the cancer has spread chest X-rays, CT scans of the lungs, liver and abdomen are done. In other cases a blood test is done to determine whether carcinoembryonic antigen which is a substance produced by some cancer cells.

The stage of cancer is determined after diagnosis and this helps in knowing choices available for treatment and it also informs prognoses. The staging method of cancer is called TNM system.

T shows how the intestine has been invaded by the cancer cells.

N shows the degree to which cancer has spread to the nearby lymph nodes.

M shows whether cancer has spread to other body organs.

Colon cancer is also grouped according to TNM classification 0 to IV. 0 Tis, N0, M0 where (Tis) is carcinoma this is when the tumor is in the inner layer of the colon or rectum only. N (Mi) shows cancer that has spread to other organs throughout the body.

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Getting care for symptoms and side effects

Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care is any treatment that focuses on reducing symptoms, improving quality of life, and supporting patients and their families. Any person, regardless of age or type and stage of cancer, may receive palliative care. It works best when palliative care is started as early as needed in the cancer treatment process.

People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional support, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, or radiation therapy. Talk with your doctor about the goals of each treatment in your treatment plan.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and palliative care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it can be addressed as quickly as possible. Learn more about palliative care.