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Frequently Asked Questions about the True Beam STx System

     True Beam STx is an advanced radio surgery system wherein it seamlessly delivers Intensity Modulated RT, Image guided RT, RapidarcTM, SRS & SBRT in synchronous with inbuilt Onboard Imaging device (OBI) and Real-time Position Management System (RPMTM) allow Radiation Oncology Team to tailor perfect treatment delivery

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It was engineered to perform noninvasive, image-guided radio surgery procedures with pinpoint accuracy and precision. It works by choreographing highly sophisticated imaging, treatment delivery and motion management technologies making it possible to deliver treatments more quickly while compensating for tumor motion. This opens the door to new possibilities for the treatment of challenging cancers throughout the body including those in the brain, spine, lung, liver, pancreas and prostate.

What is Radio surgery and how does it work?

Radio surgery is an effective treatment for many different types of cancer. It uses sophisticated technology to deliver very precise and accurate beams of radiation to a tumor while minimizing exposure to nearby healthy tissue. There are two main types of radio surgery—stereotactic radio surgery (called SRS), which is for cancers in the brain and spinal region, and stereotactic body radiotherapy (also called SBRT), for cancers in other parts of the body. Both of these treatments are noninvasive—that is, the body isn’t operated on in the traditional sense.

What is a True Beam STx treatment?

A doctor may prescribe treatment with TrueBeam STx for many reasons. This technology gives medical professionals the tools to treat many different types of cancers and other medical conditions.

TrueBeam STx is fast, with most treatments taking just a few minutes a day. A TrueBeam STx system can deliver treatments 2.4 to 4 times faster with a dose delivery rate of up to 2,400 monitor units per minute—double the output of most other radiosurgery systems. A radiosurgery treatment that typically takes 30 to 60 minutes can be completed in just 5 to 20 minutes. In addition to enabling for a more comfortable experience, as the patient spends less time on the treatment couch, faster treatments also allow for reduced chance of patient and tumor movement during treatment.

The precision of the TrueBeam STx system is measured in increments of less than a millimeter. This accuracy is made possible by the system’s sophisticated architecture, which choreographs imaging, patient positioning, motion management, beam shaping and dose delivery, performing quality checks every ten milliseconds throughout the entire treatment.

TrueBeam imaging technology can produce the three-dimensional images used to fine-tune tumor targeting in 60% less time than previous Varian imaging technology. Additional functionality makes it possible to create images using 25% less X-ray dose.

For lung and other tumors subject to respiratory motion, TrueBeam STx offers Gated Rapid Arc radiotherapy, which makes it possible to monitor the patient’s breathing and compensates for movement of the tumor while the dose is being delivered in a continuous rotation of the treatment machine.

In addition to its impressive technical specifications, TrueBeam STx has also been designed to address patient comfort. It operates quietly and has built-in music capabilities so the patient can listen to music during their treatment. The therapist who operates the system can be in constant two-way communication with the patient. Plus the therapist can visually see the patient through three closed-circuit monitors.

What kind of radiation does TrueBeam STx use?

The treatment beam is generated by a machine called a medical linear accelerator. This machine shapes beams of energy with varying intensities generated by the machine. The treatment beam can be aimed at a tumor from multiple angles to hit the target in a complete three-dimensional manner. In fact, TrueBeam STx’s treatment beam can be delivered with sub millimeter accuracy and varying intensity. The idea is to deliver the lowest dose possible to the surrounding healthy tissue, while still delivering the maximum dose to the tumor.

Does radiosurgery expose people to radioactive substances?

Many people, when they hear the word “radiation,” think immediately of radioactive substances. However, no radioactive substances are involved in the creation of the beam by a medical linear accelerator. When a linear accelerator is switched “on,” radiation is produced and aimed directly at cancer cells. Then, like a flashlight, when the system is switched off, radiation is no longer emitted by the system.

What happens when a person is treated with radiosurgery?

Radiosurgery treatment, including TrueBeam STx treatment, involves three basic steps: visualization of the tumor, the planning of the individual treatment and the delivery of the treatment.

After their diagnosis, the medical physicist generates three-dimensional diagnostic images (usually CT or MRI) of the tumor and the area around it. They then use these images to specify the dose of radiation needed to treat the tumor. A radiation oncologist will work with a physicist to plan an individualized treatment. After this, individualized TrueBeam STx treatments can be delivered according to a schedule specific to the treatment plan.

During a TrueBeam STx treatment, the linear accelerator can rotate around the patient to deliver the radiation. The radiation is shaped and reshaped as it is delivered from many different angles. Most treatments usually take only a few minutes a day.

Treatment Preparation

X-rays and/or CT scans may be taken in preparation for planning the treatment. Following these scans, the treatment planning process can take several days. When the treatment plan is complete, TrueBeam STx radiosurgery treatments can begin.

Most cases require a treatment preparation session. Specially molded devices that help the patient maintain the same position every day are sometimes developed at this point. The patient’s radiation oncologist may request to have the treatment area marked on their skin to assist in aligning the equipment with the target area.

Treatment Delivery

The first TrueBeam STx treatment session may sometimes be longer than subsequent ones so that additional images can be acquired to check the positioning of the tumor on the day of the treatment. This is at the discretion of the treatment team.

In the treatment room, the medical team uses the marks on the patient’s skin to locate the treatment area. Then the patient is positioned on a treatment table. Sometimes, specially molded devices are used to help the patient stay still and provide correct positioning.

The radiation therapist can also use the machine’s imaging technology to position the patient for a treatment that is accurate to less than a millimeter. This involves the use of high-resolution X-rays of the targeted area to verify positioning of the tumor before administering the treatment.

The radiation therapist then leaves the treatment room before the machine is turned on. The machine rotates around the patient to deliver the radiation beams, which are shaped by a special attachment called a high-definition (HD) multileaf collimator. This HD device has 120 computer-controlled mechanical “leaves” or “fingers” that can move to create apertures of different shapes and sizes.

Who are the professionals a patient may typically encounter?

  1. The radiation oncologist is a doctor who has had special training in using radiation to treat diseases and prescribes the type and amount of treatment. The radiation oncologist may work closely with other doctors and the rest of the healthcare team.
  2. A medical physicist participates in the planning process and ensures that the machines deliver the right dose of radiation.
  3. A dosimetrist plans the treatment with the oncologist and the physicist.
  4. A radiation therapy nurse provides nursing care and may help the patient learn about treatment or how to manage any side effects.
  5. A radiation therapist positions the patient for treatment and operates the equipment that delivers the radiation.

How long is a course of treatment on a TrueBeam STx system?

The delivery of a patient’s treatments varies depending on the diagnosis, so ask the medical professional for information about their specific diagnosis. Generally, radiosurgery is completed in just one to five treatment sessions over a week or two.

What is Radio surgery and how does it work?

External radiosurgery does not cause anyone’s body to become radioactive. A patient need not avoid being with other people because of treatment. Even hugging, kissing, or having sexual relations with others pose no risk to them of radiation exposure.

Side effects of radiosurgery most often are related to the area that is being treated. A patient should consult with their medical professional to discuss the specific diagnosis, prognosis and possible side effects* from treatment.

What is unique about radiosurgery using TrueBeam STx system?

The main advantages of TrueBeam STx are ease, precision and speed. Thanks to its unprecedented accuracy, the TrueBeam STx system can be used to treat some tumors in sensitive areas such as the brain, spine, lung, liver, pancreas and prostate.

 Treatments focus powerful radiation on the tumor while minimizing exposure of surrounding healthy tissues. TrueBeam STx was designed from its inception to seamlessly integrate sophisticated imaging and radiation delivery systems. What this means for patients is accuracy, speed and comfort. What it means for medical professionals is the ability to treat many different types of complex conditions.

Chemotherapy

The care team often first meets when your cancer is diagnosed. It includes all of the health professionals involved in

  • Diagnosing and treating your cancer.
  • Managing symptoms and side effects.
  • Providing support to manage feelings or concerns that may arise during your care.

Our team may include surgeons, oncologists (specialists), pathologists and radiologists, specialist nurses, psychological services, allied health and palliative care services as needed through to survivor-ship or palliative care

  • Comprehensive cancer care is given in coordination with volunteer, psychological ,physiotherapist.

Day Care Center with exclusive specialized staff trained in oncological emergencies and anti cancer drug administration.Majority of chemotherapy is done on day care basis.

  • Chemotherapy, Immunotherapy and Targeted therapy and Autologus transplants are done routinely.
  • Chemotherapy drug mixing is done at separately designated area under laminar-hood flow to ensure patent safety and to prevent health hazard. In order to make administration of chemotherapy safe and more patient friendly, use of Central catheter and Ports is routine in the department. The department is backed up by modern and highly efficient blood bank offering facility for blood and blood components round the clock.

Site specific specialists man the discipline of oncology so that the best possible results can be delivered in this field of cancer therapy. The specialized services available are for

  • Breast Cancer
  • Colorectal cancer
  • Endocrine tumors
  • Gastrointestinal & Hepatic tumors (Liver, Pancreas, Intestinal etc.)
  • Head & Neck Tumors
  • Neuro Oncology
  • Soft Tissue & Bone tumors
  • Plastic & Reconstructive surgery
  • Thoracic Surgical oncology
  • Uro oncology

Reconstruction After Cancer Surgery

The different techniques used in surgically treating cancers can be life saving, but they may leave a patient with less than pleasing cosmetic or functional results.

Depending on the location and severity of the cancer, the consequences may range from a small but unsightly scar to permanent changes in facial structures such as the nose, ear, or lip.

In such cases, no matter who performs the initial treatment, the plastic surgeon can be an important part of the treatment team. Reconstructive techniques- ranging from a simple scar revision to a complex transfer of tissue flaps from elsewhere on the body-can often repair damaged tissue, rebuild body parts, and restore most patients to acceptable appearance and quality of life. Dr Naveen Rao, Consultant Plastic Surgeon, Apollo hospitals, Bangalore, discusses with us, the techniques and methods involved in reconstructive surgery.

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For which kinds of cancers typically do you do reconstruction?

In the treatment of cancers, it is mainly 3 modalities that play important roles – surgery, radiotherapy and chemotherapy. While surgery in certain areas [like removal of part of the stomach or colon etc] do not need reconstruction, large defects following removal of tumors elsewhere, particularly in the region of the head and neck, will need reconstruction. This is particularly important to preserve important functions like speech, chewing and swallowing etc.

What is the process of assessment?

The need for reconstruction is based on an assessment of the likely functional and structural loss after major excisional surgery, which could be very mutilating and disabling without reconstruction. For example, in a person with a tumor of the tongue, a large excision may be needed, sometimes even including half the mandible [jaw bone]. Such a resection will inevitably leave a major disability in speech and swallowing unless a good reconstruction is done.

What would be the quality of Life after reconstruction?

Reconstructive techniques have dramatically improved in the last 3 to 4 decades, thanks to a vastly improved understanding of anatomy and physiology as well as a quantum leap in operative techniques like microvascular surgery. Earlier, plastic surgeons were restricted in their repertoire by the availability of tissues in the vicinity of the excised defect, which was quite often inadequate or of poor quality, or both. However, all this has changed, thanks to “microvascular tissue transfer”. Essentially, this consists of safely and precisely removing tissues from elsewhere along with their blood supply, shaping and contouring them as required, transferring them to the defect and connecting the artery and vein to new blood vessels near the defect, thus providing a healthy and viable reconstruction immediately following the resection. Even complex and extensive resections can be and is commonly safely performed and reconstructed by such techniques with success rates of over 95 %. The donor sites [from where the tissues are taken] are chosen in such a way as to minimize the discomfort and morbidity that can arise from removal of tissues.

What are some of the new techniques in reconstructive surgery ?

Tissue expansion, as a technique in plastic surgery, was a relatively new concept 4 decades ago, but is now fairly firmly established.

In essence, it is a technique that grew out of simple observation of a common event like pregnancy and practical application of the principle that all living things respond in a dynamic fashion to the mechanical stresses placed upon them!

In the medical world it was CG Neuman, in 1957, who was the first to expand skin by using an inflatable balloon. Radovan, after 2 decades, successfully expanded an arm flap using a temporary tissue expander. He used this to cover an adjacent defect after removal of a lesion.

Till then, the options for providing skin to cover defects were either to use skin grafts or flaps. Grafts are basically tissues, which are transferred from one part of the body to another.

Flaps, on the other hand, are tissues, which are transferred to neighboring skin regions while retaining some attachment to their parent area of origin.

While tremendous advances have been made in the understanding of anatomy and considerable sophistication has been achieved in the techniques for flap transfer, nevertheless the basic disadvantage of depriving one part of the body to provide for another part remains. In addition, there are issues pertaining to color and thickness mismatch, poor sensation and viability of the transferred skin. Tissue expansion, on the other hand, utilizes extra tissue generated by expanding normal skin, uses adjacent skin which most closely resembles the lost skin, and retains most of the sensation.

Essentially, the concept as well as the technique is fairly simple. When an expected skin defect [say, after removing a burn scar, birthmark or tattoo] cannot be adequately closed by suturing the adjacent margins together, a silastic bag of an appropriate size is buried in the plane below the adjacent normal skin in a surgical procedure. This is connected by a short piece of tubing to a small silastic dome called port, which is also usually buried under the skin a short distance from the bag. Once the surgical wound has healed, in about 2 weeks, the bag is inflated by injecting saline through the port at regular intervals, usually once or twice a week. The enlarging balloon slowly expands the normal skin and although some amount of thinning takes place, a considerable portion of the expanded skin is newly generated by the stress imposed on it. When the surgeon feels that enough skin has been generated, the bag and the port are removed, the lesion [scar, birthmark or tattoo as the case may be] is excised and the extra skin is advanced to close the wound.

Several expanders can be placed at the same time [this author has placed 5 at a time] in different areas so that time can be saved on the overall reconstructive procedure. Two types of expansion are recognized and used clinically today: prolonged tissue expansion (PTE), in which expansion occurs over 1-6 weeks, and rapid intraoperative tissue expansion (RITE), in which the expansion is performed cyclically in the operating room. Prolonged tissue expansion allows resurfacing of even wider defects with neighboring skin similar in color, texture, sensation, and retained adnexal structures like sweat glands and hair follicles. The uses of such a simple technique are obvious – the coverage of skin defects following excision of tumours, scar etc with good quality skin especially where there is need for specialized skin like the hair bearing scalp or for coverage of newly reconstructed organs like the ear etc. It is no surprise that the technique has found ready acceptance among reconstructive surgeons around the world.

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Targeted Therapy

Cancer therapy is getting smarter, with new drugs that act specifically against cancer cells. Targeted therapy is a new type of cancer treatment that uses drugs or other substances to identify and attack cancer cells while doing little damage to normal cells.

Targeted therapies are a major focus of cancer research today. Many future advances against cancer will likely come from this field.

Cellular Changes during Cancer

Normally, cells grow and divide to form new cells as the body needs them. Sometimes this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor.

The cells in malignant (cancerous) tumors are abnormal and divide without control or order. They can invade and damage nearby tissues and organs. Also, cancer cells can break away from a malignant tumor and spread to other parts of the body.

Alterations in two types of genes can contribute to the cancer process. Proto-oncogenes are normal genes that are involved in cell growth and division. Changes in these genes lead to the development of oncogenes, which can promote or allow excessive and continuous cell growth and division. Tumour Suppressor genes are normal genes that slow down cell growth and division. When a tumor suppressor gene does not work properly, cells may be unable to stop growing and dividing, which leads to tumor growth.

These changes happening in the genes can lead to the production of abnormal proteins. Cancer develops when abnormal proteins inside a cell cause it to reproduce excessively and allow that cell to live longer than normal cells.

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Targeted therapy

Targeted therapy is a general term that refers to a medication or drug that targets a specific pathway in the growth and development of a tumor. Targeted therapy agents work by targeting specific PROTEINS and processes that are limited primarily to cancer cells or that are much more prevalent in cancer cells. Inhibition of these processes prevents cancer cell growth and division.

Mode of action of Targeted Therapies

Targeted cancer therapies interfere with cancer cell growth and division in different ways and at various points during the development, growth, and spread of cancer.

Many of these therapies focus on proteins that are involved in the signaling process. By blocking the signals that tell cancer cells to grow and divide uncontrollably, targeted cancer therapies can help to stop the growth and division of cancer cells.

Types of Targeted Therapy

Tyrosine kinase receptor inhibitors

A tyrosine kinase receptor is a molecular structure or site on the surface of a cell that binds with substances such as hormones, antigens, drugs, or neurotransmitters. When it binds with one of these triggering substances, the receptor performs a chemical reaction, which in turn triggers a series of reactions inside the cell. Examples of these drugs would be Gefitinib, Erlotinib,Trastuzunab etc.

Angiogenesis inhibitors

Tumor cells, like normal cells, need an adequate blood supply in order to perform vital cellular functions. This new blood vessel formation is called angiogenesis and the proteins that trigger this process are called proangiogenic factors.

The main proangiogenic factor is VEGF, which stands for vascular endothelial growth factor. In essence, by secreting VEGF and other related proteins to stimulate new blood vessel growth, tumors support and feed themselves, allowing them to grow. The concept behind angiogenesis inhibition, then, is to thwart this process and thereby fight tumor progression. Bevacizumab is one example of this category of drig.

Proteasome inhibitors

The proteasome is a structure inside the cell which breaks down proteins that have been labeled to undergo degradation and recycling. By binding part of the proteasome, a drug can inhibit the breakdown of some of these proteins that have been marked for destruction. Example would be a drug like Bortezomib.

Immunotherapy

Targeted immunotherapy agents bind to their targets, not to interfere with growth signals, but rather to trigger immune signals.Targeted immunotherapy drugs are essentially a collection of monoclonal antibodies, all of which have different targets. Antibodies are proteins that seek out and bind to specific antigens; every antibody has a particular antigen with which it "fits". Antibodies are named for the antigen that they bind, eg: the anti-CD20 antibody binds to the antigen CD20. When there is a radioactive substance (radioisotope) attached, these drugs are called radio-immunotherapy agents. Example - Rituximab, Tositumomab, Ibritumomab.

Antisense oligonucleotide drugs

Antisense oligonucleotide drugs offers the ability to target almost any cellular process with complete specificity. If a protein is helping a cancer cell to grow, then the appropriate antisense oligonucleotide could be used to prevent that protein from ever being made.

Drugs that affect Molecular receptors

Our cells constantly monitor their surroundings for the presence (or sometimes an absence) of regulatory molecules in the environment. These signals control decisions regarding cell division, movement and even death. Many diseases like Cancer, can be traced back to dysfunctional signaling pathways. In cancer these malfunctions may lead to unregulated cell division and the development of tumors. Particular signaling pathways are often affected in a given type of cancer. Drugs designed to inhibit these specific signaling pathways promise to inhibit cancer growth without harming normal cells. Example - Bexarotene, Denileukin diftitox.

Advantages of Targeted Therapy

Reducing Toxicity

• One significant advantage that targeted therapies have over most traditional therapies is that they tend to be less toxic to non-cancerous cells.

• Because they tend to have fewer effects on non cancer cells and therefore tend to be less toxic, targeted agents are particularly amenable to use in combination with other agents since their combined side effect profiles would still be acceptable

• The advantage of the less toxic targeted therapy is that it can be given to patients with poor performance status who may not otherwise be candidates for cytotoxic treatment.

The Future of Targeted Therapies

Early trial data presented at basic and clinical science meetings continue to shed light on the more promising drugs, and help to identify the most effective regimens and/or sequence of regimens of these agents when used in conjunction with traditional cytotoxic therapies.

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