Every Day is Breast Cancer Awareness Day

AP's First Digital Mammography with

Aug - 2015 Aug - 201512

Date of Publication: 05.08.2015Date of Posting: 15.08.2015

Vol - 5 Issue - 2 Hyderabad August - 2015 Pages - 12 Prices Rs - 1. 00| | | | |

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HIPEC (Hyperthermic Intraperitoneal Chemoperfusion)

Allows for high doses of chemotherapy

Enhances and concentrates chemotherapy within the abdomen

Minimizes the rest of the body's exposure to the chemotherapy

Improves chemotherapy absorption and susceptibility of cancer cells

Reduces some chemotherapy side effects

ADVANTAGES

Belmonte Hyperthermia PumpHIPEC

* Conditions Apply

Aug - 2015

Dual role of F 18 positron emission

t o m o g r a p h y - c o m p u t e r i z e d

tomography in diagnosis and radio

therapy treatment planning in

critical oncological conditions.

Authors

§ Dr.V.V.S.Prabhakar Rao, MD(Radio Diag), DNB (

Radio Diag ),DNB(Nucl Med), DRM, PG

Dip(Geriatric Med). HOD Nuclear medicine &

PET CT Department, OMEGA Hospitals.

§ Dr.Koustubh Sharma, Medical Officer, Nuclear

medicine Department, OMEGA Hospitals.

Introduction

F 1 8 Po s i t r o n E m i s s i o n To m o g r a p h y -

Computer ized Tomography (PET-CT) has

established itself in the field of oncology as an

inva luable d iagnost ic armamentar ium by

identification and localization of early cancer by

the metabolic component of mitotic disease,

which precedes anatomical changes. In a

revealed malignancy PET-CT often upstages and

down stages disease thus altering therapeutic

regimes and options. However it has a vital role in

precision planning of gross tumor volume and

planning tumor volumes in radio therapy while

irradiating vital structures and saving vital

adjoining structures , delivering precise dose

exclusively to the organ or areas of interest

sparing adjacent critical areas .

Illustrative Case

A 44 year old male presented with a mass in the

right side of the neck of two years duration with a

history of increase in size from past one month

associated with pain.

Physical examination revealed a nodule of 5 x 4

cms in the right lobe of the thyroid gland

moving with deglutition with enlargement of level

III cervical lymph nodes on left side. FNAC of the

thyroid nodule showed features of anaplastic

carcinoma, Patient underwent total thyroidectomy

with removal of enlarged cervical lymph nodes.

Histopathology revealed polygonal to spindle

cells, showing organized pattern with clumped

chromatin, moderate to abundant cytoplasm with

areas of necrosis, focal hemorrhage, abundant

extracellular brownish black (HMB 45 positive,

Perl’s negative) melanin pigment , Sections from left

lobe of thyroid showed features of medullary

carcinoma of thyroid with amyloid production

without melanin.

In view of the medullary carcinoma and melanin

production further work up was done by whole body

iodine 131 Meta Iodo Benzyl Guanidine (MIBG)

scan to outline any residual or metastatic foci with

high dose of Iodine 131 MIBG therapeutic intent.

However there was no MIBG localization in the neck

or elsewhere. Thus due to non therapeutic options

with MIBG and known radio resistance to radio

therapy of melanotic medullary carcinoma thyroid

patient was kept on close follow up. One year later patient presented with diffuse boggy

swelling in right side of neck associated with severe

Aug - 20153

08

impending SVC obstruction diagnosed and

managed by timely radio therapy using PET based

diagnostic and RT Planning technique with gratifying

outcome high lights the vital role of PET CT in clinical

oncology.

Legends

Fig 1

F 18 FDG PET-CT showing an intensely hyper

metabolic hypo dense intra luminal tumor thrombus

in the right IJV , EJV, subclavian vein, innominate vein

up to SVC.

Fig 2

F18 FDG PET CT after radiotherapy showing

complete metabolic regression in the intra vascular

tumor and significant reduction in the tumor

thrombus load (Fig 2).

pain radiating to the right ear, however there was no

puffiness of face, no engorgement of veins in the

neck or chest wall. Clinical examination revealed a

firm diffuse fixed mass along the right jugular region.

A F 18 PET-CT was performed which revealed an

intensely hyper metabolic hypo dense intra luminal

filling defect in the internal jugular vein (IJV), and also

in the external jugular vein (EJV) right subclavian vein

confluencing at the right innominate vein with inferior

extension into the superior vena cava (SVC) falling

just short of the right atrium suggestive of tumoral

thrombus with no residual mass in the thyroid bed

(Fig 1). With limited therapeutic options and

impending cardio vascular catastrophe and large

tumor thrombus load in major veins of the neck like

right IJV,EJV, and SVC, an immediate blunderbuss

salvage radio therapy was considered with F18 PET

CT image based IMRT planning sparing the carotid

vessels to prevent carotid artery blow out and

adjoining trachea . Patient tolerated the entire course

without any complications and became symptom

free by the end of the radiation course. Patient was

kept on clinical follow with a metabolic assessment

with F18 PET CT after three months which revealed

complete metabolic regression in the intra vascular

tumor and significant reduction in the tumor

thrombus load (Fig 2). Follow up at 6 months patient

continues to be symptom free and free of tumor

thrombus.

Conclusion

A rare case of Melanotic Medullary carcinoma with

tumoral thrombosis into internal jugular, external

jugular veins and superior vena cava presenting with

Aug - 20154

Advances in rad io the rapy i n

management of spine metastasis

Spine metastases are a common complication of

cancer. While similar to other bone metastases in

terms of vertebral bone involvement, spine

metastases have unique clinical considerations.

One is spinal bone pain, which is the most common

initial presenting symptom. The other is that these

metastases can present with a soft tissue mass at

the paraspinal area or as an epidural compression.

Therefore, patients with spinal metastases

invariably have severe back pain, often with

associated neurological problems, which can

further compromise their performance status.

The main presenting symptom of spine metastases

is back pain. Therefore, the primary goal of

radiosurgery for spinal metastases is pain control

(relief). The treatment of spine metastases has

largely been with conventional fractionated

radiotherapy. Although the most common regimen

of radiotherapy has been 30 Gy in 10 fractions, the

radiation dose-pain response has not been well

settled. Early RTOG study for bone metastasis

reported that low-dose short course radiotherapy

was as effective as a high dose protracted regimen.

However, the duration and rate of pain control of

bone metastases was limited by the conventional

method of radiotherapy. In a subgroup of patients

with spine metastases, only 61% of patients

experienced partial or complete pain relief at 1 month

post-treatment. Recently, there has been an

increasing trend of diagnosing more localized spine

metastases (i.e., oligometastases), although the true

incidence of solitary spine metastasis is not known.

These patients may have a prolonged survival time.

Therefore, there is pressing need to improve the pain

control of patients with spine metastases, which may

be connected to an improvement in quality of life and

probably a cure in the setting of solitary spine

secondary.

It is evident from the studies that a single dose of

radiotherapy is as effective as 10 fractions of

radiotherapy. This suggests that a further increase in

the single dose of radiation may improve the rate of

pain control. The difficulty is that there is a dose

limiting organ, the spinal cord, within close proximity

to the vertebral body, and spine metastases often

are present with epidural tumor masses. Therefore,

accurate targeting and radiation intensity-

modulation will be required to minimize the spinal

cord dose.

In this effort, radiosurgery or stereotactic body

radiotherapy (SBRT) has emerged as an innovative

and accurate treatment option for spinal

metastases. While the spine region does have the

benefit of minimal breathing-related organ

movement and easy imaging, safely delivering a

more intensive dose of radiation requires not only

precise targeting due to the proximity of the spinal

cord, but also accurate treatment planning and

delivery.

Aug - 20155

Dr. L. YUGANDHAR SARMAMD (Radiotherapy), Junior Consultant-Radiation Oncology

Preclinical physical and dosimetric studies have

demonstrated the applicability of patient

positioning, immobilization, and dosimetric

characteristics of spinal radiosurgery for spine

metastases. The first approach to establish clinical

feasibility was to determine the accuracy and

precision of radiosurgery to treat the spine and

epidural/paraspinal tumors that are adjacent to the

spinal cord. SBRT on Cyberknife offers a perfect

solution in planning and delivery of treatment.

Advantages of SBRT with Image

Guidance using Cyberknife

Ÿ Rapid and durable pain relief

Ÿ Treating with extreme accuracy helps in sparing

of the spinal cord which is very close to the target

which in turn helps in rapid recovery of

neurological function.

Ÿ Only the involved vertebra is treated—this results

in sparing of bone marrow and no discontinuation

of systemic treatment is needed which is very

important in these cases.

Ÿ Treatment can be completed in one to three days

as opposed to 10-15 days of conventional

therapy—rapid institution of systemic therapy

especially in oligometastatic setting.

Ÿ SBRT is a non-invasive treatment and it can

potentially reduce the need for open surgery.

Spine Image Guidance in Cyberknife

The tracking of spine treatments in Cyberknife is done

using X-Sight spine tracking system. This system is

capable of monitoring the patient movement to a sub-

millimetre level ss that treatment is delivered

accurately.

CARCINOMA BREAST WHERE ARE WE NOW?

Aug - 20156

We all know the fact that the breast cancer is the most common cancer among the women in urban areas, where as carcinoma cervix is the most common in rural women. There are changing trends in the genetics, environment, causing tumor heterogeneity, …..  in the same manner there are change in trends in diagnostic and therapeutic modalities.

Those were the days when women used to come

with big palpable lumps sometimes with skin, chest

wall, axillary nodal involvement, eventually go for

radical / modified radical mastectomy. The present

trend is to diagnose as early as possible using

imaging techniques such as 2D/ 3D mammography,

MRI scan, PET scan;  have confirmation by FNAC/

needle biopsy and go for conservative surgeries i.e.

wide local excision. Wherever the facility for frozen

section and adjuvant radiotherapy are available,

the choice of surgery is conservative; which is

universally acceptable according to standard

guidelines (ASCO –CAP; ST GALEN etc).

In the good o lden days, h is topatho logy

examinations for tumor type, axillary nodal

involvement were only available to medical

oncologist. Later came up the hormone receptor

studies for estrogen and progesterone receptors,

helpful for adding anti- estrogens. With the

invention of targeted therapy for HER2 positive

patients by trastuzumab, about one and half decade

ago , a lot many changes happened and now the

adjuvant therapy is based on molecular

classification (luminal A, luminal B, HER 2, Triple

negative), hence there is rapid development in

diagnostic  modalities as we started looking for

genetic signatures of tumors.   

Aug - 2015

Some of the genomic testing options available

are:

ONCOTYPE DX 

This test includes analysis of 16- genes and 5

controls, done by RT-PCR technique on formalin

fixed ,paraffin embedded tissues , in both pre and

postmenopausal women having stage1&2 breast

cancer (node negative/ or 1-3 nodes positive; ER &

PR positive). This   analysis gives recurrence

scores, risk stratification (low, intermediate, high),

which helps to make a choice in chemotherapeutic

options.

MAMMAPRINT

This test includes analysis of 70 – gene expression

signature  focused on proliferation, done by Micro-

array , can be done only on fresh tissue only,   in

both pre and post menopausal women having

stage 1&2 breast cancer (node negative / positive,

up to 3 nodes; ER positive / negative). This analysis

gives two risk groups (low, high), helps to make a

choice in chemotherapeutic options.

PROSIGNA

PAM 50 based genetic signature which includes

analysis of 50 genes and 8 controls. It can be done

on formalin fixed, paraffin embedded tissues, in

post menopausal women only, having stage 1 & 2

breast cancer (node negative / positive, 1-3

nodes; ER/PR positive). The analysis gives a

prosigna score for risk stratification (node

7

DR. SNEHALATHA DHAGAM

Consultant Pathologist, MD (Pathology), DNB (Pathology)

negative-3 risk groups- low, intermediate, high:

node positive – 2 risk groups –low, high), helps to

make a choice in chemotherapeutic options.   

SMOKING CESSATION

INTRODUCTION 

It has been estimated that at least 70 percent of

smokers see a physician each year; 70 percent

also report a desire to quit and make at least one

serious attempt to do so. A physician's advice to

quit as an important motivating factor for

attempting to quit; brief advice from a physician

leads to a spontaneous quit rate of 2 to 4 percent.

BACKGROUND

Despite the benefits of smoking cessation,

clinicians are not adequately screening and

treating patients who smoke. One study, for

example, found that only 50 percent of smokers

seeing a primary care physician in the past year

were asked about their smoking or urged to quit.

An even smaller proportion was counseled to quit. The American Psychiatric Association (APA) also released nearly identical guidelines. Clinicians now have available a clearly defined standard of screening and intervention to use with their patients.

The AHCPR has proposed the model of "5 R’s" in promoting motivation to quit smoking:

l Relevance — Motivational information to a patient is more effective if it is relevant to a patient's circumstances (such as prior quitting experience, disease status, or health concerns).

l Risks — The acute and long-term risks of smoking should be stressed. It is most effective if smoking can be tied to the patient's current health or illnesses. For the healthy patient, environmental risks, such as exposing spouses and children to smoking and thereby increasing their risk of ill-health should be included. Smokers should also be made aware that children of smokers are more likely to smoke.

l Rewards — Encourage the patient to identify potential benefits of smoking (such as saving money, performing better in sports, improving the health of children and other household members, etc).

l Roadblocks — Ask the patient to identify barriers or impediments to quitting and note elements of treatment (problem solving, pharmacotherapy) that could address barriers.

l Repet i t ion — Repeat the mot i va t iona l intervention each time an unmotivated smoker visits the clinic setting.

TREATMENT STRATEGIES

Patients should also be encouraged to make the following preparations for quitting:

Ÿ Inform family, friends, and coworkers of the plan to quit, and explicitly ask for support.

Ÿ Avoid smoking in the home, car, and other places where a lot of time is spent.

Aug - 20158 Aug - 20159

Ÿ Review prior quit attempts. What worked? What didn't work and may have contributed to relapse?

Ÿ Anticipate nicotine withdrawal symptoms, cues to smoking, and "danger situations."

Three elements of successful smoking cessation

treatment strategies have been identified:

Ÿ Social support

Ÿ Pharmacologic therapy

Ÿ Skills training or problem-solving techniques

Several medical centers now have patient resources or learning centers in

which patients can access additional self-help materials. Web site resources include the following:

Ÿ  — The web site for the www.lungusa.orgAmerican Lung Association, sponsor of the American Smoke-out Day, includes an online guide for smoking cessation

Ÿ — www.cancer.gov/cancertopics/tobacco The National Cancer Institute web site contains information on smoking cessation , as well as general information on the health effects of tobacco

Ÿ  — A n e x c e l l e n t , w w w. q u i t n e t . c o mcomprehensive resource for patients

Ÿ www.ahrq.gov/consumer/index.htm?l# smoking — A good source for pat ient pamphlets on smoking cessation.

LOCALIZATION OF NON PALPABLE BREAST MASSES

Suspicious clinically occult breast lesions are found frequently as a result of widespread mammograph ic sc reen ing p rograms o f asymptomatic women .Some 15–20% of these lesions are malignant, and their removal should be preceded by a rad iograph ica l l y gu ided localization procedure to assure an accurate and low tissue volume biopsy.

Several techniques have been developed as a

diagnostic and therapeutic tool. Wire-guided

local izat ion (WGL) is present ly the most

commonly used localization method for non-

palpable breast lesions. However, the ideal

technique should involve precise localization,

avoid the excessive surgical resection of healthy

breast tissue, improve the rate of free margin, not

discomfort the patient and decrease operative

time. Although WGL has been shown to accurately

localize the lesions, the technique has some

disadvantages. The placement of the wire is

difficult in dense breast tissue. The wire may be displaced during surgery. For surgical

excision with free margins, the surgeon must

follow the wire through healthy tissue until the

lesion is found, and this can cause removal of

healthy breast tissue. Furthermore, migration or

rupture of the wire leads to a small risk of

Dr.Syed SafiullahHOD & Consultant, Department of Radiology

Dr. Md. Hidayath HussainMBBS, DTCD, DNB ( Pulmonology), MNAMS

Aug - 201510 Aug - 201511

pneumothorax, and the discomfort of the patient

and injuries for both the surgical team and the pathologist are other

restrictions of the procedure.Radioguided occult lesion localization (ROLL) is a

new method for the localization and resection of

non-palpable breast lesions. The approach involves

the intratumoral injection of a small amount of

n u c l e a r r a d i o t r a c e r u n d e r g u i d a n c e b y

ultrasonography or stereotactic mammography.

Radioactivity allows for the radiolabeling of the

lesion and subsequent surgical excision guided by

a handheld gamma ray detection probe. During the

last decade, ROLL has gained popularity on

account of several advantages associated with a

reduced excision volume, more accurate centricity

of a lesion within the surgical specimen, better

cosmetic results and a higher percentage of tumor-

free margins.