"Proton Beam Therapy is ideally suited to treat brain tumours and is the global benchmark of excellence in treating paediatric brain tumours."

Diagnosis

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The treatment roadmap begins with a world-class diagnosis. An accurate diagnosis is the critical start-point of the process. Robust diagnostic capabilities are especially crucial in CNS cancer because brain tumours are often not diagnosed until the late stages. Our CNS Tumour CMT is powered by diagnostic capabilities that match the benchmarks of the finest in the world. Our experts make detailed examinations that take into the account test results, medical history and lifestyle habits of the patient. These vital variables in the equation are studied to determine the most suitable prognosis for the medical condition.


Typically, the diagnostic process in the case of CNS cancers would involve any of the following:


  • Neuro Imaging Studies
  • Histopathology
  • Molecular neuropathology
  • Neuro Imaging Studies
MRI

The diagnostic process typically begins with a magnetic resonance imaging or a MRI. The MRI uses magnetic fields rather than traditional x rays to produce detailed images of the body. After determining the propensity of the tumour to spread across the CNS, our specialists recommend an MRI of the brain or spine or in some cases both. After detailed neuro-examinations, we decide which type of MRI would work best for the patient.


  • Intravenous (IV) gadolinium-enhanced MRI
  • Functional MRI
  • Magnetic resonance spectroscopy (MRS)
  • MR Perfusion studies (ASL + DSC)
  • Texture Analysis
CT Scan

CT scans use powerful x-ray beams to detect tumours. The x-ray beams are projected from different angles giving us a 3-dimensional picture of the inside of the body. Powerful computer algorithms combine these images into a detailed, cross-sectional view that shows up any abnormalities or tumours. CT scans are especially to patients with pace-makers as they cannot undergo the MRI procedure.

NEURO-PATHOLOGY

Histopathology


Histopathology is a vital cog in the diagnostic process. It is the catalyst to an effective prognosis. A biopsy for brain cancer involves the removal of a small amount of the affected tissue from the brain. An in-depth pathological analysis of this tissue helps us evaluate the tumour to plan your brain cancer treatment. It is the only definitive way a brain tumour can be diagnosed.


Stereotactic biopsy is a surgical procedure where a thin needle is inserted into the brain by a neurosurgeon to extract a small piece of tissue to examine under a microscope.


It is only after a biopsy can we say with 100% certainty what a detected abnormality represents - a cancerous tumour, a benign tumour, an infection, an inflammatory process, a vascular abnormality, or other pathology. When we because treatments for each of these conditions are so different from the other, it becomes clear how critical it is to have clarity on the lesion so that appropriate treatment can be recommended.


Tumour Histology


A tumour’s propensity to grow and spread is known as its grades. In the case of brain tumours, we use tumour histology to determine the type of tumour, the grade, and additional molecular features that predict and influence how quickly the tumour can grow. Taken in its entirety these factors paint a picture that helps our doctors understand the behaviour patterns of the tumour. This becomes the foundation to determine a patient’s treatment options.


Immunohistochemistry


Our advanced diagnostics also use the powerful microscopy-based technique called immunohistochemistry (IHC) for visualizing cellular components, for instance, proteins or other macromolecules in tissue samples. The strength of IHC is the next-gen visual output that demonstrates the existence and localization of the target protein in the context of different cell types, biological states, and/or subcellular localization within complex tissues.


Though clinical data, imaging techniques, and per-operative findings offer some valuable clues to the diagnostic possibilities, the histopathologic examination is on the cutting-edge diagnosis of brain tumours. It has become imperative for an exact diagnosis and subtyping.

MOLECULAR NEUROPATHOLOGY

Our CMT leverage state-of- techniques and our world-class pathologists to recommend further examination of the tissue samples. Intensive Molecular neuropathology processes are undertaken to identify specific genes & proteins unique to the tumour. These tests help in setting biomarkers that help doctors determine a patient’s prognosis and make a significant impact on the chance of recovery. Effective molecular testing which includes MGMT, IDH, 1p19q, BRAF & TERT mutation testing gives a better understanding on the biology of the tumour and is invaluable to the CMT to decide final treatment protocols best for the patient.

Skull Base Tumour Diagnostic Tests

While investigating skill base tumours our team of experts carefully chooses the tests that are best for each specific tumour. One or more of the following tests may be used to determine a skull base tumour and also see if it has spread. Imaging tests, these may include:


  • CT or CAT (computed axial tomography) scans
  • MRI (magnetic resonance imaging) scans
  • PET (positron emission tomography) scans
  • Angiography

Biopsy: One of these biopsy methods may be used:


  • Fine-needle aspiration (FNA)
  • An endoscope inserted through the nose and sinuses
  • Surgery

Functional testing to find out how certain parts of the head and neck are working. These tests are chosen based on your symptoms and where the skull base tumour is. They may include:


  • A hearing test (audiogram, auditory brainstem response (ABR)
  • Vestibular tests (video nystagmography, rotary chair testing)
  • Vision testing
  • Video stroboscopy of vocal fold function
  • Swallowing testing (modified barium swallow)
APCC CNS CMT Multi-Disciplinary Team Meetings

All patients with a CNS tumour will have their records reviewed in APCC’s weekly CNS CMT’s weekly MDT Meeting, which will comprise of dedicated professionals from different fields (oncologists, surgeons, pathologists, imaging experts, rehab specialists, etc). The aim of these meetings would be critically evaluated each patient’s data for accurate diagnosis and customizing a personalized treatment plan as per scientifically derived evidence, available resources etc. Appropriate individualized treatments will be then discussed with the patient and family to provide the maximum chance of high-quality care. These interactions will also provide an opportunity for patients/families to participate in suitable clinical trials.

Treatment

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The definite edge of a multi-disciplinary approach to cancer care is borne out in the advantage that is accrued to the patient in the treatment stage. Experts from radiation, surgical and medical oncology put forth their cumulative knowledge and determine the best course of action. At the Apollo Proton Cancer Centre we have the best expertise in surgical oncology, the best technology for radiation and the deepest knowledge and experience in chemo. The Cancer Management Team uses these powerful variables to deliver the most effective solution for our patients.


The treatment procedures most commonly used for brain tumour are:


  • Neuro Surgery
  • Radiation Oncology
  • Medical Oncology
  • Personalized Medicine
  • Rehabilitative Services
  • Palliative Care
Surgery

NEUROSURGICAL ONCOLOGY


Neurosurgery is a highly specialized niche that plays an integral role in the treatment of brain tumours. The brain is the complex and delicate organ in the human body; planning brain surgery demands that we address the challenge of quality of life post the procedure. Maximum Safe Debulking is a process that refers to the maximum size of the abnormal tissue that can be surgically removed without compromising critical brain functions. Often neurosurgery is used as the first line to defense to reduce the size of the tumour to manageable sizes; post this, other forms of treatments are used to eradicate it.


TYPES OF SURGERIES


Tumours at difficult and deeper locations of the brain are removed effectively and safely using cutting edge technology and expertise, thereby facilitating adjuvant therapy if needed. This includes the tumours of the Thalamus, Hypothalamus, pineal region and the brain stem.


Minimally Invasive craniotomy


Keyhole surgeries to remove the tumours at the depth with an eyebrow incision are performed routinely achieving an excellent cosmetic outcome and minimizing the hospital stay.


Awake craniotomy


Our team at APCC has the expertise in performing the maximum number of awake craniotomies in the country, minimizing the risk of paralysis during the surgeries in the key areas of the brain.


Spine tumours both inside and outside the spinal cord are handled efficiently with spine specific D wave monitoring which is the gold standard along with dorsal column and sphincter monitoring to prevent incontinence post operatively. Spinal neuronavigation with integrated Intra op digital C arm helps in localizing and removing spine tumours with smaller incisions.


Childhood Brain and spine tumours


The higher incidence of malignant tumours and the smaller blood volume with the anesthetic challenges associated make the Scylla and Charybdis of paediatric neuro-oncology. APCC is well equipped to make this difficult journey as safe as possible for the affected child.


ADVANCED SKULL BASE SURGERY


Large tumours of the skull base require a multi-disciplinary approach with a combination of endoscopic and microsurgical excision of tumours. Our neurooncology surgeons and the Head and neck team work together to achieve maximal tumour clearance.


We also perform high flow vascular bypass to radically eliminate skull base tumours.


Operating Microscope - ZEISS KINEVO 900


The most advanced system available worldwide, has redefined surgical visualization for advanced surgical certainty. With its unique Robotic visualization system and the blend of optical and digital modalities, Kinevo provides the neurosurgeons, the much-needed armamentarium in their fight against CNS cancers.


StealthStation S 8 Neuronavigation system


Allows us to precisely locate anatomic structures in either open or percutaneous procedures. The most advanced version worldwide, S8 StealthStation, is a combination of hardware, software and tracking algorithms, image data merging and specialized equipment to help the neurosurgeon map his way along this difficult terrain during surgery.


CUSA - SonopetCavitron Ultrasonic Surgical Aspirator


Uses ultrasonic technology to help to remove tumours. The tips vibrate in very high frequency in the range of more than 50 GHz and create an environment of negative pressure in the targeted tissue. The cells expand under the increasing pressure until they burst. This process selectively spares healthy tissue, blood vessels and nerves while cavitating and selectively sucking out the tumour tissue.


IONM


Intraoperative Neuromonitoring makes use of advances in electrophysiology to minimize the risk of injury to neural pathways during neurosurgical procedures of the brain and spine - SSEP, MEP, EEG, EMG, BAEP, VEP, mapping of the motor and sensory cortex, language areas and subcortical tracts mapping have made surgery much safer to protect vital nerves of the body.


Tumour Fluorescence in Brain tumour surgery


The advanced Kinevo operating microscope facilitates the use of fluorescent dyes (5- ALA & Sodium fluorescence) during surgery for brain tumours to identify and distinguish tumour cells from normal cells in the Brain. This facilitates the removal of tumours selectively and preserves the normal nerve tissues surrounding the brain.


Radiation Therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy tumour cells. Doctors use radiation therapy to cover microscopic subclinical disease after maximum safe debulking. It is also used in combination with chemotherapy in some types of tumours that respond better to a combined approach improving treatment outcomes. The duration of treatment can range from a single day treatment up to 6-7 weeks of daily irradiation. In each clinical scenario, the technique, dose, expected outcomes, and related toxicities vary depending upon the diagnosis and treatment site.


A radiation therapy regimen could comprise of several treatment techniques:


Proton Beam Therapy


Proton Beam Therapy is ideally suited to treat brain tumours and is the global benchmark of excellence in treating paediatric brain tumours.


The tumour’s proximity to delicate and vitally important tissues and structures makes absolute accuracy an imperative. Using the Braggs Peak method, Proton Beam Therapy fixes the point of maximum radiation on the tumour; this ensures that unnecessary radiation is avoided before and after the peak. This pinpoint precision allows proton therapy to deliver higher doses of radiation to target brain cancer, with less damage to surrounding tissues.


Proton Beam Therapy is the global benchmark of excellence in treating paediatric brain tumour. Brain Tumours in children are even more challenging because the treatment must ensure that long term quality of life is not impacted. To address this challenge Proton’s Therapy, with its unprecedented precision, is the most effective solution.


Indications of Proton Beam Therapy in Brain Tumours:


  • Paediatric Brain Tumours (Medulloblastoma, Ependymoma, Craniopharynigiomas, Germ cell tumours, embryonal cell tumours, progressive/residual low-grade gliomas, etc)
  • Skull base Tumours (Chordoma, chondrosarcoma, epithelial skull base cancers, etc)
  • Benign Tumours (Meningioma, Vestibular Schwannoma, Acoustic Neuroma, AVM)
  • Pituitary Gland Tumours
  • Pineal Tumours
  • Re-irradiation in transformed gliomas and other CNS tumours
  • Low & High-grade tumours

TomoTherapy


TomoTherapy is the combination of intensity-modulated radiation delivered with the precision and accuracy of computed tomography scanning technology. This integrated approach is a powerful weapon to fight brain tumours. At APCC we use state of the art and latest technologically advanced Radixact system for our TomoTherapy procedures.


Stereotactic radiosurgery


Stereotactic radiosurgery (SRS) is a non-surgical radiation therapy used to treat functional abnormalities and small tumours of the brain. It can deliver precisely-targeted radiation in fewer high-dose treatments than traditional therapy, which can help preserve healthy tissue.


Craniospinal Irradiation


When the tumour has spread along with the covering of the spinal cord or into the surrounding cerebrospinal fluid, then radiation may be given to the whole brain and spinal cord. In these we use a whole brain and spinal cord radiation therapy referred to as craniospinal radiation.


Chemotherapy

Chemotherapy is the treatment of certain types of brain tumours with cytotoxic drugs. Chemotherapy is useful for a variety of brain tumours including lymphomas, medulloblastomas, germ cell tumours, PNET and some gliomas. Commonly used drugs used for brain tumours are CCNU, BCNU, vincristine, Cisplatin, Temozolomide etc. Generally, these drugs are given in combination every 4 to 6 weeks to a maximum of 6 cycles. Sometimes, if one combination of drug regimen stops working for the tumour, another drug or a combination (2nd line) may be tried. Most of the chemotherapy treatment may be administered on an OPD basis although some may require admission. Blood tests for hemoglobin, white blood count, platelets and sometimes, liver and kidney function tests are done before each cycle of chemotherapy.

Cancer Immunotherapy

Brain Tumours is one of the major cancer types for which new immune-based treatments are currently in development. Current immunotherapies for brain cancer fall into six broad categories: cancer vaccines, checkpoint inhibitors, oncolytic virus therapy, adoptive cell therapy, adjuvant immunotherapies, and monoclonal antibodies.


Our team of oncologists is highly experienced and trained in the field of immunotherapy and would be working with close liaison with other experts to select the appropriate patients for this treatment after careful evaluation of its indications, potential benefits vis a vis risk etc.


Rehabilitation after treatment


  • Physical therapists will assess the patient’s ability to walk safely and climb stairs before being released from the hospital. They may also help the patient improve strength and balance.
  • Occupational therapists will assess the patient’s ability to perform activities of daily living such as getting dressed, using the toilet and getting in and out of the shower. Occupational therapists also test the patient’s vision and thinking skills to determine whether the patient can return to work, driving or other challenging tasks.
  • Speech-language pathologists: If the patient’s brain tumour affects speech, speech-language pathologists will evaluate problems with speech, language or thinking. They may also evaluate the patient for swallowing disorders.
What can I eat?

The treatment and management of brain tumour may affect nutrition and diet. You may find it difficult to eat what you normally do, and as a result, loss of nutrition can worsen your problems. While no special diet is required in most patients, a well-balanced diet will enable you to:


  • Tolerate your treatment better.
  • Improve your body's ability to fight infection and thereby reduce other problems that may arise during and after treatment.
  • Maintain your weight at a suitable level or regain lost weight.

If required, meet your hospital or the dietician for advice. The dietician will, after consultation with you regarding your normal food intake, plan out a balanced, nutritionally-enriched diet to overcome nutritional deficiencies you may face. Generally, there are no dietary restrictions for brain tumour patients. It is also advisable to check with your doctor if you plan to smoke, drink, or take any other stimulants or medicines as this may affect your treatment. Food supplements can be provided free of cost to needy patients. Please ask your doctor for more details.

Winning Over Cancer

Our Medical Director Dr. Rakesh Jalali emphasises on the key steps that include comprehensive care and safety measures to be taken by the general & neuro-oncology communities for brain tumour treatments during COVID-19.

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From the desk of Medical Director. 5 tips to ensure the health & safety of patients from an oncology perspective during COVID-19. He also explains how hospital authorities can help patients and their families with the right information about treatments during this challenging time.

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Watch the exclusive session on Cancer Management during Covid-19 by Dr Rakesh Jalali, Medical Director- Radiation Oncology at Apollo Proton Cancer Centre. He elucidates on how cancer care is being affected globally and throughout the country by COVID -19 and how one should face and be prepared to protect during these tough circumstances.

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For treating a patient, more than adavnced treatment techniques, ensuring an enhanced quality of life during and after treatment is important. - Dr Rakesh Jalali, Medical Director & Head - Neuro Oncology

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Dr. V.R Roopesh Kumar, Senior Consultant & Lead, Neurosurgery talks about the journey of our international patient Mrs.Jebin who flew down from London for treating her mother who had a highly complicated block in the vessel that carries blood to the right brain.

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Mr. Abhilash from Bangalore takes us on an emotional journey of his son's treatment. Further, he explains how Dr Rakesh Jalali, Dr Roopesh and the entire team at APCC took care of his son despite the challenges due to the lockdown.

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Watch Dr. Arun Kati share his experience here, at Apollo Proton Cancer Centre.

He thanks Dr. Jalali, Dr. Srinivas Chilukuri, Dr. Anand Murgusen and the entire team for their constant support and care during the treatment.

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"Difficult roads lead to beautiful destinations."

Watch Mr Jayant Kumar Dubey as he shares his son's journey during proton therapy at Apollo Proton Cancer Centre. He thanks Dr. Jalali and the entire team at APCC for assisting them in transport needs during this lockdown period.

The joy in the kid’s parent's eyes is truly unmissable!

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Mr. Piyush from Raipur, Chhattisgarh shares his experience at Apollo Proton Cancer Centre where his grandfather was provided with proton therapy for metastatic cancer in brain.

He thanks the entire team for helping him and his grandfather with travel, accommodation and other necessary arrangements during this challenging time of lockdown.

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Here is a glimpse of Mr. Ahmed Mahmoud who fought against brain cancer with 17 operations before he approached Apollo Proton Cancer Centre where he was successfully treated through proton therapy. He said not to lose hope because every problem has a solution.

Thank you for sharing your experience with us. We wish you good health & happiness.

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Mrs. Meghana Sawardekar, who was diagnosed with Meningioma shares her experience at Apollo Proton Cancer Centre along with her husband Mr. Paresh Sawardekar.

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Watch the 1st part of the Sun News interview where Dr. Rakesh Jalali and Dr. Roopesh Kumar spoke about Neuro-oncology and the latest surgical & radiation advancements in cancer treatment.
They also spoke in detail about the significance of Proton therapy and how it is a matter of great pride & reassurance to the entire nation.

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Watch the 2nd part of the Sun News Tamil interview where Dr.Rakesh Jalali and Dr. Roopesh Kumar cleared the myths around brain surgeries and spoke about the latest advancements in tumor treatments and cure for hereditary cancers.

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"Watch the 1st part of the Sun News interview where Dr. Rakesh Jalali and Dr. Roopesh Kumar spoke about Neuro-oncology and the latest surgical & radiation advancements in cancer treatment.
They also spoke in detail about the significance of Proton therapy and how it is a matter of great pride & reassurance to the entire nation."

FOR APPOINTMENT

Watch the 2nd part of the Sun News Tamil interview where Dr.Rakesh Jalali and Dr. Roopesh Kumar cleared the myths around brain surgeries and spoke about the latest advancements in tumor treatments and cure for hereditary cancers.

FOR APPOINTMENT

Other Central Nervous System Tumours

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