Cancer Hospital in Chennai

Highlight

Highly qualified and dedicated full time medical Oncologists

• Complete expertise in the management of haematological malignancies
• Personalised chemotherapy to individualise chemo treatment for every patient
• Efficient and updated with the newest technologies and practices including targeted therapy & immunotherapy
• Exclusive day care chemotherapy ward
• Molecular and targeted therapy for cancers
• Immunotherapy for cancer
• Hormonal therapy for hormone dependant malignancies like Breast and Prostate
• Expert care including Dedicated ICU for care of Patients on chemotherapy- if necessary

What is chemotherapy?

• Chemotherapy is the use of drugs that destroy cancer cells.
• There are many different kinds of chemotherapy medicines that may be used in different ways.
• The type of medicine that a patient receives and how often it is needed will depend on the type of cancer, its response to treatment and how the body copes throughout the treatment process
• Chemotherapy can be delivered in a number of different ways, including orally, inserted into the vein or directly into the area affected by cancer.
• Patients will usually receive chemotherapy in multiple cycles over a certain amount of time

How does chemotherapy work?

Chemotherapy works by killing cells that are rapidly dividing.

While this is effective in attacking cancer cells, chemotherapy also targets normal healthy cells that are rapidly dividing.

However, unlike cancer cells, normal cells can repair the damage and recover

Is there any side effects?

• Chemotherapy works by attacking cancer cells, however in the process few healthy cells are also damaged.
• This is what causes many of the common side effects of chemotherapy, which are often temporary.
• The side effects experienced will vary depending on specific chemotherapy medicines and how body tolerates the treatment.

What is Immunotherapy?

• The immune system helps body fight infections and other diseases, including cancer, by detecting and destroying abnormal cells that have become cancerous.
• Immunotherapy in its various forms can either boost the immune system to help it fight the cancer, or make it easier for immune system to identify cancer cells and destroy them
• The different types of Immunotherapies are Cancer vaccines, monoclonal antibodies and Checkpoint Inhibitors
• Immunotherapies have lesser side effects than chemotherapy

Highlights

High end advanced technology with innovative true beam STx machine

• Treatment of small and large tumours located in critical areas with multi-disciplinary approaches
• Best outcome with minimal toxicity
• Sophisticated image guidance and motion management tools
• Effective treatment in breast, gynaec, lung, head & neck, gastrointestinal, Genito-urinary, spinal column, soft tissue, bone and benign tumours
• 3D conformal radiotherapy (3DCRT)
• Intensity modulated radiotherapy ((IMRT)
• Image guided radiotherapy (IGRT)
• Rapid ARC (volumetric modulated ARC therapy)
• Stereo tactic radio surgery (SRS), including intensity
• Modulated radiosurgery and image guided radio surgery (IGRS)
• Stereo tactic radiotherapy (SRT)
• Stereotactic body radiotherapy for extra cranial sites

What is Radiotherapy?

Radiotherapy (Radiation Therapy) uses High-energy beams of radiation rays focused on cancerous tissue to kill them or stops them from multiplying.

How is radiotherapy given?

There are two main ways of giving radiotherapy:

• External radiotherapy where the radiation comes from a machine from outside the body.
• Internal radiotherapy where the radiation comes from implants or liquids placed inside the body.

What are the latest techniques in radiotherapy?

New ways of giving radiotherapy are being developed. These may be used for the treatment of some but not all cancers. These are helpful in minimizing side effects of radiotherapy

The new methods of radiotherapy include:

• Intensity-modulated radiotherapy (IMRT), which is particularly useful for cancers in the head and neck.
• Image-guided radiotherapy (IGRT), which allows more accurate targeting of radiotherapy to the cancer.
• Stereotactic radiotherapy (SRT), which can be used to target very small cancers.

Breast cancer is the most common invasive cancer in women and the second leading cause of cancer death in women after lung cancer.

Advances in screening helps in early diagnosis of Breast cancer and advances in treatment have improved survival rates.

Highlights

The patient is at the heart of everything we do at Gleneagles Global Breast centre.

We believe that our patients should experience nothing less than exceptional level of medical care.

Our compassionate doctors, with special expertise in treating all types of Breast cancer (early to advanced cancer) provide the Best care for Breast cancer.

The UNWAIT philosophy aims to complete Triple assessment (clinical assessment, Imaging and Pathological examination) of Breast cancer within 24 hours of first visit

Screening

• State of art FULL FIELD DIGITAL MAMMOGRAM
• High Resolution Ultrasound of Breast
• MR Mammogram
• Dedicated breast imaging SPECIALIST RADIOLOGIST

Interventional Breast Radiology services

• Ultrasound guided biopsy of Breast Lump
• Stereotactic biopsy – Mammogram guided Biopsy
• Sentinel Lymph node biopsy
• Pre-operative Wire Localisation of non-palpable Breast Lumps
• Pre surgical Image guided tissue marker placement before giving chemotherapy (neoadjuvant chemotherapy)
• Specimen mammogram localisation of Early non palpable breast tumours
• USG guided drainage of Breast cysts/ Breast abscess
• Fine Needle aspiration cytology/ Core needle Biopsy

Management

• Breast Lumps can be either benign or malignant.
• More than 90% of Breast lumps are usually benign. ( not cancerous)
• The management for the disease and further therapy and follow up depends on the same.

Benign Breast Diseases

The most common Benign Breast Lumps are Fibroadenoma and Breast cysts. Benign Breast Lumps are evaluated and diagnosed by High Resolution Ultrasound. Small cysts or Fibroadenoma require no intervention and are kept under observation. Larger Fibroadenomas can be removed surgically in a day care procedure by scarless surgery or by Vacuum assisted Biopsy.

Malignancy of Breast- Breast Carcinoma

Diagnosing breast cancer

Tests and procedures done to diagnose breast cancer include Full Field Digital Mammogram, USG of Both Breast and Biopsy from the Breast Lump.

After diagnosis, patient may need further scans (PET scan, CT chest, Bone scan) to stage the patient as early or advanced or metastatic Breast cancer.

Surgery for early breast cancer

The surgical options for Early Breast cancers are

• Breast Conservation Surgery – Wide Local excision of Breast lump with adequate margins- Frozen section analysis and Oncoplastic Breast Reconstruction.
• Management of Axillary nodal metastasis
• Axillary occult nodal metastasis can be addressed by State of the art Sentinel Lymph node biopsy using Radio-active sulphur colloid and Gamma camera.
• Avoids unwanted axillary dissection and associated morbidity

After Breast conservation surgery, the residual Breast is reconstructed. This is called as Onco-plastic Breast Reconstruction

• Onco-Plastic Breast Reconstruction is performed with
• Local oncoplastic procedures
• Pedicled LD flap
• Micro vascular free flap reconstruction like DIEP
• Breast Silicone Implants
• Modified Radical Mastectomy

It is complete surgical removal of Breast and all axillary lymph nodal tissue. With recent advances in Management, nowadays this is being done in a select few patients with advanced Breast cancer and who are not eligible for Conservative Breast Surgery

OTHER treatments for breast cancer

Hormone Therapy

• Hormone therapy is used to treat breast cancers that are sensitive to hormones.
• Commonly used hormone therapy in Breast cancers is directed against estrogen receptor positive (ER positive) and progesterone receptor positive (PR positive) cancers.
• Hormone therapy can be used before or after surgery or other treatments to decrease the chance of cancer returning.
• Treatments that can be used in hormone therapy include:

• Medications that block hormones from attaching to cancer cells (selective estrogen receptor modulators)
• Medications that stop the body from making estrogen after menopause (aromatase inhibitors)

Targeted Therapy

• Targeted drug treatments attack specific abnormalities within cancer cells.
• As an example, several targeted therapy drugs focus on a protein that some breast cancer cells overproduce called human epidermal growth factor receptor 2 (HER2).
• The protein helps breast cancer cells grow and survive. By targeting cells that make too much HER2, the drugs can damage cancer cells.

Chemotherapy

• Chemotherapy uses drugs to destroy fast-growing cells, such as cancer cells.
• If the cancer has a high risk of spreading to another part of the body, the patient may be recommended to undergo chemotherapy, after surgery to decrease the chance of recurrence.
• Chemotherapy is sometimes given before surgery in women with larger breast tumours to downstage tumours. The goal is to shrink a tumour to a size that makes it easier to remove with surgery.
• Chemotherapy is also used in women whose cancer has already spread to other parts of the body.

Radiotherapy

• Radiation therapy uses high-powered beams of energy, such as X-rays and protons, to kill cancer cells.
• External beam radiation of the whole breast is commonly used after a lumpectomy.
• Breast brachytherapy may be an option after a lumpectomy if patients have a low risk of cancer recurrence.
• Radiation therapy to the chest wall might be needed after surgery for larger breast cancers or cancers that have spread to the lymph nodes.
• Breast cancer radiation can last from few days to six weeks, depending on the treatment

Phyllodes Tumour

• They are a rare form of breast tumours arising from the stroma of breast.
• They may be benign, malignant or borderline.
• Based on the histology and site and size, the patient may need surgery in the form of wide local excision or mastectomy.
• Adjuvant Therapy is needed in case of advanced and high-grade histology.

Highlights

• One amongst the very few centres in the country to offer BMT (Bone marrow Transplantation) for life threatening benign & malignant disorders
• BMT is offered for
• Haemotologic disorders like thalassemia, sickle cell disease
• Childhood cancers like leukemia, lymphoma
• Immune deficiencies like SCID, CGD
• Aplastic anaemia like Fanconi anaemia and other acquired aplastic anaemias and Inherited metabolic disorders
• Dedicated team of paediatric & adult BMT physicians, intensivists, Infectious Disease Specialist
• Pathologists, 24×7 Blood bank facility, expert staff
• Expertise to perform all types of stem cell transplantations
• Allogeneic stem cell transplantation using matched related or matched unrelated donors
• Allogeneic stem cell transplantation using a haploidentical (Half Matched) donors
• Allogeneic unrelated cord blood transplantation
• Autologous stem cell transplantation

Highlights

Comprehensive treatment facilities for all types of childhood cancers

• Acute lymphoblastic leukemia
• Acute myeloid leukemia
• Chronic myelogenous leukemia
• Juvenile myelomonocytic leukemia
• Hodgkin’s lymphoma/Non-Hodgkin’s lymphoma
• Bone tumours
• Nephroblastoma
• Neuroblastoma
• Rhabdomyosarcoma/Soft tissue sarcoma
• Germ cell tumours
• Brain tumours
• Advanced paediatric intensive care unit

Cancer is one of the leading causes of death in India.

It is estimated that there are nearly 2.5 million cancer cases at any given point of time, with over 11.5 lakh new cases and more than 7.84 lakh deaths occurring every year due to this disease.(Globocan 2018)

5 MOST COMMON CANCERS IN INDIA (*Source Globocan 2018)

• Over 70% of cancer cases are report in advanced stage of the disease, resulting in poor survival.
• The only way to win the battle against cancer is through Prevention & Early Detection.
• Regular screening helps detect many cancers in early stages, when they can be treated successfully giving the best survival.
• Department of Preventive Oncology primarily focuses on creating awareness among the public about the need to screen for early detection of cancer.
• If clinically or through test report we detect any pre-cancerous lesions or early cancers they are cured completely.

Preventive Services offered in GGHC are

• Awareness Programs
• Screening Camps
• Screening Tests

Breast cancer screening

Cancer Screening is a collective term given to a series of medical tests performed on asymptomatic and apparently healthy individuals to check for the presence of precancerous lesions. Breast cancer screening involves evaluation of symptom-free, apparently healthy females aged between 20-70 years for early detection of breast cancer. Breast cancer screening is done through clinical examination and mammography.

• Clinical Breast Examination (CBE): It involves a detailed evaluation of history, physical examination of breasts and under-arm regions, palpation of breasts in different positions and examination of lymph nodes.
• Mammography (FULL FIELD DIGITAL MAMMOGRAM): Mammography uses low-dose X-ray radiation to detect precancerous and cancerous growth in the breasts.

Colorectal cancer screening

Colorectal cancer screening is performed to detect abnormal growths called polyps, which protrude from the inner walls of colon and rectum. Colorectal cancers become symptomatic only in the advanced stages.

• Faecal Occult Blood Test (FOBT): It is performed to check for blood in the faecal matter, which is a sign of a polyp or early-stage colorectal cancer.
• Upper/Lower Gastrointestinal Endoscopy: Upper and lower GI endoscopies act as extremely sensitive cancer screening tools and help doctors in detecting precancerous lesions or polyps that could be signs of early-stage colorectal cancer.

Prostate cancer screening

Prostate cancer progresses at a slower rate; therefore, regular screening may help in catching cancer even before it starts exhibiting symptoms. Prostate cancer screening is done through PSA test and digital rectal examination.

• PSA test (Biomarker Assessment):

It is a simple blood test performed to assess the levels of Prostate-Specific Antigen (PSA), which is a special protein biomarker produced by both malignant and benign prostate tissue. High PSA levels in the blood may indicate the risk of prostate cancer.

Cervical cancer screening

Cervical cancer is100 percent preventable. Cervical cancer screening is performed to detect any abnormalities in the cervical cells that could lead to cervical cancer. Regular screening helps in their early detection in the Precancerous state. Pap test is an effective cervical cancer screening method.

Pap smear test: During a Pap test or Pap smear, samples of cervical cells are collected and checked for irregularities. Precancerous cellular changes can be managed with appropriate treatment.

Colposcopy clinic: Colposcopy clinic offers diagnosis and treatment for pre-invasive diseases of the cervix, vulva, and vagina. When appropriately treated, cancers of these sites may be prevented.

Vaccination to prevention cancer

Vaccinations are available for the oncoviruses – Human papillomavirus (HPV) and Hepatitis B Virus (HBV)

Human papillomavirus (HPV) vaccination:

• HPV vaccine helps prevent cervical, vaginal, vulvar, penile and anal cancers along with oropharyngeal cancers.
• HPV vaccines are recommended for individuals aged 9-26 years.
• It must be noted that the HPV vaccine is not a substitute for cervical cancer screening; all women, including those who are vaccinated, should undergo cervical cancer screening regularly.

Hepatitis B Virus (HBV) vaccination:

• HBV causes Hepatitis-B, which if left untreated, may cause liver cancer. Individuals of all age groups can take HBV vaccines.

Other services

Counselling on Lifestyle Modification

• Cancer is a lifestyle disease that a healthier and active lifestyle can prevent.
• Factors like sedentary lifestyle, unhealthy diet and chronic stress can trigger tumour formation.
• These factors also aggravate the tumour growth in patients with stage 1 and stage 2 cancers.
• Lifestyle modification counselling sessions focus on creating awareness on the importance of having an active lifestyle, prudent diet and effective stress management strategies.

Tobacco and Alcohol Cessation Clinic

Tobacco and alcohol are the causes of several preventable diseases, including cancer. Abstaining from tobacco and alcohol consumption is proven to reduce the risk of crucial diseases like cancer.

Obesity Clinic

Healthy weight management helps in bringing down the risks of various cancer types. Carefully planned diet regimens can help obese individuals maintain a healthy weight and reduce the risk of various chronic diseases.

Interventional Radiology Procedures which help in investigation, diagnosis and management of cancers include

Intervention Breast procedures are offered at Gleneagles Global Breast Centre

• USG or CT guided biopsy of solid organ tumours / bony lesions
• USG guided FNAC for thyroid nodules or suspicious Lymph nodes
• USG /CT guided catheter placement- PICC line and Portacath insertion
• Interventional Radiology services for Liver tumours
• Percutaneous Liver Biopsy
• Transcatheter arterial chemoembolization TACE
• Transcatheter arterial Radioembolisation TARE
• Radio frequency ablation RFA of liver tumours
• Percutaneous Transhepatic Biliary drainage PTBD for Jaundice
• PTBD and biliary stenting

Interventional Radiology services for Renal Tumours

• Biopsy of suspicious renal lesions
• Percutaneous nephrostomy/ Stenting

Interventional Radiology services for Lung Tumours

• Biopsy of Lung tumours
• Pleural collection aspiration/ drainage/ pigtail or ICD insertion
• Pleurodesis

Advanced endoscopic and colonoscopic procedures

Endoscopy/ Colonoscopy is an important test done for diagnosis, evaluation, management and follow up of most Gastro Intestinal malignancies.

The endoscopic and colonoscopic procedures offered in our Hospital for cancer care are

• Upper GI endoscopy with Narrow band Imaging to localise doubtful/suspicious tumours
• OGD scopy and biopsy of oesophageal/ stomach lesions
• OGD scopy and stenting (metallic/plastic)
• Capsule endoscopy
• Chromoendoscopy
• Endoscopic Ultrasound guided biopsy of pancreatic tumours
• Endoscopy guided procedures for early gastric tumours- Endoscopic submucosal dissection ESD and Endoscopic mucosal Resection EMR
• ERCP
• ERCP and Biliary stenting for jaundice
• Colonoscopy with biopsy of suspicious lesions
• Sigmoidoscopy
• Colonoscopic polypectomy
• Colonoscopic stenting to relieve intestinal obstruction

• Pathologists study the tumour specimen and help in ascertaining the grade of tumour and also post-operative specimen is analysed to stage the disease.
• Immunohistochemistry analysis helps in deciding the subtype of certain tumours and also guide regarding adjuvant therapy
• Molecular and genetic analysis helps in deciding Targeted therapy for advanced tumours
• Intra-operative Frozen section analysis helps in quick diagnosis of indeterminate lesions

Oncopathology services available in Gleneagles Global Health City are –

• Clinical pathology
• Cytology
• Hematology
• Histopathology
• Frozen section pathology (for immediate diagnosis)
• Immunohistochemistry (IHC)
• Flow cytometry
• Molecular pathology
• Molecular Genetics
• Molecular Oncology
• Bone marrow analysis

Nuclear Medicine and Radiology Services

Nuclear medicine and PET CT help in diagnosing staging and in some cases even in treatment of cancers.

Nuclear medicine services available in Gleneagles Global Health city are

• Whole Body PET CT
• Whole body FDG PET CT
• F18 PET CT
• PSMA PET scan for prostate cancers
• DOTA PET for neuroendocrine tumours
• Technetium 99 Bone scan
• Sestamibi scan for parathyroid tumours
• MIBG scan for neuroendocrine tumours
• Radio iodine uptake scan and Radio iodine ablation therapy for thyroid cancers
• Samarium therapy and Lutetium therapy for treatment of painful bone metastasis
• Sentinel Lymph node Biopsy using Radioactive Sulphur colloid for detecting Lymph node metastasis in Breast cancer

Radiology services

• Digital and computerised X ray
• High resolution USG
• 128 slice CT scan
• 1.5 T MRI scan
• Fluoroscopy services and Cath lab facilities
• 3D Doppler services

• Terminally ill patients with advanced or metastatic cancers might require specialised medical care for symptom relief – known as palliative care.
• Palliative care team is made up of different professionals who work with the patient, family, and the patient’s other doctors to provide medical, social, emotional and practical support.
• The team is comprised of palliative care specialist doctors and nurses and includes others such as social workers and nutritionists.
• Most cancer patients require palliative care for pain relief and nutrition support.
• Procedures to provide nutritional support like central line catheters or feeding tubes may be provided for patients.
• Pain relief through patient controlled analgesia, opioid patches or nerve blocks are provided
• The main goal of care focuses on the care, comfort and quality of life of a person with a serious illness who is approaching the end of life

Overview

The urinary bladder is a muscular organ in the lower abdominal cavity and its function is to store urine.

The most common type of bladder cancer is urothelial carcinoma, which accounts for approximately 85% of all bladder cancers.

Other types of bladder cancer include squamous cell carcinoma and adenocarcinoma. These types of cancer only account for a small percentage of bladder cancers (1-2%), but are aggressive (grow quickly).

Bladder cancer can be either:

Non-muscular-invasive bladder cancer – where cancer cells are only found in superficial inner layers

Muscular-invasive bladder cancer – where cancer cells have spread beyond the first two layers of the bladder into the muscle layer or into nearby tissue.

Risk Factors for Bladder Cancer

• Smoking is the leading modifiable risk factor for bladder cancer, causing approximately 50% of all bladder cancers in both men and women.
• Exposure to chemicals in the workplace such as aromatic amines, used in the dye, paint and textile industry increase the risk of bladder cancer.
• Age – bladder cancer risk increases with age, with most people being over 60 years of age when diagnosed.
• Repeated urinary infections– such as a urinary tract infection (UTI), bladder stones or kidney infections can increase the risk, as well as long-term use of catheters.
• Previous chemotherapy or radiation therapy – certain chemotherapy drugs and radiation to the pelvis area can increase the risk for bladder cancer.

What are the signs and symptoms of Bladder Cancer?

• Gross Painless haematuria in 80-90% patients. Painless haematuria must be treated as malignancy of the urinary tract until proved otherwise.
• Advanced disease may cause urine voiding related symptoms
• Lower abdominal pain in advanced cancers
• Patients with metastatic disease may present with symptoms related to organs involved

Evaluation

• Urine analysis to look for microscopic hematuria
• Complete blood panel evaluation
• Renal function tests
• Urine for malignant cells
• CECT or Whole-Body PET CT or MRI as needed
• Cystoscopy and biopsy of any suspicious lesions

Bladder Cancer Treatment Options

1. Treatments for non-muscle-invasive bladder cancer include:

Surgery – transurethral resection of bladder tumour (TURBT) can be done which removes or destroys the tumour. This procedure is done under general anaesthetic and takes approximately 30 minutes.

Chemotherapy – uses drugs to kill the cancer cells by inserting a catheter (soft tube) directly into the bladder via the urethra (called intravesical chemotherapy).

Immunotherapy – via the use of a vaccine (known as Bacillus Calmette-Guérin (BCG)) which was once used to treat tuberculosis, can increase the body’s natural immune system to stop the growth of the cancer cells in the bladder.

2. Treatments for muscle-invasive bladder cancer include:

Surgery – the removal of the whole bladder is a common surgical treatment in cases where the cancer has spread to the muscle.

Chemotherapy – Systemic Chemotherapy to treat muscle-invasive bladder cancer usually involves intravenous therapy (drugs given by injection into the vein).

Radiation therapy – can be used instead of surgery to treat muscle-invasive bladder cancer. It can also be used at the same time as chemotherapy to help maximise treatment outcomes.

Immunotherapy – is a treatment option for muscle-invasive bladder cancer which has metastasised (spread to distant areas of the body)

What we offer in our centre?

All the above evaluation and treatment options are available in our centre for treating bladder cancer.

The surgical options available in our centre are –

• Transurethral resection of bladder tumour TURBT
• Transurethral biopsy of bladder tumour
• Cystoscopy and DJ stenting for bladder tumours if necessary
• Partial cystectomy with bladder augmentation
• Lap/open Radical cystectomy with continent diversion for bladder cancer

Chemotherapy /Radiotherapy/ Immunotherapy based on the stage of disease being offered for the patient.

Overview

Blood cancer affects the production and function of blood cells and starts in bone marrow which is the integral source of blood production. Stem cells in our bone marrow mature and develop into three types of blood cells: red blood cells, white blood cells, or platelets. In case of cancer, the blood production process is interrupted due to the growth of an abnormal type of blood cell. The common types of blood cancer include Leukemia, Lymphoma and Myeloma

What are the symptoms of Blood Cancer?

Blood cancer is a type of malignancy which affects the blood, bone marrow, or lymphatic system.

The most common blood cancer symptoms are:

• Weakness, Fatigue and Malaise
• Recurrent infections or fever
• Sweating of body during night
• Weight loss
• Excessive or easy bruising
• Bleeding gums
• Shortness of breath
• Loss of appetite
• Lymph node (gland) enlargement
• Lumps or abdominal distension due to enlarged abdominal organs
• Occurrence of fine rashes on dark spots

Evaluation of Blood Cancer

Evaluation includes –

• Complete blood test to look for abnormality in blood cells.
• Bone marrow biopsy or biopsy from lymphnodes to diagnose the cancer
• Immunohistochemistry and gene analysis to identify the sub-type of cancer and also to look for
• The patient may need to undergo whole body PET CT for staging the disease.

What are the treatment options?

Treatment of leukaemia will be dependent on the type of leukaemia, current health and medical history as well as patient`s treatment preference.

Acute leukaemia typically requires immediate (within 24 hours) treatment.

Treatments for leukaemia include:

• Chemotherapy is the mainstay of treatment
• Radiation therapy (rarely)
• Stem cell and bone marrow transplants / Donor lymphocyte infusion
• Steroid therapy
• Tyrosine kinase inhibitory therapy (CML especially)
• Surgery for lymph node removal to diagnose the disease

What we offer in our centre?

All latest treatment options for leukaemia including advanced chemotherapy, molecular therapy and allogenic bone marrow transplant if indicated

Overview

Tumours arising from brain cannot be classified strictly into benign or malignant.

Even ‘Benign’ tumours account for significant morbidity and mortality, as they can continue to grow and cause the adverse effects of any space-occupying lesion.

The preferred terms are ‘high-grade tumour’ (a tumour that grows rapidly and is aggressive) and ‘low-grade tumour’ (a tumour that grows slowly but which may or may not be successfully treated).

Also cancers from other sites can spread (metastasize) to brain and cause symptoms- Brain metastasis

Risk factors for Primary Brain tumours

• Ionising radiation.
• Vinyl chloride is associated with high-grade gliomas.
• Immunosuppression (eg.as a result of AIDS) may cause cerebral lymphoma.
• Inherited syndromes with an increased risk of brain tumours include neurofibromatosis, von Hippel-Lindau disease, tuberous sclerosis, Li-Fraumeni syndrome, Cowden’s disease, Turcot’s syndrome and naevoid basal cell carcinoma syndrome (Gorlin’s syndrome).

What are the signs and symptoms of Brain tumours?

Anyone presenting with new, unexplained headaches or neurological symptoms needs a thorough neurological study of history and examination.

The presentation will depend on location and rate of growth but includes features of a space-occupying lesion and raised intracranial pressure (ICP)

• Headache, which is typically worse in the mornings.
• Nausea and vomiting.
• Seizures.
• Progressive focal neurological deficits – eg. diplopia associated with a cranial nerve defect, visual field defect, neurological deficits affecting the upper and/or lower limb.
• Cognitive or behavioural symptoms.
• Symptoms relating to location of mass – eg. frontal lobe lesions associated with personality changes, disinhibition and parietal lobe lesions might be associated with dysarthria.
• Papilloedema (absence of papilloedema does not exclude a brain tumour).

Evaluation of Brain tumours

• Diagnosis largely rests on brain imaging – eg. CT scan and/or MRI scan (with or without contrast). MRI is more sensitive.
• The spine may also need to be imaged, especially in CNS tumours that spread to the spine – eg. germ cell tumours and lymphoma
• Blood tests may be useful in determining any complications of the tumour (eg. bleeding disorders, hypercalcaemia or inappropriate antidiuretic hormone secretion) or in the initial assessment of other possible causes of headache
• Technetium brain scan: is useful in the diagnosis of skull vault (eg, metastases) and skull base lesions.
• Magnetic resonance angiography (MRA) and magnetic resonance spectroscopy (MRS) are occasionally used to define changing size or blood supply.
• Positron emission tomography (PET) is helpful in grading gliomas or locating an occult primary.
• Biopsy and tumour removal: stereotactic biopsy via a skull burr-hole to obtain histology of a suspected malignancy.
• Open exploration (craniotomy) may be required – eg. for a symptomatic meningioma.
• Lumbar puncture or CSF analysis is done in assessment of certain brain tumours

Brain Tumours Treatment options

Surgery

• Tumours should be resected whenever possible. Surgery will also provide tissue for a formal diagnosis.
• Surgery may not be a viable option, especially if the tumour is located in a region associated with critical function or where there is infiltration of local normal brain tissue.
• Surgery should also be considered to reduce mass effect and treat hydrocephalus in order to provide symptomatic relief.
• If surgery is not an option then radiotherapy should be considered.

Radiation

• External beam radiotherapy can be curative for many patients and also prolongs survival.
• For some types of tumours, it is the treatment of choice – eg. metastatic brain tumours, leptomeningeal metastases.
• Whole brain radiation is used with some tumours – eg. medulloblastomas, primary CNS lymphomas. An alternative technique is ‘involved-field radiation’, which means that normal brain tissue is exposed to less radiation.
• In stereotactic radiosurgery, focal radiotherapy is administered to a target, thus avoiding exposure to normal brain tissue.

Chemotherapy

• The role of chemotherapy in brain tumours is not as marked as in other tumours (except for CNS lymphoma, which requires aggressive intrathecal and intravenous chemotherapy).
• It does provide modest benefit and is important in palliative care and as an adjunct to combined surgery and radiotherapy.
• Commonly used agents include those that can cross the blood brain barrier – eg, temozolomide in glioblastoma multiforme, nitrosureas in oligodendrogliomas, platinum agents in medulloblastomas

Other therapeutic agents

• Patients may also require analgesics, anticonvulsants, anticoagulants and corticosteroids.
• Corticosteroids help to reduce mass effect of raised ICP.

Treatment of brain metastasis

• Corticosteroids should be used if cerebral oedema is present.
• Surgery may be an option for patients with three or fewer brain metastases – provided the primary is controlled. This is associated with improved survival.
• For metastases that are larger in size, stereotactic radiosurgery may be an option.
• Whole-brain radiotherapy can be given after surgery or radiosurgery. However, it is currently debated whether it should be given early or late in the illness.
• Whole-brain radiotherapy is the only treatment modality for those who are not suitable for surgery or radiosurgery.
• Chemotherapy should be considered if the brain secondaries arise from a primary chemosensitive tumour.

What we offer in our centre?

All advanced neurological treatments including-

• Awake craniotomy for brain tumours
• Surgery for skull base tumours
• Surgery for CP angle tumours
• Lobectomy for localised tumours
• Radiotherapy for brain tumours (conventional/ 3D CRT/IMRT/ Stereotactic radiosurgery)
• Chemotherapy based on stage of cancers
• Metastatectomy for solitary brain oligometastasis

Overview

• Cervical cancer is the third most commonly diagnosed cancer worldwide and the fourth leading cause of cancer death in women. Cervical cancer is the second most common cancer in India.
• It has been proven that the cervical screening programme is associated with improved rate of detection and cure of cervical cancer.
• It is one of the vaccine preventable and also screening detectable cancer and thus if detected early can be cured.
• 80% are squamous carcinomas and 15% adenocarcinoma, both cause pre-invasive and invasive disease.

Risk Factors of Cervical cancer

HPV infection is the most important factor in developing cervical cancer; HPV is detected in 95% of cervical tumours.

There are around 80 types of HPV that are related to cervical cancer. The high-risk types – HPV 16 and 18 – involved in 70% of cervical cancer.

Other risk factors include:

• Heterosexual women.
• Women with multiple sexual partners
• Smoking.
• Lower social class.
• Immunosuppression – eg, HIV and post-transplant.

What are the signs and symptoms of Cervical cancer?

Many cases are detected by screening. Abnormal vaginal bleeding is the most common symptom of cervical cancer.

Other common symptoms of established cervical cancer are:

• Vaginal discharge: this varies greatly in amount and can be intermittent or continuous.
• Bleeding: this can be spontaneous but may occur after sex, micturition or defecation, in the early stages. Occasionally, severe vaginal bleeding may necessitate emergency hospital admission.
• Heavy bleeding during menstrual periods
• Pain during / after sexual intercourse
• Vaginal discomfort/urinary symptoms.

Late symptoms

• Painless haematuria.
• Chronic urinary frequency.
• Painless fresh rectal bleeding.
• Altered bowel habit.

Screening of Cervical cancer

Cervical cancer screening recommended for all sexually active women

Screening is done by a Pap smear as an outpatient procedure.

Evaluation of Cervical cancer

All Patients need to undergo per vaginal evaluation

• Patient may need Colposcopy – allows examination of the visible cervix and if needed biopsy
• Basic blood tests
• CT and/or MRI scanning of the pelvis and abdomen are often used to stage disease, along with relevant biopsies.
• Positron emission tomography (PET) is also being used increasingly for staging.
• A CT scan of the chest, abdomen and pelvis with contrast is usually preferred to chest X-ray to assess for metastatic disease.
• In advanced cases, Examination under anaesthesia is often undertaken with abdominal, vaginal and rectal examination, with or without colposcopy, hysteroscopy, cystoscopy and sigmoidoscopy. Biopsies are taken as necessary.

Cervical cancer Treatment Options

• Very early tumours are cured by local excision procedures like conization or trachelectomy or a fertility preserving hysterectomy
• Early stage tumours are treated with concurrent chemoradiation or with surgery (hysterectomy) with excellent prognosis
• A few patients in early stage with high risk factors may need a radical hysterectomy surgery and followed by adjuvant therapy with chemotherapy or radiation as necessary
• Patients with advanced disease may need radical hysterectomy or even pelvic exenteration(anterior/posterior/ total) and pelvic lymphadenectomy followed by adjuvant chemotherapy/ radiotherapy and also targeted therapy if necessary

What we offer in our centre?

All advanced surgeries for carcinoma cervix including

• Laparoscopic/open radical hysterectomy with bilateral salping0- oophorectomy + Pelvic Lymph node dissection
• Fertility preserving surgery for young women- Conization or Trachelectomy or Radiotherapy
• Laparoscopic/open pelvic exenteration in advanced cervical cancers
• Chemotherapy/ Chemoradiotherapy based on cancer stage
• Targeted therapy / molecular therapy for advanced cancer
• Specialised screening for Cervical cancers

Overview

• Colorectal cancer is the cancer of large bowel (colon) and rectum.
• Most colorectal cancers develop with growths called polyps.
• These polyps are noncancerous growths and usually harmless, however they can become cancerous if left undetected.
• Colorectal cancer is the 3rd most common cancer in men and 2nd most common cancer in women worldwide. It is also the 10th most common cancer in India.

Risk factors of Colorectal Cancer

• Age: It is more common in older people (50 and above).
• Sedentary lifestyle
• Obesity
• Previous history of colon polyps or cancer
• Family History – Conditions like Familial Adenomatous Polyposis (FAP), Hereditary Nonpolyposis Colorectal Cancer (HNPCC), etc.
• Personal history of cancer of the colon, ovary, endometrium or breast
• History of ulcerative colitis for more than 8-10 years

What are the signs and symptoms of Colorectal Cancer?

Most patients do not have symptoms in early stages or ignore the symptoms.

The most common symptoms are –

• Blood in stools – the most common symptom found in 60% of patients. It is often mixed with mucous.
• Altered bowel habits – constipation and/or diarrhoea
• Feeling of fullness or abdominal cramps
• Unexplained weight loss
• Unexplained anaemia
• Fatigue Lump in the abdomen
• Black coloured stools

Evaluation of Colorectal Cancer

The patient needs to undergo colonoscopy/sigmoidoscopy and biopsy from the suspicious lesion or polyp to confirm the diagnosis.Patient may need to undergo either a whole body PET scan or a CECT abdomen and CT chest for staging workup. Patient will need basic blood workup and tumour markers evaluation

Colorectal Cancer Treatment options

Treatment for colorectal cancer depends on a number of factors like site of cancer, the size of the tumour, if it has spread, current fitness and general health as well as patient`s treatment preferences.

Common treatments include:

Surgery – removing all or part of the affected bowel

Radiation Therapy – uses radiation to target cancer cells and destroy them

Chemotherapy – uses specialist drugs that destroy cancer cells

Targeted therapies – this type of therapy aims to destroy only cancer cells, whilst leaving healthy cells intact

What we offer in our centre?

• Surgeries which are being done for colorectal cancer in our centre are-
• Laparoscopic/open surgery for colorectal cancers
• Lap/open Right Radical hemicolectomy
• Lap/ open Radical Left hemicolectomy
• Subtotal colectomy
• Lap/open Low anterior resection
• Ultra Low anterior resection
• Abdomino perineal resection
• Anterior/posterior/total Pelvic exenteration with lymphadenectomy
• Ileostomy/ colostomy for diversion/ obstruction
• Chemotherapy regimens with minimal side effects
• Targeted therapy for colorectal cancer patients based on genetic analysis
• Radiotherapy for tumours of rectum and anal canal

Overview

Endometrial cancer – cancer that develops in the lining of the uterus (endometrium). This is the most common type of uterine cancer.

Most of them are hormone dependant and are adenocarcinomas and a small subset is non endometroid adenocarcinoma

Risk factors of Endometrial Cancer

• Prolonged unopposed estrogen exposure is the main risk factor for endometrial cancer
• Being nulliparous – this increases the risk two- or three-fold. This may be by choice or as a result of infertility with anovulatory cycles.
• Menopause past the age of 52.
• Obesity – raises oestrogen level
• Atypical Endometrial hyperplasia is associated with the presence of concomitant endometrial cancer
• Women who have hereditary nonpolyposis colon cancer (HNPCC) have a lifetime risk of 30-60% of developing endometrial cancer
• Tamoxifen is associated with an increased risk of endometrial cancer. However, the risk of endometrial cancer is low in those women aged under 50 years who take tamoxifen for breast cancer prevention
• Unopposed oestrogen increases the risk of endometrial cancer. Progesterone, however, counteracts the adverse effect of oestrogens.

What are the signs and symptoms of Endometrial Cancer?

The most common presenting symptoms are:

• Abnormal uterine bleeding (or)
• Post- menopausal bleeding

Evaluation of Endometrial Cancer

Clinical or per vaginal examination with a transvaginal or transabdominal ultrasonography is the initial evaluation to look for endometrial thickness and endometrial polyp. Hysteroscopy and endometrial biopsy is necessary for diagnosis. Surgical staging is mandatory for staging of endometrial cancer

Endometrial Cancer Treatment options

• Post exploratory laparotomy, early stage patients may require Total abdominal hysterectomy and Bilateral salpingo oophorectomy and omental biopsy and peritoneal fluid sampling
• Higher stage or high grade endometrial cancers require radical hysterectomy with pelvic lymphadenectomy and omentectomy
• Stage 3 and Stage 4 disease requires multi-modality therapy of surgery chemotherapy and radiotherapy
• Radiotherapy and targeted therapy are useful in advanced cancer patients

What we offer in our centre?

Multimodality therapy including-

• Laparoscopic staging for endometrial cancer
• Open staging laparotomy + omentectomy + bilateral pelvic / para aortic lymphadenectomy
• Laparoscopic/ open pelvic nodal dissection based on cancer stage
• Chemotherapy based on cancer stage
• Targeted therapy / molecular therapy for advanced cancer
• Radiotherapy for advanced cancers

Overview

Head and neck cancers in our country constitute approximately 35% all cancer cases in and more than 60 to 80% of patients present with advanced disease.

Being aggressive tumours, a comprehensive cancer care is needed for treatment of head and neck cancers

Head and Neck Oncology provides comprehensive treatment and rehabilitation for patients afflicted with cancers arising in the head and neck, such as:

• Oral cancer (including gums and tongue)
• Throat cancer, also known as cancer of the pharynx or pharyngeal cancer
• Voice box cancer, also known as cancer of the larynx or laryngeal cancer
• Sinus cancer
• Salivary gland cancer

Risk Factors of Head and Neck Cancer

Smoking:

• Smoking is a risk factor for all tumour sites.
• Leaving a cigarette on the lip is predictive of lip cancer risk irrespective of cumulative tobacco consumption.
• Chewing tobacco and similar substances eg. betel quid, which is common in India is a risk factor for cancer of the oral cavity.
• A long duration of passive smoking is also a risk factor

Alcohol:

• Alcohol consumption strongly increases the risk of developing cancers of the oral cavity, pharynx and larynx.
• There is a strong relationship between the quantity of alcohol consumption and the level of risk.

Diet:

• Poor diet is a risk factor for head and neck cancer.
• Frequent consumption of fruit and vegetables is associated with a reduced risk.
• Several specific nutritional deficiencies (eg. zinc and vitamin A) may predispose individuals.
• Eating Cantonese-style salted fish increases the risk.
• There is evidence to suggest that the presence of gastro-oesophageal reflux disease (GORD) is a risk factor for laryngeal and pharyngeal cancer.

Infectious agents:

• Human papillomavirus type 16 (HPV16) seropositivity is associated with an increased risk of oral, pharyngeal and laryngeal cancer.
• The incidence of HPV-related oropharyngeal carcinoma is rising rapidly in developed countries and is easily missed.
• It has a different presentation and better prognosis than other head and neck cancers

Signs and symptoms of Head and Neck Cancer

Symptoms of H&N cancer vary according to the site of origin of cancer.

The presence of any of the following, if present for more than four weeks mandates a visit to the Head & Neck surgeon:

• A non-healing sore/ulcer in the mouth/tongue or lip
• A white or red patch on the gums, tongue or lining of the mouth
• Inability to protrude the tongue
• Inability to open the mouth properly
• Swelling of the gums that prevents dentures from fitting properly
• Unusual bleeding, pain or numbness in the mouth or cheek
• Thickening of the cheek
• Loose teeth
• Earache/headache
• Feeling of something getting stuck in the throat/ a sore throat that does not go away
• Slurred speech
• Change in voice/ hoarseness
• Painful and/or difficulty in swallowing
• Difficulty in breathing
• Swelling around and/or under the jaw which may be accompanied by numbness or paralysis of one side of the face
• Weight loss
• Swelling in the midline of the lower neck which moves with swallowing
• Progressively enlarging lumps in the neck
• Streaking of blood in sputum

Evaluation of Head and Neck Cancer

• Clinical examination and biopsy from suspicious lesion helps in diagnosing oral and other head and neck cancers.
• Upper GI endoscopy/ Direct pharyngo laryngoscopy is necessary to look for extent and other synchronous cancers
• Sometimes when neck lymph node enlargement is initial presentation, neck node biopsy helps in arriving at a diagnosis
• CECT neck helps in staging of diseases.
• CT chest/ PET CT helps in metastatic work up

Head and Neck Cancer Treatment options?

Different types of treatment options are available for patients with cancers of the head and neck.

1. Surgery

• Complex head and neck cancer resection surgeries
• Endoscopic surgery
• Reconstructive head and neck surgery
• Plastic surgery for cosmetic and functional reconstruction
• Advanced skull base tumour resections
• Orbital and maxillary tumours resection and reconstruction
• Laryngeal tumours resection with reconstruction and voice rehabilitation

2. Chemotherapy

• Oral chemotherapy drugs
• Systemic chemotherapy
• Targeted drug therapy
• Immunotherapy

3. Radiation Therapy

• Intensity-modulated radiation therapy
• Stereotactic radiation therapy
• Image-guided radiation therapy
• Motion management with CT & PET scan and CT, along with respiratory gating

4. Diagnostic Services

• Sentinel lymph node biopsy
• Ultrasound-guided biopsies

5. Radiology

• PET (positron emission tomography) scans
• High-resolution CT (computed tomography) scans
• Magnetic Resonance Imaging (MRI)

6. Speech & Swallowing Rehabilitation post-surgery

What we offer in our centre?

Complex head & neck cancer surgeries being done in our hospital, according to sub-sites include

Overview

The major salivary glands are the parotid glands, submandibular glands and sublingual glands. There are also around 1,000 minor salivary glands widely distributed throughout the oral mucosa, palate, floor of the mouth, posterior tongue, retromolar and peritonsillar area. Tumours affecting salivary glands may be benign or malignant and are diverse in their pathology.

About 80% of salivary gland tumours occur in the parotid gland and about 80% of salivary gland tumours are benign.

Classification

1. Malignant Tumors

The malignant tumours common in major salivary glands are

• Mucoepidermoid carcinoma,
• Acinic cell carcinoma and
• Adenoid cystic carcinomas.

Among the minor salivary glands, adenoid cystic carcinoma is the most common. Malignant tumors may be low grade or high grade

2. Benign tumours

Pleomorphic adenoma is the most common benign tumour and is seen commonly in parotid gland. Warthin’s tumour is the second most common benign salivary gland neoplasm, representing about 6-10% of all parotid tumours.

What are the signs and symptoms?

Most salivary gland neoplasms are a slowly enlarging painless mass. Based on location, they may cause local symptoms if it is malignant, they may cause aggressive symptoms like pain, facial nerve weakness, rapid increase in size or ulceration or sensory loss.

Signs of malignant lump includes hard, fixed and infiltration of nearby structures with or without neck nodal enlargement

Evaluation

Ultra sonogram of local part and FNAC from suspicious nodule. If malignancy is suspected, CT neck or MRI might be necessary

Treatment options and what we offer in our centre?

• Superficial parotidectomy with careful dissection of the facial nerve (Nerve sparing technique) is required for treatment of a benign parotid swelling
• Radical parotidectomy for malignant tumors.
• Neck dissection for malignant tumors of salivary glands.
• Aggressive histology may require adjuvant radiation

Overview

Liver cancer, also known as hepatocellular cancer, is a cancer that originates in the liver itself. If the cancer originates in another part of the body and spreads to the liver, it is known as liver metastases. Tumours that originate in the colon, lung, breast, pancreas, stomach and other organs and spread to the liver through the bloodstream can also give rise to liver cancer.

Risk factors of Liver Cancer

Patients with cirrhosis have the highest risk of developing HCC. 90-95% of people who develop HCC have underlying cirrhosis but non-cirrhotic HCC does occur.

Cirrhosis may be due to:

• HBV or HCV infection:
• Chronic HBV infection is the most common cause of HCC worldwide. HCV is a common cause of HCC too. There is a 3-5% per year risk of developing HCC if someone has either HBV or HCV infection. Co-infection with both HBV and HCV increases the risk of HCC further. HCC may also be associated with a high concentration of aflatoxins, a group of mycotoxins produced by the fungi Aspergillus flavus and Aspergillus parasiticus in food
• Alcoholism
• Genetic hemochromatosis
• Primary biliary cirrhosis
• The metabolic syndrome, diabetes and smoking also increases cancer risk
• Rare associations include: androgenic steroids, primary sclerosing cholangitis, alpha-1-antitrypsin deficiency or oral contraceptives

What are the signs and symptoms of Liver Cancer?

Early symptoms and signs include

• Abdominal pain/ abdominal distention
• Jaundice or Yellowish discolouration of skin or eyes
• Loss of weight and appetite
• Pale stools

Those presenting late, carry symptoms of advancing cirrhosis and liver failure.

Symptoms of Liver Cancer

• Pruritus
• Splenomegaly
• Bleeding oesophageal varices
• Weight loss
• Jaundice
• Confusion and hepatic encephalopathy
• Abdominal distension due to ascites
• Right upper quadrant abdominal pain

Signs of Liver Cancer

• Jaundice
• Hepatomegaly
• Ascites
• Spider naevi
• Peripheral oedema
• Anaemia
• Periumbilical collateral veins
• Flapping tremor

Metastases can develop in the lung, portal vein, periportal nodes, bone or brain.

Evaluation of Liver Cancer

A focal liver lesion in someone with cirrhosis is highly likely to be HCC.If a >2 cm mass is detected on ultrasound and AFP is also raised, this is diagnostic. Further investigation is only needed to determine the best treatment. CT of the liver can look for local spread and CT of the thorax can look for metastases.

MRI scanning with contrast or angiography with Lipiodol® injection with follow-up CT may also be used in assessment.

Other investigations

• AFP is elevated in 75% of cases.
• LFTs may be consistent with cirrhosis.
• Check for clotting abnormalities.
• Albumin may be low.
• CXR / CT may show lung metastases.

Treatment options for Liver Cancer

Treatment for primary liver cancer depends on the location and stage of the cancer and how well liver function is preserved. Treatment options include surgical resection, thermal ablation, systemic chemotherapy, transarterial chemoembolisation and selective internal radiation therapy. Liver transplantation may be appropriate for some patients. In patients with primary liver cancer, surgical removal with curative intent may be possible. Before treatment of the primary tumour, any complications of cirrhosis or liver failure must be treated. These include ascites, encephalopathy or spontaneous bacterial peritonitis and oesophageal varices.

1. Liver transplantation

• Only a minority of people with HCC are suitable for transplantation.
• Because of limited donors, the ‘Milan criteria’ help to select transplantation candidates carefully.
• Liver transplantation is most beneficial for individuals who are not good candidates for resection, especially those within Milan criteria (solitary tumour ≤5 cm and up to three nodules ≤3 cm).
• For patients being considered for liver transplantation, a Model for End-stage Liver Disease (MELD) score is mandatory.

2. Tumour resection

• Resection is the treatment of choice for hepatocellular carcinoma in individuals without cirrhosis.
• In the short term, resection produces similar results to transplantation but, at three years, there is a higher chance of tumour-free survival after transplantation.
• Very good liver function is needed if resection is to be considered.
• Also, the liver that is left behind after resection still has malignant potential and recurrence rates are 50-60% after five years.

3. Ablative therapy

• Image-guided tumour ablation is now a standard treatment option for patients with early-stage HCC and also Liver metastasis from other primary sites

4. Alcohol (ethanol) injection

• This is done percutaneously and has been carried out on small tumours in those with good underlying liver function. This may be the best treatment for those with small, inoperable HCCs.

5. Radiofrequency ablation

• High-frequency ultrasound probes are placed into the tumour mass. This is a relatively new technique that produces tumour necrosis.
• Radiofrequency ablation is an alternative therapy for hepatocellular carcinoma and liver metastases when resection cannot be performed or, in the case of HCC, when transplant cannot be performed in a timely enough manner.
• Radiofrequency ablation is considered as a possible first-line treatment for patients with a single small HCC tumour up to 3 cm.
• Microwave ablation – It destroys tumour cells by heat and results in localised areas of necrosis and tissue destruction.

6. Chemoembolization

• This is the delivery of high concentrations of chemotherapy drugs directly to the tumour via the hepatic artery, using embolising agents such as cellulose.
• It tends to be used in those with preserved liver function with large or multifocal tumours without vascular invasion or extrahepatic spread, and who have no symptoms.
• It seems to be effective in reducing tumour size as well as treating pain or bleeding.
• Careful patient selection is crucial prior to trans arterial chemoembolization, as the procedure may be associated with an increased risk of liver failure.
• Median survival is >2 years and there is work to improve this by using better embolic agents and increasing the local exposure to chemotherapy.

7. Systemic chemotherapy or Targeted therapy

• This may be used in advanced disease but HCC is relatively chemotherapy-resistant.
• Treatments with molecular targeted therapies, such as sorafenib, are also being investigated and are so far very promising.
• Sorafenib is the standard systemic therapy for HCC. It is indicated for patients with well-preserved liver function and with advanced tumours or those tumours progressing despite loco-regional therapies.

8. Other treatments

• Selective internal radiation therapy is recommended as a treatment option for primary HCC but uncertainties remain about its comparative effectiveness.
• Image-guided transcatheter treatments are based on selective intravascular delivery of radio therapeutic drugs into the arterial vessels supplying the tumour.
• These treatments are considered for patients with large cancers or multifocal disease that is not amenable to curative treatments.
• Chemotherapy drugs, embolic particles or radioactive materials can be injected and induce tumour necrosis.

What we offer in our centre?

All above treatment options are offered for primary Liver tumours and metastatic liver tumours including

• Liver tumour resections (primary and metastatectomy)
• Laparoscopic Liver resections for solitary liver metastasis
• Living Donor Liver Transplantation
• Transarterial chemoembolization
• Transarterial Radioembolisation
• Ablative therapies
• Systemic Chemotherapy
• Targeted therapy

Overview

Lung cancer refers to the uncontrolled growth of abnormal cells in the tissue of one or both lungs, forming of a malignant tumour. The cancer can be found in the airway tubes (bronchus) or in the spongy lung tissue (alveoli). Lung tumours may also be caused by cancer which has spread from another part of the body but these are not considered as lung cancer per se. (lung metastasis)

Classification of Lung Cancer

There are two main sub-classifications of primary lung cancer:

1. Non-small cell lung cancer (NSCLC) – this is the most common form of lung cancer, making up approximately 85% of all lung cancer cases. NSCLC can be classified into a number of types, including:
• Adenocarcinoma – typically found on the outer area of the lungs, in cells that produce mucus
• Squamous cell carcinoma – typically found in the airways of the lungs
• Large cell undifferentiated carcinoma – this type of cancer cannot be classified as either adenocarcinoma or squamous cell carcinoma.
2. Small cell lung cancer (SCLC) – this type of lung cancer tends to spread faster than NSCLC. However it is less common than NSCLC, accounting for approximately 15% of all lung cancers. Lung cancer is one of the most common cancer in Indian males but most patients present in advanced stages because the index of suspicion is low.

Risk factors of Lung Cancer

1. Smoking – Cigarette smoking carries a significantly higher risk of developing lung cancer when compared with non-smokers.

It is estimated that lung cancer cases as a result of cigarette smoking contribute to 90% of all cases in men and 65% in women

2. Exposure to asbestos and toxins –Contact with asbestos, coal gas and radiation exposure (radon gas) increases risk of lung cancer.
3. Age – The risk of developing lung cancer increases as people age. Most lung cancers are diagnosed in people over the age of 60

What are the signs and symptoms of Lung Cancer?

The symptoms of lung cancer are vague and hence patients do not seek medical attention in early stages. In few cases, the symptoms are diagnosed during routine health check-ups (X-ray Screening picks up a lung lesion).

The most common symptoms are:

• A cough that won’t go away or a change in a chronic cough
• Shortness of breath or Wheezing (due to a blockage in the windpipe)
• Blood stained sputum
• Chest pain
• Unexplained weight loss
• Hoarseness of voice or Difficulty in swallowing

Evaluation of Lung Cancer

A patient with suspected lung tumour might be evaluated with any of the following tests, as needed:

• Chest X-ray
• Computerized Tomography Scan (CT Scan)
• Positron Emission Tomography (PET Scan)
• Sputum Cytology
• Bronchoscopy
• Fine-Needle Aspiration/ Biopsy
• Magnetic Resonance Imaging (MRI) of the brain
• Endo Bronchial Ultrasound (EBUS)
• Ventilation/Perfusion Lung Scans
• Blood Tests
• Pulmonary Function Test (PFT)

Treatment options / what we offer in our centre

The main treatments for lung cancer are surgery, radiotherapy, chemotherapy and targeted/ immunotherapy. The choice of treatment will depend on the type of lung cancer, stage of the disease, functioning of lungs and patient`s general health

1. Surgery:

If cancer has not spread beyond the affected lung and same side of mediastinum, if general health is reasonably good, and if breathing capacity is sufficient, the treatment that gives the best chance of cure is Surgery.

Surgical options for lung cancer are

• Lobectomy
• Pneumonectomy
• Segmentectomy
• Sleeve Resection of tumour
• Non-anatomical/Wedge Resection
• Chest wall resection/ Chest wall tumour resection
• Diagnostic Thoracoscopy
• Mediastinoscopy
• Thoracoscopic / minimally invasive lobectomy/ pneumonectomy

2. Chemotherapy:

• Chemotherapy is the treatment of choice for patients with small cell carcinoma.
• In non-small cell carcinoma, patient may need chemotherapy after surgery to remove cancer, to increase the chances of cure. This is called ‘adjuvant’ chemotherapy.

3. Radiation Therapy:

• High-energy beams are used to kill cancer cells and shrink tumours.
• Newer techniques of Intensity Modulated Radiotherapy (IMRT) and Image-Guided Radiotherapy (IGRT) ensure maximum dose to the tumour safeguarding the normal uninvolved part of lung/ heart from adverse effects.
• There is also Gated Radiation Therapy, where the lung tumour is targeted in a particular phase of the breathing cycle.

4. Targeted Therapy / Immunotherapy:

• Some people, usually non-smokers are suitable for a newer class of drugs that are designed to act against specific genes/ mutations in lung cancer cells.
• Targeted therapy / immunotherapy is used in advanced lung cancer patients and improves survival.
• These drugs can also be taken by pill or by IV.

Overview

Musculo-skeletal Oncology deals with malignancies related to Muscles, Bones, Soft tissues & etc.

What are the signs and symptoms?

The most common presentations are

• Pain and swelling of any joint or in any part of the body.
• Restriction of movement
• Gait disturbances
• Disparity in size of limbs when compared to opposite side

Evaluation

Evaluation includes

• Clinical examination
• Imaging – CT or MRI
• Image guided biopsy of the lesion to confirm the diagnosis

Treatment options

The management depends upon the histology, the site, stage of the tumour. A few soft tissue tumours and bone tumours are chemotherapy and radiotherapy sensitive and they are treated with chemo radiotherapy for down staging. Most patients require surgery, chemotherapy and radiotherapy. The treatment is planned after biopsy based on Multi-disciplinary Tumour board

What we offer in our centre

Multimodality therapy including

• Neoadjuvant therapy (Chemo/Radiotherapy) wherever applicable – Organ preserving surgeries.
• Wide local excision with regional lymphadenectomy.
• Compartmental resection of soft tissue sarcomas with local flap/ free flap reconstruction to provide anatomical and functional stability.
• Compartmental resection with custom mega prosthesis reconstruction
• Pelvic resection and hemipelvectomy (internal/ external) +/- prosthetic reconstruction
• Amputation – in unavoidable circumstances + prosthetic reconstruction followed by rehabilitation/ physiotherapy
• Post OP physiotherapy / Rehabilitation for all patients undergoing musculoskeletal/ soft tissue sarcoma surgery

Overview

Oesophageal cancer refers to cancer that develops within the oesophagus, the tube that transports food from throat to stomach to be digested.

Classification of Oesophageal Cancer

The two most common types of oesophageal cancer are:

1. Adenocarcinoma – cancer that develops in the glandular cells which line the oesophagus. This type of cancer typically forms in the lower section of the oesophagus
2. Squamous cell carcinoma – cancer which begins in squamous cells that line the oesophagus. This often develops in the middle and upper part of the oesophagus

Risk factors of Oesophageal Cancer

Factors that cause irritation in the Oesophagus and increase the risks of oesophageal cancer are:

• Smoking
• Gastroesophageal reflux disease (GERD)
• High consumption of alcohol
• Bile reflux
• Regular consumption of hot foods
• Oesophageal burns due to accidental and intentional swallowing of caustic materials like bleach
• Chromosome and gene abnormalities

What are the signs and symptoms of Oesophageal Cancer?

Usually, oesophageal cancer symptoms are not visible until it grows enough to narrow the oesophagus.

The most common signs and symptoms are

• Pain or difficulty in swallowing
• Heartburn
• Blood in vomit
• Unexplained weight loss
• Upper abdominal pain
• Cough or hoarseness of voice

Evaluation of Oesophageal Cancer

• Upper GI endoscopy and Biopsy
• CT chest/ CECT abdomen
• Whole body PET CT
• Endoscopic USG
• Basic blood investigations

Treatment options for Oesophageal Cancer

Treatment for oesophageal cancer is based on the type of oesophageal cancer, its stage, patient`s overall health and treatment preferences. This may involve surgery, chemotherapy, radiation therapy, targeted therapies and immunotherapy.

Surgery is often the primary form of treatment, where part or all of the oesophagus is removed.

• Surgery – may involve removing individual tumours, part of the oesophagus (oesophagectomy) or the entire oesophagus and upper portion of the stomach (oesophago-gastrostomy)
• Radiation therapy – uses high-energy particles to target and destroy cancer cells. Radiation therapy is often delivered in combination with chemotherapy and/or surgery for oesophageal cancer.
• Chemotherapy – involves the use of anti-cancer drugs which are taken orally (by mouth) or injected into the body. Chemotherapy is often used before or after surgery for oesophageal cancer, or in people with advanced cancer that has spread beyond the oesophagus
• Targeted therapies – focuses specifically on treating the oesophageal cancer through targeting cancer cells, and not healthy cells. Targeted therapies are often combined with chemotherapy for advanced cancers or those that don’t respond to treatment
• Immunotherapy – uses our immune system to slow the growth of cancer cells and destroy existing cancer cells. Patient may receive immunotherapy if oesophageal cancer is advanced, has come back or has spread to other areas of the body.

What we offer in our centre

The Oesophageal cancer treatment offered in our centre includes all the above options:

1. Surgeries including-
• Laparoscopic/Thoracoscopic Transthoracic Esophagectomy
• Laparoscopic Trans hiatal Esophagectomy +/- 2 or 3 field lymphadenectomy
• Feeding Jejunostomy for advance cases.
• Oesophageal Stenting for advanced cancers
2. Neoadjuvant chemotherapy/ radiotherapy to downstage the tumours
3. Adjuvant therapy chemotherapy/ radiotherapy after surgery

Overview

• Ovarian cancer involves abnormal cell growth within the ovary and surrounding tissues
• Ovarian cancer can be one of three types:
• Epithelial– which can involve either one or both ovaries, where cancer cells grow on the outside of the ovary.
• In some occasions, the cancer will be growing along the lining of the abdomen (peritoneal lining).
• This type of ovarian cancer is the most common, accounting for approximately 90% of ovarian cancers.
• Germ cell – involves the cells that produce the eggs, and account for approximately 4% of all ovarian cancers.
• Stromal tumour – involves the tissues that support the ovary in producing oestrogen and progesterone hormones.

Risk factors of Ovarian Cancer

• Advanced age is a risk factor for development of epithelial ovarian cancer
• Lifestyle related risk factors include smoking, obesity and alcohol intake.
• Hormone replacement therapy and infertility treatment are associated with risk of developing ovarian cancer

Family history of ovarian cancer is also a risk factor for developing ovarian cancer

What are the signs and symptoms of Ovarian Cancer?

The ovarian cancer symptoms include:

• Pressure, pain and bloating in the abdominal region
• Difficulty eating and abnormal fullness after every meal
• Increased urination
• Abnormal pain during sex
• Pelvic or abdominal pain
• Severe back pain
• Changes in the menstrual cycle and constipation
• Fatigue

Due to vague localizing symptoms, almost 60% of patients present with advanced (Stage III or IV) disease

Evaluation of Ovarian Cancer

• Basic blood investigations including Tumour markers (CA 125)
• USG abdomen /CECT abdomen after a clinical, abdominal and per vaginal examination.
• MRI abdomen or PET CT might be necessary in specific cases.
• A few patients present with ascites and adnexal mass. Ascitic fluid analysis for malignant cells is done before starting chemotherapy

Treatment options for Ovarian Cancer

The main ovarian cancer treatment options include:

1. Surgery – Most ovarian cancers can be treated by surgery. The extent of surgery required usually depends on how far cancer has spread and also on the general health of the patient. The main goal of the surgery is to remove the cancer completely from the body.
Advanced cancers with peritoneal spread may benefit from CRS+ HIPEC
2. Chemotherapy – When the cancer is advanced, the patient must undergo Chemotherapy. It is a systematic treatment in which the drugs are given in a way that they reach all parts of the body.
3. Hormone Therapy – Hormone-blocking drugs are used to fight cancer in Hormone Therapy. This treatment option is helpful in treating ovarian stromal tumours.
4. Targeted Therapy – Relatively a new treatment type, targeted therapy uses drugs that directly attack the cancer cells while causing less harm to the normal cells.

What we offer in our centre?

All treatment options for ovarian cancer including

• Laparoscopic staging for ovarian cancer
• Open staging laparotomy + omentectomy + bilateral pelvic / para aortic lymphadenectomy
• Cytoreductive surgery + Hyperthermic Intra peritoneal Chemotherapy for advanced Ovarian cancers with peritoneal metastasis
• Fertility preserving surgeries/ chemotherapy whenever feasible for Borderline ovarian Tumours/ germ cell tumours
• Laparoscopic ovarian cyst excision
• Chemotherapy for advanced cancers for down staging
• Chemotherapy based on cancer stage
• Targeted therapy / molecular therapy for advanced cancer

Overview

• The pancreas serves two main functions. The exocrine portion of the gland secrete digestive juices, while the endocrine portion secretes hormones, the most important being insulin.
• Most pancreatic malignancies are exocrine. Infiltrating ductal adenocarcinomas account for 90% of pancreatic cancers
• Pancreatic cancer is a much-feared disease due to its notoriously late presentation, early metastases and poor survival rates.
• Less than a fifth of patients present with localised, potentially curable tumours and the overall five-year survival rate remains less than 5%

Risk factors of Pancreatic Cancer

• The main risk factors are smoking, diet (high BMI, red meat intake, low fruit and vegetables intake), diabetes and alcohol intake
• Chronic and hereditary pancreatitis: chronic pancreatitis is associated with a 5- to 15-fold increase in risk and hereditary pancreatitis with a 50- to 70-fold increase.
• Family history of pancreatic cancer and Familial cancer syndromes: BRCA1, BRCA2, familial adenomatous polyposis, Peutz-Jeghers syndrome, familial melanoma syndromes, Lynch syndrome, von Hippel-Lindau syndrome, multiple endocrine neoplasia type 1, Gardner’s syndrome.
• Other medical conditions: inflammatory bowel disease, periodontal disease, peptic ulcer disease.

What are the signs and symptoms of Pancreatic Cancer?

The most common presentation of pancreatic cancer include

• Abdominal pain: typically located in the epigastric region, radiating through to the back. Can present as simple back pain. Back pain is typically dull and worse when supine and eased by sitting forward.
• Jaundice: obstructive jaundice causes dark urine, pale stools and pruritus.
• Acute pancreatitis: pancreatic cancer should be considered in the differential diagnosis of any elderly patient presenting for the first time with acute pancreatitis, particularly in the absence of known precipitating factors such as gallstones or alcohol abuse
• Unexplained weight loss, anorexia.
• Steatorrhoea due to malabsorption.
• Epigastric mass (late).
• Palpable gallbladder: Courvoisier’s sign (a palpable gallbladder in the presence of painless jaundice) occurs in fewer than 25% of patients.
• Compression of the duodenum or the stomach may cause gastric outlet obstruction or delayed gastric emptying, leading to nausea and vomiting.
• Haematemesis, melaena or iron-deficiency anaemia.

Evaluation of Pancreatic Cancer

• Blood tests including Liver function tests and tumour marker CA 19-9
• USG abdomen is the primary imaging investigation
• CECT abdomen and UGI scopy and EUS and biopsy might be necessary
• Whole body PET CT for metastatic workup
• Endoscopic Retrograde cholangio pancreatico graphy helps in visualization of pancreatic and bile duct
• In patients with obstructive jaundice, ERCP and stenting might be required pre operatively

Treatment options offered in our centre includes

• Surgical resection of the tumour and neighbouring lymph nodes offers the only chance of cure but only 10-20% of tumours are suitable for resection, due to tumour size and spread at diagnosis
• Proximal pancreaticoduodenectomy with antrectomy (Whipple’s procedure)
• Proximal pancreaticoduodenectomy with pylorus preservation (modified Whipple’s procedure)
• Distal pancreatectomy: this is performed for tumours of the body and tail of the pancreas.
• Adjuvant chemotherapy in advanced pancreatic cancer.
• Stenting in case of inoperable cases

What we offer in our centre?

All advanced surgical procedures for pancreatic tumours and other therapies including

• Whipple s pancreaticoduodenectomy
• Triple bypass procedure for advanced pancreatic cancers
• Distal pancreatectomy for body and tail of pancreas tumours
• Adjuvant chemotherapy in advanced pancreatic cancer
• Stenting in case of inoperable cases

Overview

• Penile cancer is a rare cancer and it originates in the epithelium of the inner prepuce and glans of penis. Due to hesitancy from patients, most patients present late with advanced disease.
• The psychological impact of the disease is highly significant.
• The cause of penile squamous cell carcinoma is unclear but human papillomavirus (HPV) appears to be a causative factor.

What are the risk factors of Penile cancer?

• HPV infection plays a role in the development of penile cancer. About half of cancers are associated with HPV, with the main subtypes being HPV-16 and HPV-18.
• Genital warts and other conditions like lichen planus predispose to penile cancer
• Multiple sexual partners/ HIV infection is a risk factor
• Smoking.
• Other risk factors include exposure to chemicals such as insecticides, fertilisers, styrene and acrylonitrile.

 A few penile lesions are thought to be premalignant and may progress to Penile cancer. These include:

• Erythroplasia of Queret
• Bowen`s disease
• Buschke Lowenstein Tumour

What are the signs and symptoms of Penile cancer?

• Patient presents with an ulcer, lump or erythematous lesion over penis.
• Itching or burning sensation below prepuce
• Difficulty in urination in advanced disease
• Inguinal Lymph node swelling in advanced cases.

Evaluation of Penile cancer

Patient needs biopsy from the lesion to confirm the diagnosis

Staging is done by CT, MRI or by Whole body PET CT

Inguinal node may need biopsy from the lesion.

What are the treatment options?

1. Surgery

Surgical techniques include:

• For small penile lesions: circumcision or wide local excisions are mainstay treatments. Local recurrences over time may occur and re-treatment may be required.
• For glanular and distal penile tumours: it is now possible to preserve much more length, and cosmetic and functional results are far superior to conventional partial penectomy.
• In advance tumours may need total penectomy and perineal urethrostomy
• Regional lymph nodes: lymphadenectomy is the standard treatment of patients with inguinal lymph node metastases.

2. Radiotherapy

• Radiotherapy is most appropriate for small lesions in patients unfit or unwilling to undergo surgery.
• Radiotherapy as treatment of the primary tumour may be delivered either by external beam treatment or brachytherapy
• Radiotherapy for the management of regional lymph node metastases
• Adjuvant radiation to the inguinal lymphatic area has been advocated by some but there is no strong evidence of benefit

3. Chemotherapy

Penile cancer has only a limited response to chemotherapy and used in adjuvant setting

4. Topical agents

Topical agents like 5 FU cream or Laser therapy is used for premalignant lesions and Carcinoma in Situ

What is offered in our centre?

All the above treatment options for carcinoma penis including

• Surgeries like Partial penectomy for early lesions
• Total penectomy + perineal Urethrostomy
• Inguinal and Iliac Block dissection
• Chemotherapy and Radiotherapy for locally advanced disease

Overview

The peritoneum is the tissue that lines and protects the organs in the abdomen such as the stomach, bowel and ovaries. Peritoneal cancer refers to cancer that develops within or has spread to the peritoneum from other organs within the abdomen (known as peritoneal metastases).

Earlier peritoneal surface metastasis was labelled as advanced and inoperable. Now with the advent of HIPEC, patients with peritoneal surface malignancies are treated and cured.Whilst primary tumours of the peritoneum are very rare, with women more likely than men to develop cancer in the peritoneum, spread to the peritoneum from other abdominal cancers, such as stomach, colon and ovarian cancers, is very common.

What are the signs and symptoms?

Primary peritoneal cancer and peritoneal metastases can be difficult to detect as symptoms can be vague and may include:

• Abdominal pain or distention
• Loss of appetite
• Loss of weight
• Abdominal pain
• Bowel / Bladder habit disturbance
• Easy fatigue

Evaluation

• There are many different tests that are used to diagnose peritoneal cancer.
• This may include an abdominal examination, ultrasound or CA125 blood test, followed by further tests such as a CT scan, biopsy, and peritoneal fluid analysis.
• Whole body PET CT helps in detecting the spread of disease and also to ascertain operability
• Based on the extent of peritoneal spread and the histology intra-abdominal chemotherapy is planned.

Treatment options

• The treatment will be based on the stage and grade of peritoneal cancer and its size and location, in addition to patient`s age and general health.
• This may involve surgery, chemotherapy, radiation therapy and targeted therapies.
• The surgery for Peritoneal malignancy is Cytoreductive surgery + Hyperthermic Intra peritoneal chemotherapy

Cytoreductive Surgery + Hyperthermic Intra Peritoneal Chemotherapy

• Hyperthermic intraperitoneal chemotherapy (HIPEC) is a highly concentrated, heated chemotherapy treatment
• It is delivered directly to the abdomen during surgery through a circulator machine.
• 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 success
• Susceptibility of cancer cells to be destroyed more by this method.

What we offer in our centre?

• One of the very few centres in South India treating peritoneal surface malignancy.
• We have a dedicated team of surgical oncologists, medical oncologists, anaesthetists, Critical care nurses and Oncopathologists providing state of the art care for management for peritoneal surface malignancies.

Overview

Most prostate cancers are adenocarcinomas arising in the peripheral zone of the prostate gland. They are slow-growing and do not cause any symptoms for most of the patients

Risk factors of Prostate Cancer

There is known causative factors for prostate cancer but the three well-established risk factors for prostate cancer are

• Increasing age
• Ethnic origin and
• Genetic predisposition

What are the signs and symptoms of Prostate Cancer?

Symptoms for prostate cancer usually result in problems associated with urination, such as:

• Needing to urinate more frequently, often during the night
• Difficulty in starting to urinate (hesitancy)
• Weak flow when urinating
• Feeling that bladder has not emptied fully
• Dribbling urine after complete urination
• Symptoms that the cancer may have spread include bone and back pain, loss of appetite, pain in the testicles and unexplained weight loss

Evaluation of Prostate Cancer

• Basic blood tests including renal function tests and PSA which is a marker for prostate cancer
• Prostate biopsy is needed to confirm diagnosis and assign Gleason score
• MRI or PSMA PET scan for staging of disease
• Bone scan to look for metastatic disease

Treatment options for Prostate Cancer

The treatment of cancer often varies according to the degree and type of cancer affected. Different treatment options will depend on whether the cancer is within the prostate gland (localised); has spread outside of the prostate (locally advanced), or had spread to other parts of the body (advanced). There are many options available for prostate cancer treatment in India which might be used at different times depending on the cancer stage and current health state of the patient.

• Watchful Waiting or Active Surveillance – In many cases, prostate cancer grows slowly and therefore immediate medical intervention may not be required. Watchful waiting or active surveillance approach is applicable for low grade prostate cancers.
• Surgery
• If cancer has not spread outside the prostate gland, radical prostatectomy is performed, in which a surgeon removes the entire prostate gland along with the tissues around it.
• Surgery (orchidectomy) is also done for surgical castration before giving anti androgen therapy
• Radiation Therapy

Radiation therapy can be divided into external beam radiation and brachytherapy (internal radiation). In external radiation therapy, high-energy x-ray beams are directed at a tumour from outside the body.

• Hormone Therapy

This therapy is used for reducing the level of male hormones (androgens) as well as restraining them from affecting the prostate cancer cells. It is also called Androgen Deprivation Therapy (ADT) and Androgen Suppression Therapy. Lower androgen levels lead to shrinkage in the size of the prostate cancer and restrict their growth.

• Chemotherapy

Chemotherapy is used for advanced and for metastatic prostate cancer

• Vaccination Sipuleucel-T (Provenge)

Is a cancer vaccination given to boost the body’s immunity system to attack the prostate cancer cells.

• Radioisotope Therapy

Prostate cancer spreads mainly to bones and sometimes in old age the presentation is that of bone pain or fracture. In such cases, Radio isotope therapy like Strontium or Samarium to bone helps to relieve bone metastatic pain

What we offer in our centre?

Multimodality management including surgery, radiotherapy, hormone therapy, chemotherapy and Radioisotope therapy for bone metastasis is provided in our centre.

Overview

Kidney cancer refers to cancer that develops within the kidney. The different types of renal cancers are renal cell carcinoma, urothelial carcinoma, oncocytoma or renal sarcoma. Wilm`s tumour is a common renal tumour in children.

What are the signs and symptoms?

The most common signs and symptoms are

• Blood in Urine
• Lower abdominal or back pain
• Loin swelling or mass
• Fever or anaemia
• Loss of weight and easy fatigue
• The classic triad of haematuria, loin pain and loin mass is rarely seen now.

Evaluation of Kidney cancer

• Urinalysis, cytology, culture and sensitivity should be performed to exclude urinary tract infection.
• Renal function tests are to be done if planning for nephrectomy, however, if one kidney is functioning well the renal function should be normal.
• Blood tests to detect iron-deficiency anaemia (from haematuria) or polycythaemia
• CT renal scanning before and after intravenous contrast is the best initial investigation.
• MRI or ultrasound scanning may be used if the results are equivocal.
• Intravenous urogram (IVU) may be needed, especially to show any obstruction to flow.
• Cystoscopy can exclude bladder tumours as a cause of haematuria.
• Renal angiography may possibly be required to assess the blood supply.
• CXR/ CT chest or PET CT for metastatic workup if required
• Metastases: skeletal survey or bone scan may be required for bone metastases. A brain CT scan may also be indicated, depending on symptoms.
• Renal biopsy may be indicated – in patients with metastatic disease planned for systemic therapy

Treatment options for Kidney cancer

• Surgery is the mainstay of treatment for renal cancers
• Partial/ Radical nephrectomy either open or minimally invasive is preferred treatment of choice.
• Minimally invasive procedures like radiofrequency (RF) ablation, cryoablation, microwave ablation, laser ablation and high-intensity focused ultrasound ablation may be an option for patients not suitable for open or laparoscopic surgery.
• Chemotherapy is usually not effective in renal cell cancers.
• Patient may require immunotherapy or molecular therapy in case of advanced renal cell cancer.

What we offer in our centre?

All the above treatment options for renal cell carcinoma are available in our centre including

1. Laparoscopic and open surgery for Renal cell carcinoma
• Lap/open Radical nephrectomy
• Lap/open Partial nephrectomy
• Radical nephroureterectomy
2. Molecular and immunotherapeutic drugs for advanced renal cell carcinoma
3. Strontium or Samarium therapy for bone metastasis
4. Ablative procedures for those who are not fit for surgical resection

Overview

Gastric cancer is the fifth most common cancer in the world and the third leading cause of cancer death in both sexes worldwide

It is a difficult disease to cure mainly because most patients present with advanced disease

Risk factors of Gastric cancer

Certain risk factors can play a role in the development of stomach cancer. These include

• Pre-existing conditions – Including chronic atrophic gastritis , stomach polyps or pernicious anaemia
• High alcohol consumption
• Smoking
• Family history – Having one or more family members with stomach cancer increases the risk of developing stomach cancer
• Eating salted, preserved foods
• H-pylori infection

What are the signs and symptoms of Gastric cancer?

Early symptoms are usually ignored by patients and presentation is usually delayed.

• Nonspecific with dyspepsia,
• Rapid weight loss and loss of appetite
• Vomiting, difficulty in eating , blood in vomit or blackish stools
• Anaemia and easy fatigue
• 70% of patients with early gastric cancer only have symptoms of uncomplicated dyspepsia
• All at-risk patients with dyspepsia should be considered for endoscopy.
• The majority of patients present with advanced disease and symptoms such as weight loss, vomiting, anorexia, abdominal pain and anaemia.

Evaluation of Gastric cancer

• Basic Blood tests including Hemoglobin and Liver function tests
• All suspected patients should undergo Upper GI endoscopy and biopsy of suspicious lesions
• CECT of abdomen might be needed for staging of disease.
• Endoscopic Ultrasound for staging of disease is done
• PET CT is done for staging in metastatic disease patients
• Staging Laparoscopy is done for assessing operability of advanced diseases

Treatment options for Gastric cancer

Being an aggressive disease, patients require multimodality management including surgery, chemotherapy, radiotherapy and targeted therapy and combination of these.

• Surgery: Surgery is the treatment of choice for gastric cancer. The most important indicator for resectability and survival after surgery is early diagnosis and therefore early stage of disease at operation.
• Adjuvant and perioperative chemotherapy
• Perioperative combination chemotherapy has become the standard of care for localised gastric cancer
• Adjuvant chemotherapy and radiotherapy are used in advanced gastric cancers.
• Targeted therapy is useful in metastatic cancers.

What we offer in our centre?

Multimodality treatment options are available. All surgical options for early, locally advanced and metastatic stomach cancers including –

1. Laparoscopic and open surgeries for Gastric cancer
• Distal radical gastrectomy + D2 lymphadenectomy
• Total gastrectomy + D2 lymphadenectomy
• Subtotal gastrectomy+ D2 lymphadenectomy
• Partial gastrectomy with D2 lymphadenectomy
• GIST of stomach – Partial / subtotal gastrectomy
• Gastrojejunostomy for bypass
• Feeding jejunostomy for advanced cases
2. Perioperative and adjuvant chemotherapy
3. Radiotherapy
4. Targeted therapy and Immunotherapy for advanced gastric cancers

Overview

• More than 95% of testicular tumours arise from the germ cells which produce sperms and may involve one or both testis.
• Testicular germ cell tumours can be subdivided into seminoma and non-seminomatous germ cell tumours (NSGCTs).
• Testicular cancer is a relatively rare cancer with an incidence of 7.0 per 100,000 population
• Testicular cancer can occur at any age but is most common between the ages of 15 and 40 years.
• Non seminomatous cancer is rare in younger age group and seminoma is common in age group above 60 years

Risk factors of Testicular Cancer

• Cryptorchidism or testicular maldescent
• Klinefelter’s syndrome
• Family history
• Male infertility (increases risk of cancer).
• Low birth weight, young maternal age, young paternal age, multiparity, breech delivery
• Height – taller men are more at risk of developing germ cell tumours

Of all risk factors, cryptorchism and malignancy in the contralateral testis are by far the strongest

What are the signs and symptoms of Testicular Cancer?

• A painless swelling of testis
• Change in shape or size of one testis compared to opposite side
• Feeling of heaviness in scrotum
• Dull aching dragging lower abdominal pain
• History of recent trauma (which made patient notice the symptom)
• Swelling in inguinal region

Evaluation of Testicular Cancer

• Diagnosis is usually confirmed by ultrasound
• Tissue histopathology is done only after a high inguinal orchidectomy
• Disease can be staged by thoraco-abdominal CT scan or PET scan
• Elevation of tumour markers supports the diagnosis but normal marker levels do not exclude testicular cancer
• Alpha-fetoprotein (AFP) is produced by yolk sac elements but not produced by seminomas
• Beta-hCG may be elevated levels both in teratomas and in seminomas

Treatment options for Testicular Cancer

All patients need to undergo High inguinal orchidectomy to diagnose the disease. Staging is done by CECT abdomen or PET CT. Further treatment depends upon stage of disease or based on histology (seminoma or non-seminoma).

Seminoma are radiotherapy and chemo sensitive and hence treated with chemotherapy / radiotherapy in advanced stages. Non-seminoma patients are treated with adjuvant chemotherapy and may need lymph nodal dissection in advanced cases

What we offer in our centre?

• Surgical options of High orchidectomy + Ilio inguinal Block dissection
• Adjuvant Chemotherapy and Radiotherapy whenever necessary
• Option of fertility preservation/ sperm banking available and offered to our patients
• Testicular implants if necessary

Overview

• Thyroid cancer refers to cancer that develops within the thyroid, a gland found at the front of the neck.
• The thyroid is primarily made up of two types of cells:
1. Follicular cells – these produce and store the hormones T3 (triiodothyronine) and T4 (thyroxine) and the protein Tg (thyroglobulin)
2. Parafollicular cells (C-cells) – these produce the hormone calcitonin, which helps control calcium levels in the body
• Thyroid cancer is often classified by the type of cell the cancer develops from and can be differentiated or undifferentiated thyroid cancers

Classification of Thyroid Cancer

The four types of thyroid cancer include:

• Papillary thyroid cancer – slow-growing cancer that develops from the follicular cells in the thyroid. This is the most common type of thyroid cancer, accounting for 70-80% of all thyroid cancer diagnoses
• Follicular thyroid cancer – cancer that also develops from the follicular cells in the thyroid. This accounts for 15-20% of all thyroid cancer cases and includes Hürthle cell carcinoma
• Medullary thyroid cancer – an often hereditary cancer that develops from the parafollicular cells in the thyroid. This accounts for 4-5% of all thyroid cancer diagnoses and can be associated with tumours in other glands
• Anaplastic thyroid cancer – rare fast growing cancer that develops from the follicular or parafollicular cells in the thyroid. This accounts for 1-2% of all thyroid cancer cases and typically occurs in people over the age of 60

Risk factors of Thyroid Cancer

• Exposure to ionising radiation is a risk factor for papillary carcinomas, when exposure has occurred at a younger age. An increased incidence of thyroid cancer in children and adolescents was seen in Ukraine, Belarus and certain regions of Russia as early as four years after the Chernobyl accident. Thyroid carcinoma may first appear 20 or more years after radiation exposure.

Other risk factors include:

• History of goitre,
• Thyroid nodule or thyroiditis,
• Family history of thyroid disease,
• Female gender and
• Asian race.
• Genetics: approximately 20-25% of MTC are hereditary because of mutations in the RET proto-oncogene. Mutations in the RET gene cause multiple endocrine neoplasia type 2 (MEN 2), which is an autosomal dominant disorder associated with a high lifetime risk of MTC.

What are the signs and symptoms of Thyroid Cancer?

Some of the significant symptoms are:

• Most commonly, a lump or a swelling in the neck
• Difficulty in swallowing
• Change in voice or hoarseness in voice
• Irritating cough without any symptom of cold or other reason
• Breathing difficulty often with a wheezing sound while breathing

Evaluation of Thyroid Cancer

1. Blood tests
• Thyroid Function Tests should be performed for any patient with a thyroid nodule.
• However, TFTs (most patients will be euthyroid) and thyroglobulin (Tg) measurement are of little help in the diagnosis of thyroid cancer.
• Serum calcitonin is a reliable tool for the diagnosis of MTC (5-7% of all thyroid cancers).
2. Ultrasound
• Thyroid ultrasound is extremely sensitive for thyroid nodules and is used as a first-line diagnostic procedure for detecting and characterising nodular thyroid disease.
• Ultrasound features associated with malignancy include hypoechogenicity, microcalcifications, absence of peripheral halo, irregular borders, solid aspect, intranodular blood flow and shape (taller than wide).
• Ultrasound should also be used to explore the neck carefully to assess the status of lymph node chains.
3. Fine-needle aspiration cytology (FNAC)

The results of FNAC are very sensitive for the differential diagnosis of benign and malignant nodules

Radionuclide imaging: Distinguishing functioning toxic nodules and thyroid metastases from follicular and papillary carcinomas is best with 123iodine uptake studies:

• Normal iodine uptake is seen in ‘warm’ nodules. Lesions that take up excessive amounts of iodine are called ‘hot’ and those that do not take it up are called ‘cold’.
• CT, PET CT and MRI scan: CT scans and MRI scans are valuable to detect local and mediastinal spread and regional lymph nodes.

Treatment options for Thyroid Cancer

• Solitary thyroid nodules that are malignant, suspicious or indeterminate on FNA, require surgery
• Patients with suspicious nodule need to undergo hemithyroidectomy with intra operative frozen section and based on the report if malignant, may need total thyroidectomy
• Diagnosed cases of differentiated thyroid cancers may need total thyroidectomy + neck dissection of central compartment as required
• Radioiodine remnant ablation and therapy is done for a few cases of differentiated thyroid cancer
• Adjuvant external beam radiotherapy for differentiated thyroid cancer should be considered for patients with a high risk of recurrence
• Newer targeted therapies are advised for recurrent or metastatic radio iodine refractory thyroid cancers

What we offer in our centre?

All of the above treatment options are available in our centre

Surgeries including

• Hemithyroidectomy
• Total thyroidectomy +/- central compartment neck dissection
• Minimally invasive parothyroidectomy
• Frozen section analysis for immediate diagnosis of suspicious nodules.

Adjuvant therapies

• Radioactive iodine- uptake scan and ablation of thyroid neoplasm, if necessary
• Radiation therapy for advanced thyroid tumours
• Targeted therapy for metastatic / anaplastic thyroid malignancies

Overview

• When cancer starts in the vagina, it is called vaginal cancer. The vagina, also called the birth canal, is the hollow, tube-like channel between the bottom of the uterus and the outside of the body.
• When cancer forms in the vulva, it is vulvar cancer. The vulva is the outer part of the female genital organs. It has two folds of skin, called the labia.
• Vaginal and vulvar cancers are very rare.

Risk factors of Vaginal and Vulvar Cancer

Several factors may increase the chance that you will get vaginal or vulvar cancer, including

• Human papillomavirus (HPV) for a long time.
• Have had vulvar or vaginal precancerous lesion
• Have a condition that weakens your immune system (such as HIV, the virus that can lead to AIDS)
• Smoking.
• Chronic vulvar itching or burning.

What are the signs and symptoms of Vaginal and Vulvar Cancer?

Main symptoms include

• Vaginal discharge
• Itching or burning sensation in vagina
• Pain during sexual intercourse
• Lower abdominal pain

Evaluation of Vaginal and Vulvar Cancer

• If the above symptoms are present, patient may need clinical examination and biopsy from the suspicious lesion
• Staging with CECT/ MRI might be necessary
• Whole body PETCT if metastatic disease is suspected

Treatment options and what we offer in our centre?

• Treatment options depend on tumour stage and size
• Surgery and radiotherapy are very effective in early-stage disease, whereas radiation therapy is the primary treatment for more advanced stages.
• Radical vulvectomy/ vaginal excision was done earlier, and is now being replaced with conservative less mutilating surgery + reconstructive surgery
• Nodal dissection in case of nodal metastasis.