Getting ready for CyberKnife - a radiosurgery process and becoming a golden man!

Yesterday, I met Dr.Ajaikumar, who is the CEO of Health Care Global (HCG), the umbrella organization which owns Bangalore Institute of Oncology (BIO). Dr. Ajaikumar also heads the CyberKnife - the world's first non-invasive, whole-body, robotic radiosurgery system and is designed to treat tumors anywhere in the body with pin-point accuracy. During my meeting with Dr.Ajaikumar, we were accompanied by my Oncologist Dr.Niti Narang, Radiation Oncologist Dr.Kumara Swamy and Senior VP (Marketing) of CyberKnife, Mr.Tanjai Kapoor. The excerpts from our discussion with the experienced team of doctors here:

• since my disease is limited to only liver and a peri-portal lymph node near the liver, the radiosurgery has a higher probability of treating the tumors
• the tumor in the peri-portal lymph node is insignificant in the sense that it is currently less than 5 mm in size and is inactive. So, serious attempt will be made to target that tumor too during the radiosurgery.
  
• liver is one of the soft-tissues in the body and treating the tumors in the liver is a highly-skilled process. Also, since the tumors in the liver move with the respiration, it is more difficult to accurately trace the location of the tumors for any radiation based surgery technique. To do this accurately, hence, the CyberKnife technique involves implanting metallic markers made of gold in the liver so that the robot doing the radiosurgery can track and trace the location of the tumors accurately.
• the entire radiosurgery process may take between 3-5 days and I can be treated as an out-patient. This means that I need not get hospitalized!
• the radiosurgery process is completely painless and may take an hour per session per day.

After some discussion with my father, who came with me, I decided to go ahead for the radiosurgery as the next treatment. We then talked to Mr.Tanjai Kapoor regarding the financial issues of the process. A half-an hour discussion ensued and we were told that the entire treatment would cost us Rs.3.25 lakhs (this is after getting a good 20% discount!), which would include all the related scans and medicines. As a first step of the process, I was asked to get the gold-made metallic markers (called fiducials) implanted in my liver. This is a minor surgical process done under the local anesthesia. Yesterday afternoon, I went through this process of fiducials wherein three needles were used under local anesthesia to implant a total of five gold-metallic pieces in my liver. I suffered breathlessness for almost the entire day later because of this process. :( These markers would help the robotic system to accurately locate the tumors in the liver while treating them. The next step would be a planning scan to be done ten days later. Meanwhile, I was advised to be on a couple of antibiotics (both oral and IV) and on continuation of the oral chemotherapy tablets of Capecetabine. This planning scan would produce the images that would be for the robotic system to pick up and understand the structure and the location of the tumors during the actually surgery. So, finally, I have become now the golden man :) with gold-made metallic implants in my liver now! I trust the team of doctors in BIO for my treatment and I hope I would get the best possible treatment under their supervision! :D I hope with this radiosurgery, despite some suffering and difficulties, I would be free from the disease completely. :D

Signs of recovery

The results of the PET-CT scan are out today and there is really a good news:

• There are no traces of cancer in the body except three lesions in the liver. Out of those three, two are inactive and only one is active! :D
• All the rashes and other side effects like infection in my body are due to the chemotherapy! :)

I met my doctor today with the report and when she broke the news to me, I did not know how to react! Such are the moments! :) However, taking grips on my feelings and emotions, I discussed with my doctor on further plans since there are still some lesions in the liver which need to be cleared out of the body. Only then, I can say, I am completely out of cancer!

After a long and an insightful discussion, my doctor suggested me to undergo a radio surgery on the affected portions of the liver. The surgery option, according to her, is the best because:

• further chemotherapy might not be that effective on the liver lesions because two of them are inactive and might not respond to the chemo drugs
• further chemotherapy might induce more side-effects which might have deleterious effects on the body in the long-term
• a surgical procedure, especially a radiation-based, is relatively a painless process and since the disease is now confined to only liver, it is easy to control it by just working on the affected portions

Now that my doctor had suggested the surgery as the best option in the prevailing situations, I had decided to talk to Dr.Ajay Kumar, who heads the Division for robotized radio surgery in Bangalore Institute of Oncology (BIO). (I got his appointment on Friday@ 9AM.) I hope once the surgery is done, I will be free from the disease and will be on the path of fast recovery and can really hope for glory of success! :)

PS: Here are the scanned copies of the PET-CT scan report for those of you interested to go through them! (You can go through the final impression in the page 3 of the report for the gist of it.)

PET-CT scan today

I have had another PET-CT scan today morning in the Bangalore Institute of Oncology (BIO), which is the only center in Bangalore to have such facility. Given the number of patients lining up for the scan, one needs to always take an appointment at least three or four days prior to the scan day. So, I took the appointment last week (Nov 30), when I had my chemo session.

Today's scan was my seventh in the last one year of my treatment for cancer! Nevertheless, I would like to share with you my experiences of the scan process for a couple of reasons: (a) Most of us might not have heard about what PET part of the scan is, though some of us might already know what CT scan is. (b) I did not share my scan experiences in a public platform such as this blog until now. Thus, I give below more details of the PET-CT scan in the form of FAQs. Hopefully, this might give a few of the readers what a scan process might be! :)

1. What is PET-CT scan? Why should a CT scan be combined with PET scan?
PET is an acronym for Positron Emission Tomography, while CT stands for Computed Tomography. A CT scan usually gives us an idea of the structural changes of the parts/tissues/organs in the body. Thus, CT will give us what is called anatomical imaging. However, CT cannot give us the details of the metabolic activity going on in the specific part/tissue/organ in the body, which can be achieved by PET. Thus, PET will give us what is called functional imaging.
Let us take an example of a cancerous growth in Liver. CT will show the images of the liver with its shape, changes in the size and any other properties such as color, which might be due to the presence of cancer. PET will capture how these cancer tissues or cells are moving or spreading. So, a combination of both PET and CT images of the body not only gives the anatomy and changes in the structure of the part, but also how the part is functioning.

For more technical details on PET-CT scan, interested readers might want to see the following web resources:
(a) PET-CT
(b) Positron Emission Tomography
(c) What is PET-CT scan?

2. Is PET-CT scan the only technique available for effective diagnosis of cancer in the body?
PET-CT scan is the widely used technique world-wide to detect the nature and extent of the cancer in the body. Though there are other kinds of tests used to detect the cancer, such as mammography test (for breast cancer), Pap smear to test (for cervical/uterus cancer), and various others, they only detect the cancer in a specific area of the body. PET-CT scan detects the abnormal activity in any part of the body thus helping an oncologist in effective diagnosis.

3. Is PET-CT scan a painless process?
Yes, the PET-CT scan is mostly a painless process since the actual scan will be performed in a machine where the body is exposed to a painless radiation, similar to that of an X-ray machine.

4. How expensive the scan is?
Given the logistics and investment of the tools and equipment required for the PET-CT scan, it is usually expensive. For instance, BIO charges anywhere between Rs.12000 to Rs.20000, depending on the reference of the doctor and whether you are an internal or external patient. (Of course, one can negotiate always for a discount with the help of your doctor :) )

5. What the process for a typical PET-CT scan is?
The process for a typical PET-CT scan might be as follows:

(a) The patient should be on fasting for at least eight hours before the scan! He can only take water during the fasting period. (In my case, I had my dinner at around 9 PM yesterday and did not have any thing later to that until my scan was complete at 12 noon today.)

(b) The patient when reports to the PET-CT center, is checked for his vitals, such as blood pressure level, sugar level, white blood cell count, weight and height. If any of the first three are abnormal, the scan will not be done on the day and will be rescheduled. (For example, the fasting sugar level should be less than 200 mg/dl i.e., 200 milli grams of glucose per deci liter of the blood.)

(c) An intra-venous (IV) needle will be injected in one of the veins of the patient, usually in one of the hands, which would later carry the radioactive tracer before and during the scan.

(d) The patient is then administered with a small dosage of fluorodeoxyglucose (FDG) through the IV line. (FDG contains the radioactive tracer as fluorine-18, a radioactive isotope of Fluorine, with half-life of around two hours! This tracer is absorbed by the abnormal areas of the body and emit gamma rays, which are captured by the PET-CT machine.)

(e) The patient is quarantined from others since now he carries the radioactive tracer in his blood.

(f) The patient is then asked to have one liter of liquid, usually water, with soluble FDG. This is to ensure that the body will have enough dose of FDG to absorb. The intake of this fluid, also called oral contrast, should be slow and even and should be over a period of 45 minutes to one hour.

(g) The patient is then shifted to the PET-CT machine, where the actual scan of the body will take place. It usually takes 15-20 minutes for the scan to complete. The whole process of scan can take any where between 1.5 - 2 hours.

Once the scan is complete, the patient is advised to be in observation for another couple of minutes before he is let out. (Once he is let out, of course, he is free to break his fast now! :) )

Now that I have had my scan, I am eagerly waiting for its report, which would be available to me tomorrow morning! Hope there are quite positive results in the report and my recovery is complete without any further chemo sessions! :)

Chemo-18 today.

I have had my eighteenth dose of Cetuximab today. This is the last dose as originally recommended by my doctor. Like I did last week, I went to the hospital today with (a) severe pain around the edges of my feet which were split in several areas thus affecting severely my walk and (b) lot of inflammatory abscesses in my face and both the legs which were a major irritation.


A few highlights of today's chemo session:

• Blood counts have only marginally improved with the white blood count going up from 2.44 last week to just 2.85 today! This value still is below the minimum value of the preferred range of 4 - 11. Nonetheless, it was fine for the infusion of the Cetuximab.
• After a couple of trials, the nursing staff found a vein in my right hand.
• My weight has gone down marginally from 89 kg to 87 kg!

Though my doctor Dr.Niti did not visit me, her junior Dr.Smita did so and advised me having a PET scan next Monday (i.e., 30th Nov) and consult Dr.Niti with the scan report. The scan will show the latest status of the disease inside my body and it is the only known way currently to detect cancer in the body. So, I have one more week of rest and one more good thing of not having Capecetabine this week! Phew!

Chemo-17 today.

I have had my seventeenth dose of Cetuximab today. I went to the hospital today with (a) severe pain around the edges of my feet which were split in several areas thus affecting severely my walk and (b) lot of inflammatory abscesses in my face and both the legs which were a major irritation.

A few highlights of today's chemo session:

• Blood counts have again dropped with the white blood count going down from an amazing 8.49 last week to 2.44 today! Though the value of 2.44 does not fall in the recommended range of 4 - 11, it is fine for the infusion of the Cetuximab.
  
• The ordeal of finding a vein in my hands for the infusion of the chemo drug was again back. Finally, after a couple of trials, the nursing staff found a vein in my right forearm.
• My doctor, Dr.Niti Narang, did not visit me today for the simple reason that by the time the intra-venal (IV) infusion had started, it was again already 3 PM and that was the time when my doctor usually completes her duty. However, the assistant doctor Dr.Smita visited me and enquired about my health condition in general. When I told her about the rashes on my face and legs, she told me that these were the side-effects of the chemotherapy, especially, the infusion of the Irinotecan, and were expected. She assured me that they would go away over time.
  
• My weight has improved marginally from 84 kg to 89 kg! Though my father, who accompanied me today, was at discomfort with the abnormal weight, he left a sigh of relief when the doctor and I reassured him that it was a good sign given that chemotherapy is going on now.