Breathing with the tumor , Advances in cancer care

Mrs. Sharma, aged 77 years presented with few months back developed severe headache, intermittent
fever, pain all over the body and dry cough. Investigations led to the diagnosis of malaria which was a great
relief for her. But during the investigations in addition to certain benign findings in addition to the changes in
the brain indicative of blood supply problems (ischaemia) a small mass in the left lung. The size of the mass
was less than 2cms. A CT guided Biopsy was done revealed cancer of the lung. In medical terminology it
was very early stage of lung cancer, in this situation diagnosed accidentally when investigating for other
problem. Is it a blessing in disguise?

Just a few years back it would not have been a blessing. The only choice for this stage at that time was only
surgery and many times surgery was not possible in this situation because of relatively advanced age &
associated diseases like that of heart. There goes up in smoke the slogan “cancer is curable if detected
early”. Additionally, in such an age, surgery did carry a risk of mortality. A few years back a new technique of
radiotherapy was designed. That is stereotactic body radiotherapy, in short SBRT. Stereotaxy means ability
to locate a point in the body in three-dimensional space. If that is attained, then one could deliver relatively
high dose of radiation to the tumour avoiding the normal tissue attaining the same result that of surgery.
Theoretical foundation was laid, later came the implementation.

The first problem was tackling the movement of tumor in the lung. It was realized early that the tumor moves
as much as 4 cms during the breathing, not only up and down but in all directions. The way out was to treat
the volume encompassing all the positions of the tumour. This was done by including 1 to 2 cms of normal
lung tissues around the tumor and dose of radiation was kept a level that could be tolerated by normal
tissues with acceptable side effects. Tumor control rates were encouraging but were not significant.

With what is known as 4Dimension CT scan tumor movement can be mapped. And radiation was directed to
the tumor when it came with in specific phase of breathing cycle, usually in late expiration and beginning of
inspiration phase. The other variation in technique was to make the patient hold her/his breath in particular
phase of breathing and forcing the tumour to lay still. This popularly came to be known as “Gated
Radiotherapy”. With this technique, volume of normal tissue included decreased and dose of radiation could
be increased. The radiation with this technique started giving good results so much so that it became a
standard of care in early stage carcinoma lung when surgery was not possible.

Yet, with this SBRT technique there was need for some margin normal tissue around the tumor during
treatment, hence, the hunt was on for perfecting this technique which culminated in the development of
CyberKnife(steroetactic Robotic Radiosurgery).

Here, Gold seeds (being inert and with excellent density) are introduced into or around the tumour. These
gold seeds, technically named as internal fiducials, acted as shadows for the movement of the tumour
permitting the machine to know the exact location of the tumour, moment to moment, automatically.

But the supreme aspect of CyberKnife technology was the development of automatic correction of the
patient position if the tumour has moved from expected and placing the tumour in the expected path of
beam. This technology was important because it potentially eliminated the need for giving the normal tissue
margin around the tumour decreasing the possibility of side effects drastically and increasing the possibility
of tumour control. The increase in the dose gave results better than expected and it was realized that the
mechanism of action of radiation at higher dose per treatment was different and much more efficient in
handling resistant cells.

The machine that was developed mastering this technology was aptly named as CyberKnife. It is considered
as knife, even though no scalpel was used, because it is capable of cutting of the tumor biologically from the
word go. Subsequently, usually over 3 months tumor cells would either undergo rupture (apoptosis) or cell
death, get digested and put out of body as waste products. At the end of 3 months, responding tumors will
show metabolic activity near normal, with disappearance or significant reduction in size. Some damaged
cells survive for long time try to multiply and after few multiplications give up and die.
With this background in mind and unwilling to undergo the surgery with the risks involved Mrs. Sharma flew
in from Mumbai with PET CT scan and reports, for CyberKnife treatment. On Day two of the arrival, she
underwent insertion of 4 gold seed fiducials, one inside the cancer and rest around it (with the knowledge of
risk of possible pnumothorax – collection of air in the cavity around the lung which might have required a
minor surgical procedure of insertion of tube inside the pleural cavity for a day or two in an occasional
patient). She rested for 2 hours in the hospital and went back to hotel. She was given the option of flying
back to Mumbai and return after 5 days. But she decided to enjoy the stay at Bangaluru.

In day 7 treatment planning process started. A vacuum fixture, which takes the shape of the patient when air
is sucked out of it, was prepared for her to keep her still as far as possible during the treatment. A planning
PETCT scan was done and images were pushed to computer planning station. The cancer, normal tissues
like lung, heart, spinal cord etc. were delineated and radiation dose to the cancer and maximum limits well
with in the tolerance of the particular organ was prescribed. The plan was generated and checked in all
aspects and approved plan was sent to the machine on Day 8. Mrs. Sharma was counseled about how to be
in the treatment couch as comfortable as possible, and taken up for the first of the 3 sessions. Patient is
positioned perfectly, moving fiducials are identified, respiratory movements are modeled, automatic patient
corrections are set and robot started moving around from a safe distance under the watchful eye of the
treating team.

The procedure was repeated in subsequent 2 days and on Day 10 the treatment sessions was over. Next
step was about after care. In radiation sensitive people and/or in those who have persistent infection of the
throat and bronchus, this area might show up as pnumonitis (something similar to localized pneumonia),
which might require a course of steroid and antibiotics. This can happen generally anywhere from 1 month to
6 months after the completion of treatment. The best way is to prevent this side effect. Therefore, Mrs.
Sharma was counseled regarding the ways of preventing the infection, taking a course of antibiotics at the
first sign of infection. She is also put on a drug for 3 months, which is expected to reduce this type of side
effects. Brief discussion went on regarding the lifestyle changes to improve the body immunity.