Breast Cancer:

Breast Cancer is the commonest cancer in women in most of India’s metros. Each year, more than 80,000 women in this country develop breast cancer. Breast cancer is the uncontrolled growth of breast cells. Cancer occurs as a result of mutations, or abnormal changes in the genes responsible for regulating the growth. Normally, the cells replace themselves through an orderly process of cell growth, healthy new cells take over as old ones die out. But over time mutations can ‘turn on’ certain genes and ‘turn off ‘ others in a cell. The changed cell gains the ability to keep dividing without control or order, producing more cells just like it and forming a tumour. A tumour can be benign (not dangerous to health) or malignant (has the potential to be dangerous). Benign tumours are not considered cancerous: their cells are close to normal in appearance, they grow slowly, and they do not invade nearby tissues or spread to other parts of the body. Malignant tumours are cancerous. Left unchecked, malignant cells eventually can spread beyond the original tumour to other parts of the body. Usually breast cancer either begins in the cells of the lobules, which are the milk-producing glands, or the ducts, the passages that drain milk from the lobules to the nipple. Less commonly, breast cancer can begin in the stromal tissues, which include fatty and fibrous connective tissues of the breast. Over time, cancer cells can invade nearby healthy breast tissue and spread to the underarm lymph nodes and to ther parts of the body.

Breast cancer is always caused by a genetic abnormality. However, only 5-10% of cancers are due to an abnormality inherited from mother or father. About 90% of breast cancers are due to genetic abnormalities that happen as a result of the aging process of life in general.
DIAGNOSIS

When a woman finds an abnormal mass on examination or an abnormal area is detected by screening mammogram, a careful history and physical examination should be carried out. A thorough physical examination of the breast should be done by a doctor. The specialists at Apollo who treat breast cancer include surgical oncologists, medical oncologists and radiation oncologists.
TREATMENT

Breast cancer is considered to be a systemic disease to start with, in majority of the cases. This does not mean that there is an obvious cancer at different sites. It only means that while the primary disease in the breast is obvious, there is the possibility of microscopic disease elsewhere, which is not detectable, but all the same needs treatment. Hence treatment is required for local area and distant sites. Local treatment is removal or destruction of the local tumour by either surgery or radiation. The treatment of distant sites is either by chemotherapy or hormonal treatment. Patients may need one form of treatment or require four forms of treatment either simultaneously or in sequence.
SURGERY

Surgery is the most common treatment for cancer, where the breast or part of it is removed. Reconstructive surgery can be by an artificial implant between the skin and chest wall or by the woman’s own tissues. The tissues can be taken either from the abdomen or from the back. Other procedures include sentinel lymph node biopsy (SLNB) where the sentinel lymph node is identified, removed, and examined to determine whether cancer cells are present.
RADIATION THERAPY

In common terms it is called ‘heat’ therapy where a high-energy x-ray beam is used to damage cancer cells. Radiation is also of two types:

External radiotherapy and
Implantation radiotherapy (also called Brachy therapy)

When external radiotherapy to the breast or chest wall is given post operatively the treatments are usually given for 5 days a week for 5 or 6 weeks. At the end of this an extra boost is usually given at the site of the breast tumour removal. The boost may be external or by using an implant.
CHEMOTHERAPY

Drugs are used to kill cancer cells. In the current setting drugs by themselves will not cure breast cancer. Usually more than two drugs are used. Usually these drugs are given by injections. The injections can be given in outpatient sitting day care or after short admission to the hospital depending on which drugs are used. General condition of the patient also dictates a short stay in the hospital. When chemotherapy is given after surgery and is called adjuvant chemotherapy and in this setting it is used to take care of microscopic disease elsewhere. When it is given before surgery is called Neoadjuvant chemotherapy and in this setting the purpose is to reduce the size of a large tumour, and make it surgically removable. Whether it is adjuvant or Neo-adjuvant – it is administered several times over a period of months with breaks between treatments.
HORMONAL THERAPY

Hormonal therapy is used as oral tablets such as Tamoxifen, Raloxifen or Letrazole which block the cancer cell from taking up oestrogen from the blood. Oestrogen promotes the growth of breast cancer. This is usually given to those patients in whom cancer cells are hormone receptor positive (oestrogen and or progesterone receptor positive). Sometimes the same effect is obtained by removing the source of oestrogen (overies). Like chemotherapy, hormonal therapy is also given to control systemic disease elsewhere.

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Apollo Hospitals

Cordocentesis:

Cordocentesis — also known as percutaneous umbilical blood sampling — is a highly specialized prenatal test in which a sample of the baby’s blood is removed from the umbilical cord for testing.

Cordocentesis can be used to detect certain blood conditions and infections. Cordocentesis can also be used to deliver blood transfusions and medication to a baby through the umbilical cord.

Use of cordocentesis is decreasing, however, since newer forms of technology can sometimes provide the same information from tests that pose a smaller risk of miscarriage — such as amniocentesis or chorionic villus sampling.

Cordocentesis might be offered when:

The desired information can’t be obtained any other way
Results from other prenatal tests are unclear
Test results might have a significant impact on the immediate management of the pregnancy

Cordocentesis is used primarily to detect and treat blood conditions, such as fetal anemia — a lack of healthy red blood cells in a developing baby.

If you have an infection, cordocentesis might be used to determine whether the baby has the infection, too.

If necessary, cordocentesis can be used to deliver blood transfusions and medication to the baby through the umbilical cord.

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Fortis Hospitals

What is Fetal Surgery

We offer the full spectrum of feral therapies except FETO or open fetal surgery at present.

Fetal surgery is a highly complex surgical intervention to repair birth defects in the womb that requires the most expert care for both mother and unborn baby.

Its estimated that there would be about 487,000 babies born with birth defects in India, out of these 7200 per year are in Delhi. Maternal-fetal specialists have long known that some birth defects could be successfully treated after birth. But as technology, fetal imaging and prenatal testing have improved in the past few decades, so too has our knowledge of fetal development.

Expanded diagnostic tools have allowed us to identify more precisely when conditions worsen during fetal development. This knowledge has helped us develop new ways to help babies sooner. Today, fetal therapy is recognized as one of the most promising fields in fetal medicine, and prenatal surgery is becoming an option for a growing number of babies with birth defects.

We follow the principles laid down in 1982 when fetal surgery was first contemplated.
Pre-requisite for considering fetal surgery*
Fetal conditions which warrant in utero therapy are usually simple structural defects that interfere with normal fetal development but if corrected will allow normal development to proceed
Accurate prenatal diagnosis
Exclusion of associated structural and genetic abnormalities
Normal fetal karyotype
An understanding of the natural history of the disease with established prognosis – fetal intervention is justified only if there is a reasonable probability of benefit from it
Serial evaluation of the fetus to differentiate those with mild disease who may not need intervention from those with severe disease who will not survive without intervention
Therapy proven to be useful at least in animal models
Informed consent after detailed discussion with the family regarding risks and benefits including long term outcomes
Multidisciplinary team comprising obstetrician with interest in high risk pregnancy, fetal medicine specialist, neonatologist, paediatric surgeon and psychologist
Centre equipped with the logistics, instruments, expertise and intensive care nursery to deal with these uncommon procedures

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Apollo Hospitals

Rhinoplasty:

Rhinoplasty is a surgical procedure to improve the function or the Appearance of a human nose.

In rhinoplasty one or more of the following are done

* Elevation of a depressed nose by adding cartilage
* Bone or silicone implant
* Removal of a hump
* Reduction of the bulk of the tip
* Narrowing of the nasal bones elevation of the tip of the nose
* Reduction of the size of the nostrils
* Narrowing of the base of the nose

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Apollo Hospitals

Single Incision Laparoscopic Surgery:

One of the latest additions to Bariatric surgery is the new technique of port entry called the Single Incision laparoscopic Surgery. SILS is the next generation of laparoscopy, where the access is only through a single port instead of multiple ports. This utilizes new specialized port and roticulator instruments thus making the procedure literally scarless as it will be buried inside the belly button. This procedure though consumes more time, gives early post operative recovery with less pain than in conventional laparoscopy thus making it a treatment of choice for patients.

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Apollo Hospitals

What is Bone Marrow Transplantation?

Bone Marrow Transplantation is a form of intensive treatment used to treat certain cancers like leukaemias, lymphomas and some non-cancerous diseases like thalassaemia.

Bone marrow is found inside our bones, and is the ‘factory’ that makes blood. It is responsible for producing white blood cells (to protect against infection), red blood cells (to carry oxygen around the body) and platelets (to prevent bleeding). Stem cells are blood cells at their earliest stage of development in the bone marrow, before they have become committed to developing into white cells, red cells or platelets. It is these ‘mother’ cells which are the key factors in transplantation.
What are the different types of bone marrow or stem cell transplantation?

There are two main types of transplants – Autologous and Allogeneic.

Autologous Transplants: This means that the bone marrow or stem cells used for the transplant are one’s own. A little bit of the patient’s bone marrow or stem cells is taken and stored before high dose treatment. When the treatment is over, the bone marrow or stem cells are given back through a vein.

Allogeneic Transplants: In this type of transplant, bone marrow donated by someone else is used. It is essential that the donor’s tissue matches. The most suitable donor is usually a close relative, most commonly a brother or sister. It is possible to get a good match from an unrelated donor, but this facility does not exist in India.

What is the basic process?

There are three main steps in the transplantation process

The first step is the collection of the bone marrow or stem cells (the harvest) from the donor. We now know that the umbilical cord blood is also a rich source of stem cells.

The second step is to completely destroy the existing bone marrow and thereby help the patient receive the new stem cells.

The third step is to infuse the bone marrow or the stem cells through the intravenous route, like a blood transfusion. There may be no signs of a new bone marrow growing for two to three weeks, and occasionally it may be a few months before the new bone marrow produces all the components of the blood adequately.
How does one prepare for transplantation?

Having a transplant can be very demanding, physically and emotionally, and the family and friends too, may find this very stressful. It may help if patients can talk about their fears and concerns.

It is important to understand why one is having the transplant and what the actual processes will be, so that the patient can make practical arrangements and also prepare himself or herself mentally. It is a good idea to discuss the entire process with the doctors and nurses involved, before the patient goes into hospital.

Here are some questions one may like to ask:

What are the benefits of the treatment?
What are the risks of the treatment?
How will the transplant affect the way I live?
Will I be able to have children after a transplant?
How long will it be before I can start leading a normal life again?
What are the other treatments available to me?
Can one predict how the disease will progress?
Who can visit me?
Will my treatment make me feel too unwell to see people?
Is there a television in the room?
Is there a telephone link in the room?
Can I bring in my own clothes?
What do you suggest that I bring to the hospital to make my stay more comfortable?
Where can the attenders stay?

Being fully informed and prepared will help to make the transplant process easier for the patient and the family.
Who can be a donor for an Allogeneic transplant?

Matching bone marrow is done by blood tests alone. It is not necessary to test the donors bone marrow at this stage.

It is usual to start by testing the brothers and sisters, as they are likely to provide the best match; parents are not usually good matches.

The donor should be in good health. He or she will be given a thorough medical checkup to make sure that there will be no risk to his or her own health from the procedure.
Collecting bone marrow

About a week or two before the bone marrow harvest is done, the patient (or the donor, for an Allogeneic transplantation) may have 1 to 2 units of blood withdrawn. This will be given back during the bone marrow harvest.

The harvest itself is carried out under general anaesthesia, so one will feel nothing. It involves the removal of some marrow from inside the bones at the back and front of the pelvis (the hip bones).

The patient or donor will have to stay in hospital overnight to recover fully from the general anaesthesia. Usually it feels sore for a few days and mild painkillers may be required. These will be administered by the nurses or doctors.
How are the stem cells collected?

Stem cell harvesting is done following a course of daily injections of a growth factor. This procedure takes about 3 hours. The patient will be made to lie down on a couch and a transfusion will be put into the vein of each arm. Blood will be collected from one arm, into a machine called a centrifuge, which spins it to separate out the stem cells. These are collected, and the remaining blood is returned through the IV in the other arm. The stem cells can even be frozen.
What is Umbilical Cord Blood Transplantation?

Many children and young adults with serious blood diseases, such as leukaemia, need a bone marrow transplantation to give them a chance to live. Unfortunately a marrow donor cannot always be found. Sometimes searching for a donor takes so long that the patient dies before a compatible donor is available.

However, now a new source of blood forming stem cells has been found – Umbilical Cord Blood.

This is the blood that is left behind in the placenta and the umbilical cord after the delivery of a baby. Cord blood is rich in stem cells and can be used instead of bone marrow for transplantation.

The stem cell in the cord blood is of high quality and very potent in producing blood cells. Cord blood transplants appear to cause less serious immunological side effects. The ‘matching’ between donor and recipient appears to be less critical. This means that the chance of finding suitable cord blood for transplantation is much greater than that of bone marrow.
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Apollo Hospitals

Treatments for Kidney Disease
Dialysis

Dialysis is the process of removing wastes and impurities from the blood and is done when a person’s kidney doesn’t function properly, due to kidney failure, severe diabetes, a congenital kidney disease, hypertension or other health problems.

Dialysis is a form of renal replacement therapy. Dialysis can be done for a short period, in case the patient is waiting for a kidney transplant. If the patient doesn’t qualify for the transplant, life-long dialysis will be needed.

There are two types of dialysis:
Hemodialysis

In hemodialysis, a machine called a dialyser is used to filter the blood. A catheter is placed in a vein in the arm, and a needle inserted into this catheter is connected to a tube that carries blood into the dialyser. In the dialyser, a semi-permeable membrane separates the blood from a dialysis fluid. The wastes in the blood pass through the membrane into the fluid, and the clean blood is sent into the body.
Peritoneal Dialysis

In peritoneal dialysis, the abdomen is filled with a glucose-based liquid through a small hole created in the peritoneal membrane (lining of the abdominal cavity). This solution cleans the blood of wastes.

Peritoneal dialysis can be done when the patient is performing regular activities. Such dialysis is called Continuous Ambulatory Peritoneal Dialysis. The patient will be trained to infuse and drain out the fluid a few times every day. Peritoneal dialysis can also be done with the help of a machine, at night, when the patient is sleeping.

Plasma exchange may be done along with dialysis, to filter clotting factors and unwanted proteins. Charcoal hemofiltration in which a charcoal layer is used to remove wastes from blood, a process similar to dialysis, may sometimes be used.

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Apollo Hospitals

Spondylosis:

The gradual deterioration of the disc between the vertebrae is referred to as Degenerative Disc Disease (DDD) or Spondylosis. Degenerative Disc Disease is very common affecting 40-50% of people over the age of 40 and becomes increasingly common as we age. It is a kind of wear and tear disease similar to osteoarthritis. Although it can occur at any spinal level, it is most common in the lumbar spine (low back). DDD can cause the discs to flatten losing their normal height. This disc height is important as it separates the disc above from the one below. When disc height is lost, the nerve pathways may become narrowed and cause nerve impingement, inflammation, and pain.

As the ‘discs’ degenerate, they become thinner. Sometimes the vertebrae develop small, rough areas which may irritate the nearby nerves. This causes troublesome symptoms like severe neck pain and stiffness and pain down the arms and hands.

Most patients tend to get better with medication and exercises. However occasionally the spondylotic changes can lead to compression of the spinal cord or the nerve roots and this may result in pain, numbness and weakness in the upper limbs (radiculopathy).

Cervical spondylosis is chronic degeneration of the bones of the neck (cervical spine) and the cushions between the vertebrae (inter vertebral disc). The treatment involves removal of worn out discs or bone spurs – depending on the underlying problem. If required the surgeon will fill the gap with a graft of bone or other implants made of metal combined with bone.

Patients have reported their symptoms as being as mild occasional backaches to chronic low back pain that is severe enough to limit their activities at work and play. The pain is typically mechanical in nature. This means the pain increases as more stress or load is placed on the low back. Bending, lifting, and twisting are the types of movement that may exacerbate DDD.
Management

Rarely does DDD require surgery. There are several non-surgical treatments including anti-inflammatory medication, physical therapy and exercise programs. Surgery is only considered when the patient’s symptoms are debilitating; interfere with activities of daily living, and non-surgical treatment has failed after a reasonable period of time, usually at least six months.

Fusion permanently stops the motion of the spine at the level of the degenerated disc. This helps to relieve pain. Fusion for DDD is best when limited to one or two discs. Fortunately we have five discs in the lumbar spine. The un-fused discs take over to provide adequate function of the lower back.

An artificial disc can also be inserted into the space after removing the entire degenerated disc. This surgery is done from the front. This restores disc height, improves spine function, and helps to eliminate debilitating pain.

Spinal Tumors

A spinal tumor or a growth of any kind – whether cancerous or not, can impinge on nerves, leading to pain, neurological problems and sometimes paralysis. The symptoms include loss of sensation or muscle weakness, especially in the legs, difficulty in walking, sometimes leading to falls and loss of bowel or bladder function.

Newer techniques and instruments enable surgeons at Apollo Hospitals, India to reach tumors or treat delicate injuries even in the most inaccessible areas. High-powered microscopes are used during surgery and in some instances even intradural tumors are removed. In select patients, Total Spondylectomy – removal of the entire vertebra is done as a definitive cure.

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Apollo Hospitals

Scoliosis

The spine has normal curves if seen from the sides and is seen as a straight column from the front. But in certain conditions the spine shows curvatures from the front and it is called scoliosis. The abnormal forward bending of the spine is called kyphosis.

Scoliosis is a term taken from a Greek word meaning curvature. During the 19th Century physicians thought poor posture was the primary cause of scoliosis. Today scoliosis is known to be either congenital (present at birth) or developmental and may be hereditary. The disease causes the spine to curve to the side usually in the shape of an “S” or “C”. The curvature is measured in degrees.

Adolescent Idiopathic Scoliosis is the most common type of spinal curvature. It occurs around the onset of puberty in otherwise healthy boys and girls. It is more common in girls. Physical signs may include uneven shoulders, one hip lower than the other, a rib hump when bent over at the waist and leaning to one side.

Whatever the patient’s age, the goal is to stabilize the spine to prevent additional curvature. Some patients with scoliosis are pain free and do not seek treatment until the deformity is noticed. Unfortunately, at that point it may be too late to treat the disease. The size of the curve is measured in degrees on an X-ray. The progression of scoliosis is monitored by periodic x-ray studies. When scoliosis is severe it may cause the spine to rotate, which can cause spinal spacing to narrow on the opposite side of the body.

While minor deformities may be treated non-operatively, more severe and progressive ones require surgery.
Surgical Management of Scoliosis

Surgical treatment of scoliosis is employed if the curvature at detection is of greater magnitude. The aim of surgical correction is to achieve a well-balanced spine in which the patient’s head, shoulders and trunk are centered over the pelvis. This is done by using instrumentation to reduce the magnitude of the deformity and obtaining fusion in order to prevent future curve progression.
Usage of Staples

A more recent development in the treatment of Scoliosis is the use of staples on the convex side of the curve, which correct and maintain the curve till the patient is skeletally mature. These staples allow differential growth to take place i.e. less growing speed on the stapled side than the concave side thereby correcting the curve as the child grows.

Special spinal implants made from Nitinol – a titanium based alloy has been studied extensively and is being employed clinically in a few centers in USA and Europe. The staples are in the shape of ‘C’ when they are manufactured at room temperature. When the staples are cooled to below freezing point the prongs become straight but clamp down into the bone in a ‘C’ shape when the staple returns to body temperature providing secure fixation. These are called Shape Memory Alloy (SMA) staples. As no fusion is done the child grows normally and even the residual deformity tends to improve with growth.

This novel procedure was performed for the first time in India at Apollo Hospitals, Chennai, on a 6-yr old girl, from a small town near Madurai, by the senior spine surgeon Dr. Sajan Hegde and his team.