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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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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Gliomas (Astrocytoma)

Gliomas are brain tumors that begin in the glial cells. Glial cells generally surround and support the proper functioning of nerve cells.

Astrocytomas are brain tumors that develop in astrocyte cells. Astrocytes are a specific type of glial cell. About half of brain tumors in children are astrocytomas.

As most gliomas originate from astrocytes, the terms are often used interchangeably. Gliomas are classified as either low-grade or high-grade based on how likely they are to grow and spread. Low-grade gliomas usually are slow growing and stay in a local area of the brain.

High-grade gliomas grow quickly and spread easily throughout the brain. High-grade gliomas are the most common lethal tumors in adults, but also occur in children.

Due to the location of the tumor, these patients may have seizures and significant paralysis at the time of diagnosis. High-grade gliomas are much more aggressive and they need more intensive treatments.

Treatment of Gliomas:

The treatment for Gliomas (Astrocytoma) include : 

  • Chemotherapy
  • Radiation and
  • Surgery.

Surgery is more recommended by doctors.

Next Article: Diffuse Intrinsic Pontine Glioma (DIPG)

Primitive Neuroectodermal Tumor (PNET) and Pineoblastomas

Primitive Neuroectodermal Tumor (PNET) and Pineoblastomas tumors develop generally in the upper part of the brain.

PNETs and pineoblastomas have a similar pathology to medulloblastomas and are treatment.

Brain tumor is generally associated with, the patient’s initial problems including the onset of seizures or eye abnormalities, as well as problems with headache,  nausea and vomiting.

Treatment:

The treatment options for Primitive Neuroectodermal Tumor (PNET) and Pineoblastomas are:

  • Chemotherapy
  • Radiation
  • Surgery.

Multiple Myelomas and Treatment Options

Multiple Myeloma and its treatment options. Structure of multiple myeloma

Multiple Myeloma

Multiple Myeloma is a type of cancer that develops in the plasma cells of the immune system.

 

The plasma cells are essential in helping the human body ward off diseases, by producing antibodies that will help identify and attack microorganisms.

These cells are found inside the bone marrow, a great site for Multiple Myeloma. The cancer cells will grow and proliferate inside the bone marrow of the patient to the point that they totally crowd the normal blood cells.

The issue here is that, instead of the plasma cells producing normal and healthy antibodies, the cancerous cells start producing abnormal proteins.

The plasma cells can grow uncontrollably and produce a certain tumor known as plasmacytoma.

Common signs and symptoms of Multiple Myeloma include:

  • Low blood cell count
  • Frequent infections
  • Pain in the bones
  • Excessive calcium
  • Kidney problems
  • Nausea
  • Loss of appetite
  • Confusion
  • Weight loss
  • Fatigue etc.

A PET CT or a CT when PET CT is not available is recommended.

Available Treatment Options for Multiple Myeloma:

The treatment for multiple myeloma is not usually necessary especially if there are no signs and symptoms of the diseases yet. However, treatment might be recommended when there are obvious signs and symptoms.

The treatment options help in controlling the disease. Again, therapy can help manage the symptoms of multiple myeloma such as pain and other related complications that might be debilitating to the patient. Survival rates for myeloma vary widely from patients surviving many years and some succumbing within a few years.

Some of the recommended standard treatment options available include:

Chemotherapy

Chemotherapy drugs are effective in destroying any fast growing cells including the affected cancerous plasma cells in multiple myelomas. Your oncologist will determine the right chemotherapy drug for you and how long you will need to take it.

Corticosteroids

They are super helpful in regulating the bodies’ immunity and to control any inflammation in the body. In short, these drugs help in the prevention of inflammation in the body, somehow preserving and preventing any further cells and tissues damage. Corticosteroids such as dexamethasone and prednisone are also active against the myeloma cells. Again the right dosage and  type of corticosteroid will be determined by the hematoncologist.

Radiation Therapy

This treatment method uses radiation to destroy the Multiple Myelomas cells, completely neutralizing their growth as well as stopping their growth. Radiation can be used locally to help shrink the tumor cells in a specific area such as very painful tumor inside the bone of a specific place.

Targeted Therapy

This treatment method focuses on the specific abnormalities within the cancerous plasma cells that allow them to thrive or survive.

There are drugs that act by blocking the action of some substances inside the myeloma cells that  usually break down proteins, examples include Bortezomib and Carfilzomib. The cancerous cells die, since the supply of protein is limited.

Biological Therapy

These drugs make use of your body’s immune system to combat the multiple myeloma cells. Examples of such drugs include Thalidomide, Lenalidomide and Pomalidomide. They work by enhancing the immune system cells responsible for identifying and destroying the cancer cells.

Stem Cell Transplantation

It is a procedure that involves the replacement of your diseased bone marrow with a healthy one. Before the stem cell transplantation process is done, the blood forming stem cells will be collected from your blood.

A controlled high dose of chemotherapy will then be administered to destroy your diseased bone marrow. The stem cells are then infused into the bone marrow. They stem cell will begin multiplying and rebuilding your bone marrow.

The stem cell transplantation option does not come as a first option; a patient will have undergone the other options before the transplantation is considered. Always stay close to your doctor so that you are informed on the best and right treatment option for you.

Stem cell transplantation costs between usd 25000 to USd 36000 and cost of chemotherapy before the disease goes into remission is additional.

Multiple Myeloma treatment is available at most of the best cancer hospitals in India.

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Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.

A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.

If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the treatments described above, such as surgery, targeted therapy, immunotherapy, radiation therapy, and chemotherapy, but they may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.

People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. Learn more about dealing with cancer recurrence.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication.

Systemic chemotherapy gets into the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).

A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time.

Although chemotherapy is useful for treating most types of cancer, kidney cancer is often resistant to chemotherapy. However, researchers continue to study new drugs and new combinations of drugs. For some patients, the combination of gemcitabine (Gemzar) and capecitabine (Xeloda) or fluorouracil (5-FU, Adrucil) will temporarily shrink a tumor.

It is important to remember that transitional cell carcinoma, also called urothelial carcinoma, and Wilms tumor are much more likely to be successfully treated with chemotherapy.

The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.

Learn more about the basics of chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases.

Immunotherapy

Immunotherapy, also called biologic therapy, is designed to boost the body’s natural defenses to fight cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.

Interleukin-2 (IL-2) is a drug that has been used to treat later-stage kidney cancer. It is a cellular hormone called a cytokine that is produced by white blood cells and is important in immune system function, including the destruction of tumor cells.

High-dose IL-2 can cause severe side effects, such as low blood pressure, excess fluid in the lungs, kidney damage, heart attack, bleeding, chills, and fever, so patients may need to stay in the hospital for up to 10 days during treatment. However, some symptoms may be reversible. Only centers with expertise in high-dose IL-2 for kidney cancer should recommend IL-2. Some centers use low-dose IL-2 because it has fewer side effects, although it is not as effective.

Alpha-interferon is another type of immunotherapy used to treat kidney cancer that has spread. Interferon appears to change the proteins on the surface of cancer cells and slow their growth. Although it has not proven to be as beneficial as IL-2, alpha-interferon has been shown to increase survival when compared with an older treatment called megestrol acetate.

Researchers have tested many combinations of IL-2 and alpha-interferon for patients with advanced kidney cancer, and these treatments have also been combined with chemotherapy. It has not been shown in research studies that these combinations are better than IL-2 or interferon alone.

Researchers are working to learn more about how IL-2 and interferon destroy kidney cancer cells and which patients can benefit the most from these treatments. Newer forms of immunotherapy called checkpoint inhibitors are also being tested in clinical trials .