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MULTI-DISCIPLINARY EXCELLENCE

At APCC, we believe that cancer is a complex enemy. Conquering cancer demands the coming together of the finest experts of specific cancer groups. This belief is best exemplified by our unique Cancer Management Teams (CMTs).

Each CMT is made up of specialists who come from diverse disciplines like Surgery, Radiation & Medical Oncology, Pathology, Rehabilitation, and more. Supporting these experts is our world-class staff that includes nurses, dieticians, therapists and clinical trial coordinators. These experts play a pivotal role in drawing up the treatment blueprint based on vast experience, the unique needs of the patients, and the collective expertise of the team.

MULTIPLE DISCIPLINES EMPOWER OUR SINGULAR FOCUS. ON YOU.

Our approach to cancer care is best defined by our unique Cancer Management Teams (CMTs). We believe that cancer is complex enemy; conquering it demands the coming together of the finest experts in specific cancer groups.

Each CMT, at the Apollo Proton Cancer Centre, is made up of specialists who straddle diverse disciplines like surgery, radiation & medical oncology, pathology, rehabilitation and several others. A CMT is further fortified by world-class support staff like nurses, dieticians, therapists and clinical trial coordinators. These experts play a pivotal role in drawing up the treatment blueprint based on vast experience, the unique needs of the patients and the collective expertise of the team.

The CMTs helm the entire disease management process and provide the crucial insights and leadership at every aspect of diagnosis and treatment. They play a pivotal role in drawing up the treatment blueprint based on vast experiential learnings, the unique needs of the patients and the collective expertise of the team.

The treatment plans prepared by the Cancer Management Teams are optimized for maximum efficacy because they are tailor-made to suit the needs to the patient. Each person, each case of cancer is different; the CMT’s deep repository of domain knowledge and collective experience ensures the focus is on individual patients and their unique and personal battle against cancer.


CNS BRAIN TUMOURS CMT

The Central Nervous System (CNS) is made up of the brain and the spinal cord. CNS tumours are abnormal cells in the brain and spinal tissue. Commonly referred to as brain tumours, these cancers are rampant and have an increasingly large global incidence.

Brain tumours that originate in the brain are called primary brain tumours; the ones that spread to the brain are known as metastatic brain tumours. These tumours can be benign or malignant - both of which require specialized treatment!

The CNS Cancer Management Group at APCC helps patients navigate the complex journey from their first visit to the Centre to post-treatment rehabilitation. The singular focus is to offer patients a personalized and comprehensive plan that leverages the inherent multi-disciplinary expertise of the team and recommends treatment protocols with the best possible outcomes and one which ensures the highest quality of life post treatment.

The CMT represents the confluence of cutting-edge science, unwavering patient focus and the strong emotional bedrock required to conquer the challenge of brain tumour. Under the guidance and leadership of Dr Rakesh Jalali, the CNS Cancer Management Team is constantly pushing the envelope to advance the clinical and basic science behind various brain and spinal cord tumours both benign and malignant including management of skull base tumours.


Skull base Tumours

In India, we have few institutes that offer programmes focused on skull base tumours. APCC is one of the specialized centres with a comprehensive programme that provides the best possible care for malignant and benign skull base tumours.

Our unique Cancer Management Teams (CMT) are comprised of leading experts, and support staff to give you personalized, complete care. Our specialists work together to devise a treatment plan keeping in mind the unique needs of the patients and the best, safest treatment options available.

The approach begins with an exchange of ideas and theories between our group of specialists after the patient’s first visit. This approach continues throughout the patient’s journey through diagnosis, treatment, rehabilitation and follow-up.


Skull base tumour types

Skull base tumours are grouped by location and the type of cells in the tumour. Where a skull base tumour begins can make a difference in the type of cancer cells. Location also can influence symptoms and treatment.



Skull Base Tumour Symptoms

Skull base tumours may not produce symptoms until they grow large. If they do have signs, they vary from person to person depending on where the tumour is and how fast it is growing

Skull base tumour symptoms may include:

Having one or more of these symptoms does not mean you have a skull base tumour. But you should talk to your doctor if you have any of these signs. They may mean you have other health problems.

Skull base Tumours

APCC is one of the few cancer centres in India with a comprehensive programme focused on malignant and benign skull base tumours. This high level of experience and expertise could make a difference in the success of your treatment.

APCC's CMT based approach to skull base tumours brings together renowned experts from many specialties to give you comprehensive, personalized care. A group of specialists meets regularly to discuss your unique needs and the best possible options available for you. This exchange of ideas sets the stage for delivering the highest level of care for skull base tumours. This approach begins the patient’s first visit and continues through diagnosis, treatment, rehabilitation and follow-up. The specialized team may include surgeons, radiation and medical oncologists, ophthalmologists, nutritionists, nurses and social workers – all united by their passion and expertise in the latest technology and techniques to diagnose and treat skull base tumours.

Skull Base Tumour Types

Skull base tumours are grouped by location and the type of cells in the tumour. Where a skull base tumour begins can make a difference in the type of cancer cells. Location also can influence symptoms and treatment.

Skull base tumours may start from:

Skull Base Tumour Symptoms

Skull base tumours may not produce symptoms until they grow large. If they do have signs, they vary from person to person depending on where the tumour is and how fast it is growing

Skull base tumour symptoms may include:

Having one or more of these symptoms does not mean you have a skull base tumour. But you should talk to your doctor if you have any of these signs. They may mean you have other health problems.

CNS BRAIN TUMOURS CMT

The Central Nervous System (CNS) is made up of the brain and the spinal cord. CNS tumours are abnormal cells in brain and spinal tissue. Commonly referred to as brain tumours, these cancers are rampant and have an increasingly large global incidence.

Brain tumours that originate in the brain are called primary brain tumours; the ones that spread to the brain are known as metastatic brain tumours. These tumours can be benign or malignant - both of which require specialized treatment!

The CNS Cancer Management Group at APCC helps patients navigate the complex journey from their first visit to the Centre to post-treatment rehabilitation. The singular focus is to offer patient’s a personalized and comprehensive plan that leverages the inherent multi-disciplinary expertise of the team and recommends treatment protocols with the best possible outcomes and one which ensures the highest quality of life post treatment.

The CMT represents the confluence of cutting-edge science, unwavering patient focus and the strong emotional bedrock required to conquer the challenge of brain tumour. Under, the guidance and leadership of Dr Rakesh Jalali, the CNS Cancer Management Team is constantly pushing the envelope to advance the clinical and basic science behind various brain and spinal cord tumours both benign and malignant including management of skull base tumours.

 

SETTING THE DIRECTION WITH ACCURATE DIAGNOSTICS

The treatment roadmap begins with world-class diagnosis. An accurate diagnosis is the critical start-point to the process. Robust diagnostic capabilities are especially crucial in CNS cancer because brain tumours are often not diagnosed till the late stages. Our Central Nervous System 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.

 

NEURO IMAGING STUDIES

MRI

The diagnostic process typically begins with a Magnetic Resonance Imaging or an MRI. After detailed neuro-examinations we decide which type of MRI would work best for the patient. These would include:


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 show up any abnormalities or tumours. CT scans are especially for patients with pace-makers as they cannot undergo the MRI procedure.


Positron emission tomography (PET)

In a PET scan a small amount of a radioactive substance is injected into the patient’s body. This substance is taken up by cells that are actively dividing. Tumour cells, which are more prone to dividing, absorb more of the radioactive substance. The activity is detected by the scanner and is used to produce images of the inside of the body.


Histopathology

Histopathology is the 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 the 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 are considering the fact that treatments for each of these conditions are so different from the other, it becomes clear how critical it is to have the clarity on the lesion so that appropriate treatment can be recommended.


MOLECULAR NEUROPATHOLOGY

Our CMT leverage state-of- the 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 which 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.


Tumour Histology

A tumour’s propensity to grow and spread is known as it’s grade. 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 demonstrate 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, histopathologic examination is on the cutting-edge diagnosis of brain tumours. It has become imperative for an exact diagnosis and subtyping.


Skull Base Tumour Diagnostic Tests

While investigating skull base tumours, our team of experts carefully choose 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:


Biopsy: One of these biopsy methods may be used:


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


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 to critically evaluate each patient’s data for accurate diagnosis and customising a personalised treatment plan as per scientifically derived evidence, available resources etc. Appropriate individualised 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 the patients/families to participate in suitable clinical trials.

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 use these powerful variables to deliver the most effective solution for our patients.

 

Neuro Surgery

Neuro surgery is a highly specialized niche that plays an integral role in the treatment of brain tumours. The brain is a 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 of defence to reduce the size of the tumour to manageable sizes; post this, other forms of treatments are used to eradicate it.

 

Awake craniotomy

An awake craniotomy is an operation where the patient is awake during the procedure. This is a preferred technique for operations to remove tumours close to, or involving functionally important regions of the brain. This type of procedure empowers the doctor to test regions of the brain before they are incised or removed. It also allows for real-time testing of the patient’s function continuously throughout the operation.

 

Intra Op MRI guided surgery

In this procedure, our doctors use the iMRI technology that creates a stream of accurate pictures of the brain which guide them in removing brain tumours and other abnormalities during operations. It helps the surgeon keep track of real-shifts of the brain during surgery and accurately distinguish the edges of a brain tumour from normal tissue from abnormal tissue. Imaging with iMRI during surgery helps confirm successful removal of the entire brain tumour.

 

Neuronavigation and Electrophysiological Monitoring

Localization and delineation of extent of lesions are critical for safe maximal resection of brain and spinal cord tumours. Neuronavigation systems help in image-guided neurosurgery to aid in the accurate resection of brain tumours. The main clinical utilities are: localization of small intracranial lesions, skull-base surgery, intra cerebral biopsies, intracranial endoscopy, functional neurosurgery and spinal navigation.

 

Radiation Oncology

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 which 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. 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 pin point precision allows proton therapy to deliver higher doses of radiation to target brain cancer, with less damage to surrounding tissues.

Indications of Proton Beam Therapy in Brain Tumours:


Intensity modulated radiation therapy (IMRT)

In this method, the radiation beams are broken up into smaller beams whose intensity can be modulated. The more intense beams, with higher radiation, are used to target the tumour.

 

Image Guided Radiation Therapy (IGRT)

Image Guided Radiation Therapy (IGRT) helps Doctors and the treating team to locate and track the brain tumour at the time of treatment, and conform the radiation to the tumour, limiting radiation exposure to nearby healthy brain tissues. This decreases side effects and complications, while delivering the same radiation dose.

 

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 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, or the use of drugs to fight brain tumours, can be used as a stand-alone treatment method or in conjunction with radiation treatment. The goal of chemotherapy can be to destroy tumour cells remaining after surgery, slow a tumour’s growth, or reduce symptoms.

Systemic chemotherapy gets the drugs into bloodstream to reach tumour cells throughout the body. The medication is administered via a pill, or IV .

In the case of brain tumours, chemotherapy is typically given after surgery and possibly with or after radiation therapy. The chemotherapy regimen usually consists of a specific number of cycles given over a set period. A patient may receive one drug at a time or combinations of different drugs given at the same time.

 

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


PERSONALIZED MEDICINE

At APCC the focus of therapy is to provide patient centric cancer care. This is ensured using IBM Watson Oncology (First one in India), which is a cognitive computing system designed to support the physicians as they consider treatment options with their patients. It helps surface relevant data, bridge disparate sources of information, and identify treatments that are personalized to each unique patient.


REHABILITATION SERVICES

Brain and other central nervous system tumours have a very high likelihood of producing long-term disabling effects owing to the tumour itself and the effects of treatment.

Even benign or low-grade brain tumours can cause significant disability. It is seen that the effects vary with the type of tumour and the age of the patient.

Regardless of a patient’s age, a tumour can impact a patient’s speech, movement, vision, balance, thinking and memory. While the brain is able to heal itself, it is a slow process that varies greatly from patient to patient. Most brain tumour patients require physical, speech and/or occupational therapy to regain function, mobility and cognition.

We at APCC provide a comprehensive rehabilitative service to ensure speedy recovery and better outcomes.


PALLIATIVE CARE

An important aspect of our care ecosystem is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

We take care to ensure palliative care is started as early as needed in the treatment process. People often receive treatment for the tumour while they receive treatment to ease side effects. In fact, patients who receive both at the same time often have less severe symptoms, better quality of life, and report that they are more satisfied with treatment.

Our experts offer palliative treatments which may cover a range of important areas like medication, nutritional changes, relaxation techniques, emotional support, and other therapies.


Skull base Tumor Treatments

Once a skull base tumour has been diagnosed, the experts in our CMT plan and determine the best options to treat it. Treatment modality most often depends on the following:

Most skull base tumours may require surgery. Some can be treated without surgery (for example with radiation or chemotherapy). At APCC, treatment for a skull base tumour is tailor-made for the demands of the case.


Surgery

Surgery is often part of the treatment for skull base tumours. The location deep in the structures of the head presents significant challenges because important nerve and brain structures may be involved.

Our surgeons have pioneered techniques and surgical approaches that allow for maximum safe removal of tumours in this delicate and complex area. They are experts in open and minimally invasive diagnostic and surgical approaches to skull base tumours.

APCC’s renowned skull base tumour surgeons work in multi-specialty teams. They perform a high number of skull base tumour surgeries each year, using the least-invasive, most-advanced techniques.

The main types of skull base tumour surgery are:

Open surgery: Incisions (cuts) are made in the skin or the membranes of the nose or throat to expose the bone of the skull base. The incision often can be hidden in the hair, skin creases, nose or mouth.

The affected bone is removed to expose the tumour and to identify the important nerves and blood vessels. After the tumour is removed, the membrane that protects the brain and the surrounding soft tissues is closed to seal off the skull base. Occasionally, when large skull base tumours are treated, plastic surgeons rebuild the soft tissues and bone to optimize function and appearance.

Minimally invasive endoscopic surgery: Using no incisions or a few small ones in the skull or back of sinuses, the surgeon uses an endoscope (link to definition) to biopsy or removes the skull base tumour. This approach may:

Image-guided surgery: CT (computed tomography) or MRI (magnetic resonance imaging) scans are taken before surgery. They then are used in the operating room to help guide the surgeon to the precise location of the tumour. This enhances the accuracy and precision of minimally invasive surgery of the skull base.

Real-time MRI: Provides surgeons with precise, "live" images of the tumour and surrounding areas during surgery. This increases the surgeon’s accuracy and the chance for complete removal of the skull base tumour.


Radiation Therapy

For patients with skull base tumours that are responsive to irradiation, our radiation oncologists prepare three-dimensional treatment plans for the precise delivery of radiation therapy. New radiation therapy techniques and remarkable skill allow APCC doctors to target skull base tumours more precisely, delivering the maximum amount of radiation with the least damage to healthy cells. APCC provides the most advanced radiation treatments, including:


TomoTherapy:

Our TomoTherapy System delivers radiation in small beamlets, enabling your doctor to devise a treatment plan that delivers an optimal dose of radiation to your tumour.


Proton therapy:

Apollo Proton Cancer Centre is the first in South-Asia and India. It’s the only proton therapy facility in the country located within a comprehensive cancer centre. This means that this cutting-edge therapy is backed by all the expertise and compassionate care for which Apollo group is famous.

Proton therapy delivers high radiation doses directly to the skull base tumour site, while decreasing the risk of damage to nearby healthy tissue. It is especially valuable for some cancers deep in the body (such as skull base tumours) because it is targeted to deposit energy only in the area of the tumour. For some patients, this therapy results in better cancer control with less impact on the body.


Chemotherapy

The choice of chemotherapy is based on the type of tumour cell that is found in the skull base tumour. APCC offers the most up-to-date and advanced chemotherapy options.


Rehabilitation

Giving patients with skull base tumours the opportunity and the tools to enjoy life fully is an important part of care at APCC. Many patients can overcome limitations caused by skull base tumours or treatment effects with the help of caring professionals, who may include audiologists, behavioural psychologists, language therapists, neuropsychologists, nutritionists and occupational, physical, speech and swallowing therapists.

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