Septuagenarians look forward to spending time with family and the fruits of retirement. However, it was not the case of a 74 year old. Being diagnosed with cancer at any age is worrisome and the memories of the treatment were not very pleasant one especially postoperatively along with chemotherapy in 2014. However, the fight was not over just yet for the patient as there was a recurrence of ovarian cancer that was detected during a follow up check up in 2017.
At age 77, chemotherapy was no longer an option and surgical removal of the tumor was the only option left. The patient was apprehensive and reluctant about the surgery given her previous experience, which was not a very encouraging. That’s when Dr Anupama R, Clinical Professor, Gynaecologic Oncology, Amrita Institute of Medical Sciences suggested robotic surgery. This case was discussed in the multidisciplinary tumor board and all doctors agreed that robotic surgery would be the best option for the patient. The affected area was completely removed using robotic assisted surgery, da Vinci Surgical System. This time around, the patient was discharged on the next day as the procedure was completely and hence pain free.
This is one of the many cases where Amrita Hospital has embraced modern technology, particularly the use of robot assisted surgery. Contrary to popular belief, the surgeon uses the robot as a tool to perform the surgery and it is not an automated process. The advantage of using robotic surgery is the short, sometimes unimaginable, recovery period is shorter than routine laparoscopic procedure. However, robotic technology with its better vision and small and precise instruments helps the surgeon perform complicated surgeries with minimum tissue damage since oncologic surgeries are more complex than routine gynaecologic surgeries. The use of robotic surgery translates into shorter hospital stay, lesser fatigue and faster recovery for the patient. Additionally, the duration of the surgery on an average is 1 to 2 hours.
In countries like the United States and UK, robotic surgery is being offered even for routine procedures and slowly even India is catching up. Robotic surgery was introduced at Amrita Hospital in January 2015. In the short span of two and a half years, Dr Anupama R has treated over 260 patients with gynaecological cancer and other gynaecological problems with the help of robotic surgery.
The department of Pathology, Amrita Institute of Medical Sciences, Kochi, organised a two day international seminar on ‘Amrita Annual Pathology Update 2017’ (AAPUD) during July 15-16, 2017. Swami Purnamritananda Puri, General Secretary, Mata Amritanandamayi Math inaugurated the seminar. Dr. D. M. Vasudevan, Head, PG Programs and Research, Amrita University; Dr. Vishal Marwaha, Principal, Amrita School of Medicine; Dr. Prathapan Nair, Chairman, Admissions and Accreditation, Amrita School of Medicine; Dr Ajit Nambiar, Head, Pathology and Dr. Indu R. Nair, Organising Secretary attended the function.
The main theme of the seminar was “Pathology of Female Genital Tract.” Many international and national experts delivered lectures to over 200 delegates. According to the experts at the seminar, gynaecological cancers are the most common form of cancer in women with a high mortality and morbidity hence it is an important public health issue. However with the advances in medical science, early detection facilities along with customised patient care and cure are now available. The seminar comprehensively reviewed the latest cutting edge diagnostic and therapeutic modalities.
The department of Radiation Oncology at Amrita Institute of Medical Sciences, Kochi recently conducted Amrita Annual High Precision Radiation Therapy Workshop and CME over the course of three days on 30th June, 1st and 2nd July 2017. The workshop focused on imparting hands on training on the use of CyberKnife. The academic session included a live demonstration on the treatment of liver tumors. Liver tumors are very common in Kerala and it is difficult to treat using traditional methods in certain cases. However, radiosurgery serves as a treatment option for these patients. Additionally, the experts taking these sessions represented top hospitals across the country including Tata Memorial Hospital, Fortis Hospital and Apollo Hospital just to name a few.
CyberKnife is an option in Inoperable and Recurrent Liver Cancer: Dr Debnarayan Dutta
Hepatocellular carcinoma is a cancer of the liver cells. It is usually associated hepatitis infections, toxins (hepato-toxins), many chemicals we use daily, alcohol and also with substance abuse. As per the ICMR data, incidence of hepatocellular carcinoma ranges from 0.7 to 7.5 per 100,000 in the Indian population. Liver cancer is a problem in Kerala; there is an assumption that the incidence is higher than the national average.
Majority of these primary liver cancers (hepatocellular carcinoma) are treated with surgery, trans-arterial chemo embolization (TACE) and radiofrequency ablation (RFA). But, as majority the of these patients are presented with advanced disease since recurrence is common. Many patients have blockade in the portal vein (portal vein thrombosis), and they have only few treatment options available. These patients are usually on palliative chemotherapy with dismal prognosis. Many of these patients have preserved functional status (good general condition), and there is a dilemma regarding their management. There is a need to explore newer treatment options in these 'difficult to treat' patients. Sometimes, surgery is also difficult in patients with small lesions close to porta hepatis (blood vessels) and subdiaphramatic (below the diaphragm - subdiaphramatic location) location. These patients usually don't have any suitable treatment option and are treated with chemotherapy.
Primary liver cancer is relatively chemotherapy and radio-resistant. Higher doses of radiation or specific chemotherapy are required to have any significant clinical benefit. There is a technical challenge in delivering high dose to the liver tumour and sparing other parts of normal liver. Hence, radiation therapy was never considered as a viable option in liver tumours, till recently. We have recently found a technique to deliver high dose of radiation to the tumour safely. The liver is sensitive to radiation therapy, and tolerance is low. It means that even a low dose of radiation on the whole liver will cause 'radiation induced liver injury'. Normal radiation therapy with high 'scattering' of dose leads to high 'mean' dose to liver. Therefore, it is difficult to deliver high dose with standard radiation equipment. Liver moves with respiration, hence we need to treat a larger area with standard radiation equipment, and hence higher dose to liver is delivered.
Primary liver tumour (Hepatocellular carcinoma, cholangiocarcinoma) need a higher dose of radiation needs to be delivered, which not possible with standard radiation machines. With available radiation machines deliver higher dose to normal liver and less than appropriate dose to the tumour. A high dose to liver is associated with toxicity and lower dose to tumour with response to treatment. Hence, with standard radiation therapy techniques there are higher side effects and lower response to treatment. Radiation therapy was never considered an option previously as an option even in inoperable or recurrent disease. There are only few systemic therapy options in hepatocellular carcinoma (Sorafinib) and the outcome is par below the expectations.
Radiosurgery is a precise radiation therapy delivery technique to deliver high dose radiation to the target while sparing the adjacent critical structures. Robotic radiosurgery (CyberKnife) is a robot assisted 'real time' image guided radiation therapy delivery technique where high dose short course radiation therapy is delivered to the target sparing adjacent normal liver.
High-resolution contrast CT scan and MRI scan helps to locate the tumour accurately, computer assisted contouring and planning system helps to plan the treatment precisely. CyberKnife treatment does not need any margin, as there is real time tracking and the robot 'chase' the tumour during respiratory motion. Gold seeds called 'fiducials' are placed near the tumour and the machine has the capability to track the 'fiducials' during real time imaging and treatment. Hence, high dose radiation therapy is delivered precisely with robotic arm based linear accelerator to the moving target with real time tracking and real time imaging. Accuracy of treatment is very high (within 1 mm) and monitored by computer-assisted systems.
Higher dose to the target and sparing of normal liver has enabled physicians to deliver high dose radiation to the target, which has translated to better local control with lesser side-effects. Usually, 45 Gy of radiation dose is delivered to the target in three days as out-patient procedure. As a policy, 800 cc of normal liver is saved to function properly. Usual liver volume is around 1200 to 1500 cc. There is no major toxicities during treatment and a large proportion of patients respond to treatment at 2 to 3 months follow up evaluation.
CyberKnife robotic radiosurgery is considered the most appropriate treatment option for fiducial guided liver cancer treatment. CyberKnife is an option in otherwise inoperable situations, such as tumour close to porta or subdiaphramatic location or multiple lesions in different lobes of liver. Radiosurgery with CyberKnife is now considered a standard option in inoperable, recurrent/ progressive liver tumours. There are many prospective randomized trials being conducted world over to find if CyberKnife can be an option even in smaller lesions as a non-invasive option even in operable liver cancers. Early studies with smaller lesion have shown that CyberKnife is equally effective as surgery with lesser side effects.
There is a need to increase awareness regarding the liver cancer treatment options, especially in inoperable or 'difficult to do surgery' patients those are relatively young (less than 60 years) and have preserved function status (good general condition).
A 13-year-old tribal boy Manikandan, son of plantation workers in Parambikulam, Palakkad, was the butt of ridicule since birth because of a rare medical condition called encephalocele in which brain matter oozes out of gaps in the skull into a sac-like structure, giving the patient’s head a grotesque appearance.
A fist-sized ball of brain matter used to hang from Manikandan’s nose as a pendulum. It obstructed his vision and deformed his nose and face. His life changed radically for the better a few days ago when a 10-member team of surgeons at Amrita Institute of Medical Sciences removed the external deformity in a surgery that lasted 11 hours. The entire cost of the procedure was borne by Kerala Government agencies, as Manikandan’s parents, Selvan and Ramata, are from a poor socio-economic background.
Dr. Subramania Iyer, Professor and Head, Plastic & Reconstructive Surgery, Amrita Institute of Medical Sciences, said “It was a complex surgery. Manikandan’s encephalocele was very large which had pushed the bone of his right eye outwards. For surgery, his skull was opened and the normal brain isolated from the sac of non-functioning brain matter hanging from his face. The removal of the deformity left a defect in the skull, a portion of which had to be reconstructed. The patient’s eye sockets were repositioned to remove the deformity in the right eye, and the nose was also remodelled. All these were huge surgical challenges. Manikandan has now recovered fully from the surgery and is ready for discharge. He will now be able to attend school and participate in all social activities like any other child of his age. The surgery was carried out by the combined effort the paediatric craniofacial department consisting of more than 12 surgeons and anaesthetists.”
The surgical team that operated on Manikandan consisted of paediatric neurosurgeons, craniomaxillofacial surgeons and plastic surgeons, assisted by neuro anaesthetists and a paediatric neuro ICU nursing team. The surgical team was led by Dr. Suhas Udayakumaran, Dr. Pramod Subash and Dr. Subramania Iyer and helped by the anaesthetic team led by Dr. Gokuldas and Dr. Mathew.
Manikandan’s father, Selvan said, “We belong to the Marasar tribe and work in a plantation. I have five children, who are all normal and healthy, except Manikandan who was born with a swelling on the nose which kept growing. Because of the huge deformity on his face, he never went to school or mingled with others, as people used to make fun of his appearance. After surgery, he is eager to go back home, start school and make friends. I thank the doctors of Amrita Hospital from the bottom of my heart for enabling him to lead a normal life.”
The district administration of Palakkad and the tribal welfare department stepped in to fund Manikandan’s surgery. Mr. Suresh, District Tribal Welfare Officer, Palakkad, brought the plight of the boy to the attention of Dr. P. Pugazhenthi (IFS), Director, Scheduled Tribes Development Department, Kerala. He, in turn, escalated the issue to Mr. A.K. Balan, Hon. Minister for Welfare of Scheduled Castes, Scheduled Tribes and Backward Classes, Government of Kerala. The Minister took keen interest in the matter and sanctioned funds for Manikandan’s surgery. Ms. P. Marykutty (IAS), District Collector, Palakkad, provided logistical support to liaison between the various Government departments and visited Manikandan at Amrita Hospital to monitor his progress.
Encephalocele is a rare congenital disorder, found in 1 in 5,000 births, in which bones of a baby’s skull do not close completely in the mother’s uterus. This creates an opening through which brain tissue and cerebro-spinal fluid protrudes out of the head in a sac-like structure. The condition can be fatal if the encephalocele hampers development of the brain. Past infancy, patients usually live an isolated life, ashamed to show their face in public.
The number of people affected by Multiple Sclerosis (MS) is on the raise at an alarming rate. MS is a rare demyelinating neurological disorder which affects young individuals predominantly between the age 20 to 40. Many patients suffer in silence because of lack of awareness and high cost of treatment.
The department of Neurology at Amrita Institute of Medical Sciences conducted a seminar to create awareness about this disease on June 16, 2017. Patients affected with Multiple Sclerosis and their relatives were invited to this free seminar.
The Comprehensive Multiple Sclerosis Clinic at Amrita Hospital has treated over 200 patients and is among one of the largest MS clinics in the country. The multi disciplinary clinic also involves ophthalmologist, physiatrist and physiotherapists, psychiatrist, psychologist, speech therapist, urologist and social workers. The theme of this years World MS Day is “Tips to live with MS.”