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What to Expect: Lutetium-177 Octreotate Therapy

Lutetium-177 Octreotate Therapy, Neuroendocrine Tumours, What to Expect, Patient Journey, Theranostics, Theranostics Singapore, Cancer Treatment, Dr Andrew Tan

What Is Lutetium-177 Octreotate Therapy? 

One of the therapies used to treat neuroendocrine tumours is Lutetium-177 Octreotate Therapy. It is a targeted radioligand therapy that specially targets tumours that express somatostatin receptors (i.e. neuroendocrine tumours). 

Its method of action consists of using peptide molecules such as artificial octreotate – transport – linked to a carrier agent for radioisotopes such as Lu-177 that destroy cancer cells.

What Are Neuroendocrine Tumours (NETs)?

Neuroendocrine tumours are cancers that arise from very specialised cells in the body (neuroendocrine cells). These cells have similar traits to nerve cells and hormone-producing cells. They are rare tumours and can appear in the lungs, pancreas, appendix, small intestine, and rectum.

Some produce hormones excessively (functional neuroendocrine tumours), while others produce little to no hormones (non-functional neuroendocrine tumours).

What to Expect Before Treatment With Lutetium-177 Octreotate Therapy?

If you have been diagnosed with a neuroendocrine tumour, our doctor shall do the pertinent assessment to corroborate the disease and determine the exact stage of the disease.  

Among the laboratory tests, you can expect to require a complete blood count, 24h creatinine clearance, chromogranin A, kidney, and liver function test.

In addition – before starting the treatment – a PET scan with gallium octreotate shall be carried out. This will determine the extent of the disease as well as the somatostatin receptor density on the tumours. 

Then, our doctor will explain the procedure as well as the possible side effects, together with all the recommendations that you should know after applying the treatment.

What to Expect During Treatment With Lutetium-177 Octreotate Therapy?

This type of therapy can be performed on an outpatient basis in the nuclear medicine department. Before starting, the patient will be asked to consume an average of 1.5L of fluids.

A peripheral intravenous line is placed in the patient for the administration of the treatment, in conjunction with an antiemetic before the infusion of amino acid compounds.

Administration of amino acids will be 30 minutes before lutetium-177 octreotate accompanied by intravenous fluids. This stage of the procedure takes a couple of hours.

Lutetium-177 octreotate is then given as a slow, controlled infusion, which will last for approximately 20 minutes. After that, you must wait a couple of hours while the radioactivity decreases.

The entire treatment lasts approximately 4 to 6 hours, ranging from the preparation phase and the time spent waiting for the manifestation of side effects if any.

What to Expect After Treatment With Lutetium-177 Octreotate Therapy?

After the treatment, you may experience a series of varied symptoms, for which you will spend a couple of hours in the nuclear medicine department. The most common immediate side effect is nausea. 

The medical staff will be attentive to any manifestation outside of what is expected and will treat these side effects accordingly. 

Lutetium-177 octreotate therapy has been shown to increase progression-free survival and an increase in overall survival, with excellent safety profiles.

How Long Before I Can Be Discharged After Lutetium-177 Octreotate Therapy? 

Discharge from the nuclear medicine department will be after 6 to 8 hours on average after starting treatment. The reason behind this is to wait for radioactivity levels to decrease and for the side effects to subside.

The patient must go back to the nuclear medicine department for a full body scan and check on the progress of the treatment after 24 hours.

How Will I Feel After Lutetium-177 Octreotate Therapy? 

It is normal to experience several side effects since it is a radioactive treatment. 

Some possible side effects of Lutetium-177 Octreotate Therapy include: 

  • Nausea (usually counteracted with prophylactic treatment)
  • General fatigue and tiredness
  • Marrow suppression, leading to decreased platelet and red cell counts. This is usually transient and mild, but some patients may require a blood transfusion. 
  • Renal impairment 
  • Diarrhoea

Many of these symptoms are transitory. In the face of uncertainty, please consult our doctor.

Radiation Precautions of Lutetium-177 Octreotate Therapy

In general, the patients must follow a series of recommendations that we will mention below to avoid contamination to third parties:

  • The patient must keep well hydrated for two days after treatment. In other words, he must increase his fluid intake.
  • The radiotracer will be expelled in the urine in the next few days, so you must flush the toilet twice.
  • Avoid contact with pregnant women and children under five years of age – at least 6 feet apart – for at least a week after treatment. 
  • Normal activities can be resumed after a complete post-treatment body scan.

What Questions Should I Ask My Doctor?

Most individuals feel many fears when diagnosed with some type of cancer, so it is important to clarify each of your concerns. 

Below is a summary of questions (although there may be more):

  • What are my treatment options if I have a neuroendocrine tumour?
  • How many tests do I need to know if I am a candidate for Lutetium-177 Octreotate Therapy?
  • How long is the total duration of Treatment With Lutetium-117 Octreotate Therapy?
  • Is it really necessary to do a scan 24 hours after the infusion?
  • Will my overall survival increase after therapy?
  • What recommendations should you follow after treatment?
  • How long should I wait to be intimate with my partner?

In case of presenting discomfort or not feeling in a more optimal state of mind, always remember to call or go to our specialist. They will help you mitigate any discomfort through symptomatic treatments if necessary.

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What to Expect: Yttrium-90 Selective Internal Radiation Therapy (SIRT)

Yttrium-90 Selective Internal Radiation Therapy, SIRT, Theranostics, Theranostics Singapore, Cancer Treatment, Liver Cancer, Dr Andrew Tan

What Is Yttrium-90 Selective Internal Radiation Therapy (SIRT)

Yttrium-90 Selective Internal Radiation Therapy (SIRT) is known as radioembolisation, and its purpose is to eliminate tumours located in the liver. It works as small radioactive beads that migrate to the tumour through one’s arteries. These beads emit short-range radiation, which targets the tumour but minimises damage to the surrounding tissues.

What Is Liver Cancer?

Liver (Hepatic) cancer occurs when there is an abnormal and uncontrolled growth of liver cells. Although there are many different types, the most common is hepatocellular carcinoma.

Various risk factors can lead to this type of cancer. Among them, we have episodes of hepatitis, liver cirrhosis, excessive alcohol consumption, obesity, and diabetes, among others.

Typically, there is pain in the right abdominal region and yellowing of the skin (pathological jaundice). Although it is usually asymptomatic at the beginning, it tends to generate symptoms after the disease has advanced significantly.

What Is A Mapping Arteriogram Procedure / Liver Lung Shunt Study & Why Do I Need It?

Mapping Arteriogram Procedure / Liver Lung shunt study must be performed a week before starting the SIRT treatment. Mapping will allow the identification of the blood vessels (arteries) that are directed to the tumour, as well as blocking the  passage to other organs such as the intestines. This is necessary to prevent the radiation from affecting healthy organs.

The procedure requires a series of preparations and steps before, during, and after. Everything related to mapping arteriography will be explained in detail by your treating physician.

What to Expect Before Treatment With Yttrium-90 Selective Internal Radiation Therapy (SIRT)?

Aside from the angiography, there will be a series of blood tests to assess the baseline liver, kidney and bone marrow function. 

The patient is required to fast for 6 hours before the angiogram, and there will be a clinical examination prior to the procedure. 

The angiogram will be performed with a liver lung shunt study. This involves injecting a diagnostic radiotracer into the hepatic artery catheters, which will allow the doctors to fully understand the distribution of particles into the tumour and normal tissue. The doctors will then be able to determine if the patient is a suitable candidate for Y90 SIRT and, if so, to calculate a proper dose of the radioactive microspheres.

  • Speak to Our Doctor About Other Prescribed Medications

A series of medications will most likely need to be discontinued on the day of treatment to ensure successful therapy and even mapping, so make a list of your medications and consult with our doctor.

Among them, we have anticoagulants – such as aspirin, AINES, vitamin E, oral hypoglycemic agents, and insulin – and diuretics, among others. In the case of diabetes treatment, your dose may be adjusted.

  • Reactions to Contrast 

These types of procedures generally make use of contrast media, allowing the doctor to see the arteries that communicate with the tumour. If you have previously had allergic reactions to contrast media, you should notify your medical care team to avoid complications. This will allow our doctor to look for an alternative to be used as a contrast medium.

What to Expect During Treatment With Yttrium-90 Selective Internal Radiation Therapy (SIRT)?

The actual Y90 SIRT procedure is almost entirely like the pre-treatment angiographic mapping and liver lung shunt. The only difference is the radioactive particles used. While in the assessment phase, a diagnostic tracer is used, in the treatment phase, the Y90 microspheres are injected.

How Long Does Treatment With Yttrium-90 Selective Internal Radiation Therapy (SIRT) Take?

The angiographic procedure and implantation of the microspheres depend on the complexity of the patient. Usually, the procedure will take about 90 minutes.

What to Expect After Treatment With Yttrium-90 Selective Internal Radiation Therapy (SIRT)?

After treatment, the patient will be transferred to a recovery area where they will remain for approximately 1 to 4 hours. During this period, the catheter is removed from the bladder. 

Yttrium-90 Selective Internal Radiation Therapy (SIRT) treatment has several reported side effects. These include: 

  • A fever of more than 38 ° C
  • Abdominal pain
  • Nausea and vomiting

Our specialist will indicate if antipyretic, analgesic and antiemetic medications are necessary.

How Long Before I Can Be Discharged After Treatment With Yttrium-90 Selective Internal Radiation Therapy (SIRT)? 

You are typically required to rest in bed for a minimum of 6 hours post-treatment. If everything goes well with no complications, you should be able to be discharged the next morning.

You Should Arrange For Someone to Take You Home Following Treatment With Yttrium-90 Selective Internal Radiation Therapy (SIRT)

As it is a radiation treatment that causes fatigue in patients, our doctor will recommend that someone take care of bringing you home safely. You should arrange for an accompanying adult after your treatment. 

What Questions Should I Ask My Doctor?

It is normal to experience fear or doubts when diagnosed with liver cancer, so we have prepared a shortlist of questions that you can ask your doctor. 

  • How do I know if I am a candidate for Selective Internal Radiation Therapy (SIRT)?
  • Is it mandatory to perform mapping arteriography before starting SRIT?
  • Should I stop my medication if I am diabetic?
  • What if I am allergic to contrast and am not aware?
  • If I have a device on my skin, what should I do?
  • Can I have sex?
  • What to do with my clothes in case they get stained with body fluids?
  • Is it mandatory to have a companion when I go home?
  • If I follow another treatment such as chemotherapy, should I stop it?

In case of not feeling well, you should notify your companion of your discomfort. Your companion should inform your treating physician. Side effects after therapy are generally few and short-lived.

It is essential that if your companion notices something out of the ordinary after the treatment, they should immediately notify your doctor so that they can carry out the corresponding corrections.

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What to Expect: Lutetium-177 Prostate-Specific Membrane Antigen (PSMA) Therapy

Lutetium-177, Prostate Specific Membrane Antigen, PSMA, Cancer Treatment, What to Expect, Theranostics, Theranostics Singapore, Dr Andrew Tan

What Is Lutetium-177 Prostate-Specific Membrane Antigen (PSMA) Therapy? 

Prostate-Specific Membrane Antigen (PSMA) is a type of receptor found on cell membranes throughout the body and is particularly increased on the cell surfaces of prostate cancer. 

Lutetium-177 PSMA Therapy uses two components. One of them is a PSMA molecule that binds to the PSMA receptor in cancer cells. The other is a radioactive drug known as Lutetium-177 (Lu 177), which, when transported to the cancer cell by the PSMA molecule, is able to kill the cancer through radioactivity. 

The purpose of the treatment with Lu-177 is to destroy cancer cells, preserving healthy tissue – and – although it is not a cure – it can minimise the cancer’s symptoms, slow tumour growth, and prolong the patient’s quality of life.

What Is Prostate Cancer?

Prostate cancer is one of the most common cancers among men. Approximately 1 in 9 men will be diagnosed with prostate cancer in their lifetime, and it is the second leading cause of cancer-related death in men in the United States. While the majority of prostate cancers are early stage at diagnosis, a significant portion will have regional or distant metastases. 

As men get older, the prostate increases in size. This abnormal growth often does not produce any symptoms, so prevention is key. However, this abnormal growth of the prostate gland usually oppresses the bladder and urethra, which can thus manifest the first symptoms. 

In turn, a man may present difficulties with his erection. Sterility is also a possibility.

If you suspect that you are suffering from some of the symptoms of prostate cancer, make an appointment with your doctor.

What to Expect Before Treatment With Lutetium-177 Prostate-Specific Membrane Antigen (PSMA) Therapy? 

Our doctor will conduct a series of tests – from blood tests to more specialised studies to evaluate the state of the kidney and salivary glands – that will determine if you are the right candidate for treatment with Lutetium-177 PSMA.

This will typically include a PET scan (Positron Emission Tomography) using PSMA as the ligand. This will allow us to stage the disease. Our doctor will explain the possible side effects of the treatment and clarify any concerns you may have. 

What to Expect During Treatment With Lutetium-177 Prostate-Specific Membrane Antigen (PSMA) Therapy? 

This type of therapy is typically used for men with castrate-resistant metastatic prostate cancer who have undergone previous hormonal treatments and chemotherapy and are now progressing.

Typically, this type of treatment is done in a nuclear medicine department. Treatment with Lutetium-177 PSMA Therapy minimises the effects of prostate cancer and prevents its spread to neighbouring tissues and organs. 

How Long Does Lutetium-177 Prostate-Specific Membrane Antigen (PSMA) Therapy Take?

Once you are in the treatment area, our doctor will briefly explain the procedure: a peripheral catheter will be placed in your arm to start treatment.

Generally, each treatment will take approximately 30 minutes. It consists of 2 – 4 doses with 4 – 8 weeks apart between each dose.

What to Expect After Treatment With Lutetium-177 Prostate-Specific Membrane Antigen (PSMA) Therapy? 

Our doctor may recommend the additional use of an antiemetic (for nausea) and a diuretic to help clear the lutetium from your body. 

After the administration, you must wait a few hours in the hospital while the effects of the radiation diminish. Approximately 1- 2 days after treatment, our doctor will request an imaging study, specifically a Single-Photon Emission Computed Tomography (SPECT) scan.

How Long Do I Have to Wait to Be Discharged After Lutetium-177 Prostate-Specific Membrane Antigen (PSMA) Therapy? 

Once the first treatment session is over, the patient must stay in the nuclear medicine centre for roughly two hours. Patients must wait for the radioactivity to diminish in intensity before being allowed to go home.

How Am I Going to Feel After Treatment With Lutetium-177 Prostate-Specific Membrane Antigen (PSMA) Therapy? 

In general, the infusion of the Lutetium 177 PSMA is usually fast and painless, with no complications encountered. 

As expected, any treatment brings with it potential side effects, which may or may not occur. Some of the more common side effects include

  • Tiredness or fatigue
  • Xerostomia (dry mouth). In some cases, this may be fairly severe, usually in patients undergoing multiple rounds of treatment. 
  • Nausea, not always accompanied by vomiting.
  • Effects on the bone marrow, resulting in reduced blood counts (platelets, red blood cells). This is usually transient and mild, but blood transfusion may be needed in some patients. 
  • Dry eyes

There may be radiation exposure to other organs such as the kidneys and small intestine, but reported side effects are rare. 

However, you should feel free to speak to our doctor if you have any concerns about how you feel post-treatment. 

What Questions Should I Ask My Doctor?

If you are feeling overwhelmed by your diagnosis, here are some questions that you can ask your doctor. 

  • How do I know if I am qualified to receive PSMA treatment with Lutetium-177?
  • Is Positron Emission Tomography (PET Scan) necessary?
  • How long does Lutetium-177 Prostate-Specific Membrane Antigen (PSMA) Therapy last?
  • Should I stay long after the first therapy session is completed?
  • Will I have all the side effects, and for how long?
  • Will I have sexual dysfunction-related issues?
  • Will the therapy cure my cancer?

After treatment, it is normal for the body to experience different symptoms. The type and severity of symptoms vary between patients, and the more common side effects have been outlined. 

If you have any symptoms, consult your doctor immediately, especially if prolonged or increasing in severity. Our doctors are available to clarify any doubts or concerns you have and help you minimise the side effects.

Finally, it can be concluded that therapy with Lutetium 177 Prostate-Specific Membrane Antigen (PSMA) is often a satisfactory therapy option to reduce pain and other symptoms associated with mCRPC (castration-resistant metastatic cancer) – notably if other treatments have failed. Remember to consult with your doctor for any questions you may have.

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What to Expect: Radium-223 Therapy (Xofigo) 

Radium-223 Therapy, Xofigo, What to Expect, Theranostics, Theranostics Singapore, Cancer Treatment, Patient Information, Dr Andrew Tan

What Is Radium-223 Therapy (Xofigo)? 

Radium-223 Therapy (Xofigo) is a form of targeted radioactive therapy. It is a type of radioactive treatment that targets sclerotic bony metastases.

What Is Prostate Cancer?

Prostate cancer is one of the most common cancers among men. Approximately 1 in 9 men will be diagnosed with prostate cancer in their lifetime, and it is the second leading cause of cancer-related death in men in the United States. 

While most prostate cancers are early stage at diagnosis, a significant portion will have regional or distant metastases.

What to Expect Before Treatment With Radium-223 Therapy (Xofigo)?

Our doctor must confirm that you have prostate cancer through existing studies and tests. Once this is confirmed, our doctor typically requests a series of tests to assess your general health.

You will need a bone scan that demonstrates bony metastases. 

You may also be asked to stop taking calcium before the treatment session. Our doctor will sit down with you to look at your medical history, explain the severity of the disease and everything related to the treatment. Take advantage of this moment to clarify any possible concerns you may have.

What Will My Radium-223 Therapy (Xofigo) Treatment Schedule Look Like?

Our treating doctor will explain the damage to your body caused by prostate cancer and the consequences of not being treated. They will also explain the program you must follow to achieve the best possible treatment outcome with Radium-223 Therapy (Xofigo). 

Other information that will be provided to you will be regarding possible adverse effects and the therapeutic measures that you can take to minimise these effects. 

What happens after treatment and the prevention measures to keep in mind will be explained in detail. 

Finally, you may be advised to stop any other radiotherapy or chemotherapy treatments that you are undergoing before starting Radium-223 Therapy (Xofigo).

What to Expect During Treatment With Radium-223 Therapy (Xofigo)?

The treatment program for Radium-223 Therapy (Xofigo) consists of intravenous administration (peripheral route in one arm) of the drug. 

Treatment typically comprises 4-6 sessions, with a period of 4 weeks between each one.

The drug will be administered directly in the vein, and the procedure is typically fast and painless. 

Before each session, a blood sample will be drawn to evaluate health parameters and haematological conditions.

How Long Does Treatment With Radium-223 (Xofigo) Take?

Radium-223 Therapy (Xofigo) is a relatively quick procedure, which will take no more than half an hour. The application of the intravenous drug takes no more than a minute.

As mentioned, additional time will be required while the nurse places the catheter for the intravenous line and its subsequent removal.

What to Expect After Treatment With Radium-223 Therapy (Xofigo)?

After Radium-223 Therapy (Xofigo) treatment, there will be low-grade radioactivity from the patient. Small amounts of radioactivity may be present in the urine and stools. 

One of the advantages of this type of treatment is that it will not be necessary to avoid contact with family and friends since the radiation levels received is very low. Still, the doctor will give you a card stating that you have received such treatment.

How Long Before I Can Be Discharged After Treatment With Radium-223 (Xofigo) Therapy? 

As it is an outpatient procedure, discharge after intravenous application will be quick – it will not take more than a couple of hours for the first side effects to subside. Generally speaking, within 1-2 hours, you may be on your way home.

How Will I Feel After Treatment With Radium-223 (Xofigo) Therapy? 

Once the treatment is complete, you may feel somewhat dizzy or, in some cases, fatigued. It is normal to have some discomfort since you have received radiation treatment. However, try not to worry as these symptoms should disappear relatively quickly. In case of persistence, consult our doctor.

This type of therapy for prostate cancer is one of the few that generates minimal side effects. Among them, we have:

  • Nausea
  • Diarrhoea
  • Anaemia
  • Oedema in the ankles and wrist 

If you have had a therapy session and you have persistent side effects, feel dizzy, confused, and weaker than normal, or have any other symptoms that are not expected, notify our doctor immediately.

Any prolongation of the symptoms may be a cause for alarm, so you must notify your medical care immediately. Our doctor will take the necessary therapeutic measures to correct any discomfort as your body responds to the treatment.

Radiation Safety Precautions

As mentioned above, there will be small traces of radiation particles in the urine, blood, and faeces. Therefore, you must comply with the following radiological safety conditions:

  • Flush the toilet twice and wash your hands properly.
  • Wash clothes and sheets stained with vomit, blood, urine, and faeces separately. Handle with gloves.
  • Stay well hydrated before and after therapy.
  • Use a condom when having sex to prevent your partner from becoming pregnant (it is dangerous because of the effects of radiation) – this recommendation is valid for six months.
  • Do not expose your partner to pre-seminal fluid and semen, as it may contain radioactive particles.

What Questions Should I Ask My Doctor?

If you are feeling overwhelmed by your diagnosis, here are some questions that you can ask your doctor. 

  • How do I know if I am a candidate for Radium-223 Therapy (Xofigo)?
  • Is it an outpatient procedure? Why?
  • How many therapy sessions with Radium-223 Therapy (Xofigo) do I need?
  • What happens if I don’t follow through with all the Radium-223 Therapy (Xofigo) sessions?
  • Is it mandatory to stop other methods of therapy like chemotherapy?
  • Should I stop taking dietary supplements that contain calcium?
  • Should I take any security measures with my family and partner?
  • Can I have sex?
  • What do I do if I have blood in my urine?
  • Is it mandatory to have blood tests before each session?
  • Could I end up being sterile?
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Prostate Cancer: Causes, Symptoms, Diagnosis, Treatment

Prostate Cancer, Cancer, Theranostics, Prostate Cancer Treatment, Nuclear Medicine

What Is Prostate Cancer?

Prostate cancer is one of the most common cancers in men. Statistically, it is known that 1 out of every ten men will be diagnosed with this disease.

In the United States, the diagnosis is usually in the initial stages, but it does not represent all cases, especially in Latin America, whose diagnosis is late. That is, cancer has metastasised to other organs and tissues.

The most affected population is the one between 65 years of age and older (representing 60% of cases), according to epidemiological data from the American Cancer Society (ACS).

The prostate is a small gland located below the urinary bladder and surrounding the urethra (pelvic cavity). This gland is regulated by the testosterone hormone and is responsible for producing seminal fluid or semen.

Cancer occurs when abnormal growth occurs in the prostate gland, and in many cases, it usually spreads to the surrounding tissues.

What Are the Different Types of Prostate Cancer?

The prostate cancer with the highest incidence of cases is called Adenocarcinoma, which develops from glandular cells (they produce the prostate fluid that binds to semen).

Although it is not the only type, there are others whose percentage of appearance is minimal. Among them, we have:

  • Small cell carcinomas
  • Neuroendocrine tumours (other than small cell carcinomas)
  • Transitional cell carcinomas
  • Sarcomas

Prostate cancer can also be classified according to its growth:

  • Aggressive or fast-growing: The tumour grows rapidly and usually spreads to neighbouring organs quickly.
  • Non-aggressive or slow-growing: the tumour does not grow, or its growth is very slow.

What Causes Prostate Cancer?

Doctors and scientists still do not know the causes that trigger prostate cancer. It is known that family history (a family member with cancer), exposure to radiation, or certain chemical compounds can influence the development of this pathology.

Other risk factors that have already been mentioned are advanced age, obesity, race, especially African ethnicity, which are risk factors for developing.

Age is undoubtedly a relevant factor since it occurs more frequently in men over 65 years of age and with a 14: 1 ratio in men between 60 and 69 years of age.

What Are the Symptoms of Prostate Cancer?

The symptoms of prostate cancer are not always perceptible by the subject since many can go years without knowing that they have such a disease. This event occurs commonly in those patients with slow-growing prostate cancer.

In general, the men who develop symptoms are those whose cancer has advanced in extension and/or size. Among these symptoms, we have:

  • Urinary problems: the frequent desire to urinate, slow urination stream, blood in the urine (hematuria).
  • Sexual issues: sexual dysfunction (impotence), bleeding after ejaculation.
  • Pelvic, back, or chest pain due to the spread of cancer to bone tissue, affecting these areas.
  • Numbness or loss of sensation in the legs and bladder due to the spread of cancer to the spinal cord.

The first symptoms to appear are urinary symptoms. However, some of these symptoms are associated with other pathologies such as benign prostatic hyperplasia and prostatitis.

It is important to note that if some of these symptoms occur – especially hematuria – a specialist doctor should be consulted immediately. Early diagnosis is the key to a speedy recovery.

How Is Prostate Cancer Diagnosed?

The diagnosis of prostate cancer is usually according to the individual’s preference, given that it does not generate symptoms in most cases, and its diagnosis is advantageous.

Sometimes, specific antigen tests produce a false positive, which leads to unnecessary treatments. Routine annual exams and a preventive check-up in the population at risk described above are keys to a more accurate diagnosis.

The doctor will perform a physical examination, and it will review your medical history in detail, emphasising the family history, but may also perform one of the following tests:

Lab tests

Digital rectal exam: The doctor will insert a gloved finger into your rectum to evaluate the presence of lumps, lumps, or an out-of-normal growth of the prostate.

Prostate-Specific Antigen (PSA) Test: This is a test that detects your blood levels.

Biopsy

Prostate biopsy: 

The specialist will extract a small sample of the prostate gland. This test is linked to a Gleason scale. When the score is less than 6, it means it does not have signs of cancer, and if the value is equal to or greater than 7, it may be a sign of cancer.

The PSA tests and biopsy are evaluated by a specialist doctor, who will determine the state and severity of the disease.

Imaging tests

Magnetic resonance (MRI): 

It creates a detailed image of the soft tissues, especially a very clear image of the prostate and neighbouring tissues. It is useful to determine the incision point in case of surgery.

Computed tomography: 

Although it is not a study of choice, it is used in cases where metastases to bone or surrounding organs are suspected – such as screening after chemotherapy or radiotherapy – to see the size of the prostate and determine if the treatment is being effective.

Bone scan: 

Generally speaking – if the prostate cancer has spread – it does so towards the bone tissue, and this scan allows detection of possible areas of metastasis. To corroborate this diagnosis, resonance and/or tomography should be used.

PET/CT:

This is advanced hybrid imaging that utilises radiotracers to detect specific metabolic pathways or cells. In respect to prostate cancer, a ligand called prostate-specific membrane antigen (PSMA) is typically used to detect prostate cancer cells. This form of imaging can be considered the current gold standard of prostate cancer staging.  

What Are the Treatment Options Available for Prostate Cancer?

Your doctor will recommend the best therapeutic options, according to your age and stage of the disease. In some cases, it begins with active surveillance in the absence of symptoms.

In case of preexisting symptoms, the therapeutic alternatives for the treatment of prostate cancer are the following:

1) Radiation

Radiation therapy is one of the therapeutic options used to treat prostate cancer. The most common type is the external beam of radiation, which goes to specific points on the body.

Its primary purpose is to reduce the size of the tumour and cancer cells, which is why half of the patients receive this type of treatment. Its use can be before or after a surgical intervention or in combination with other therapies.

Each radiotherapy session lasts from 10-30 minutes on average, and its frequency being approximately five a week for ten weeks. This may vary depending on the size of the cancer and the specialist’s criteria.

Here are some of the possible side effects of radiation therapy:

  • Involvement of healthy cells that will eventually recover
  • Burning, dry, itchy, and peeling skin condition
  • Diarrhoea
  • Earache
  • Dry mouth
  • Mouth ulcers
  • Throat pain
  • Nausea
  • Difficult to swallow
  • Difficult to urinate, pain, and urinary urgency
  • Sexual dysfunction
  • Joint problems
  • Oedema of the tissues or lymphedema (accumulation of fluids in the lymph nodes)

Most of these effects disappear after two months. In case of persistence, consult your doctor.

2) Chemotherapy

It is a chemical pharmacotherapy procedure whose purpose is to destroy rapidly growing cells, prevent their spread to other regions. In other words, to prevent metastasis, reduce the size of the tumour and reduce the symptoms caused by cancer. Chemotherapy is usually combined with radiation therapy, surgery, or other treatments.

One of the disadvantages of this type of treatment is that other rapidly growing cells can be affected, such as blood cells, skin, hair, and epithelial lining.

Although chemotherapy is beneficial, it generates the following side effects:

  • Presence of bruising and excessive bleeding
  • Diarrhoea
  • Dry mouth
  • Mouth ulcers
  • Fatigue
  • Fever
  • Hair loss
  • Loss of appetite
  • Nausea and vomiting
  • Weight loss
  • Pain from nerve damage
  • Infections
  • Anaemia
  • Constipation
  • Neuropathy
  • Lymphedema
  • Memory and concentration problems
  • Skin and nail changes
  • Insomnia
  • Sexual changes, such as impotence and low sexual desire
  • Fertility changes

These effects are reversed at the end of the treatment, although in some cases, you may see some organ involvement (heart, kidneys, lungs, reproductive organs, and nerves).

3) Targeted Therapy

It is a cancer treatment that uses drugs to destroy cancer cells, causing minor damage to normal cells. Each targeted therapy works differently but has the same goal, which is to destroy cancer. 

Among the most widely used drugs, we have rucaparib (rubraca) and olaparib (Lynparza), which treat metastatic castration-resistant prostate cancer. These help repair cellular DNA damage. The medic will be the one who determines if this type of treatment is necessary.

Targeted therapy has the following side effects:

  • Nausea and vomiting
  • Diarrhoea or constipation
  • Tiredness
  • Loss of appetite
  • Low red blood cell count (anaemia)
  • Skin lesions
  • Abnormalities in blood tests for the liver
  • Low platelet count
  • Cough and shortness of breath
  • Rare cases of blood clots in the legs and lungs

4) Immunotherapy

Immunotherapy is nothing more than a treatment that stimulates the immune system of men with prostate cancer to attack cancer cells. The vaccine is called Sipuleucel-T (Provenge).

This vaccine treats patients with advanced cancer who do not respond to hormone therapy and have little or few symptoms. It is created specifically for each man from his white blood cells in combination with proteins.

The vaccine does not cure cancer, but it does increase survival rates. Once again, it will be the doctor, the one person who determines if you are a suitable candidate for this treatment.

The side effects of immunotherapy are as follows:

  • Fever
  • Shaking chills
  • Tiredness
  • Headache, back, and joint pain
  • Nausea
  • In some cases, breathing problems and hypertension

5) Surgery

Known as radical or partial prostatectomy, where the entire prostate gland (radical) or only a segment of it (partial) is removed. The prostatectomy for both cases can be open, which generates a larger scar at the level of the lower abdomen or of the laparoscopic type, which would be through small incisions.

General or regional (spinal) anaesthesia is usually used, which numbs the lower body.

Patients often choose laparoscopic surgery or robot-assisted prostatectomy since recovery is faster and has fewer side effects. Other types of surgery are laser and endoscopic, and – in both – a probe is inserted through the opening of the penis.

Transurethral Resection of the Prostate and Transurethral Incision of the Prostate (TUIP) is another procedure to cut enlarged prostate segments, which are removed through the bladder.

These are some side effects of the different types of surgery:

  • Blood in the urine
  • Urinary irritation
  • Difficulty holding urine
  • Urinary tract infections
  • Inflammation of the prostate
  • Reaction to anaesthesia
  • Infection of the surgical site
  • Impotence or erectile dysfunction, transient, rarely permanent (only if the nerves are injured)
  • Transient sexual dysfunction, that is, difficulty obtaining orgasms
  • Lymphedema in the leg or genital area

6) Theranostics

In relation to this type of treatment, we will mention two options aimed at prostate cancer:

  1. Radio-223 (Xofigo) Therapy: This drug works like targeted radiation therapy, used when cancer has spread to the bone and helps prevent symptoms of the disease.
  2. Prostate-Specific Membrane Antigen (PSMA) Therapy with Lutetium-177: Like all theranostics therapies, it is a nuclear medicine radionuclide treatment. This allows for very specific and targeted radiation therapy.

These are some side effects of the theranostic treatment of radio-223 therapy (Xofigo):

  • Decrease in red, white blood cells and platelets
  • Patients with low-grade myelosuppression are the most common.
  • Nausea and vomiting
  • Diarrhoea
  • General weakness

Side effects of prostate-specific membrane antigen (PSMA) therapy with lutetium-177:

  • Decrease in red, white blood cells and platelets (transitory event)
  • Nausea and fatigue
  • 10-20% of patients experience decreased salivation

Who Will Benefit From Treatment With Radium-223 (Xofigo) Therapy?

 

It is a targeted radioactive therapy that is ideal for patients with metastatic castration-resistant prostate cancer (mCRCP) that has metastasised to bone and generates symptoms in the patient without visceral metastases and biochemical progression.

Who Will Benefit From Treatment With Lutetium-177 Prostate-Specific Membrane Antigen (PSMA) Therapy?

Lutetium-177 PSMA therapy (“Lu177 PSMA therapy”) is a treatment for those individuals who cannot tolerate chemotherapy, have bone marrow involvement, or have mCRPC.

This therapy has shown a significant improvement in these types of patients, thanks to the fact that it acts as a radiation therapy directed at cancer cells.

What Are Some Questions I Should Be Asking My Doctor When Considering Treatment Options for Prostate Cancer?

  1. How far has the prostate cancer spread? Do I have metastases?
  2. Is my prostate cancer fast-growing?
  3. What is my best treatment option?
  4. Can I be left with sexual impotence?
  5. What is my real life expectancy after treatment?
  6. Would a prostatectomy be the best option to avoid metastasis?
  7. Do you know of any trials with less invasive alternative treatments?
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Liver Cancer: Causes, Symptoms, Diagnosis, Treatment

Liver Cancer, Liver Cancer Causes, Liver Cancer Treatment, Liver Cancer Treatment, Liver Cancer Diagnosis, Theranostics, Theranostics Singapore, Dr Andrew Tan

What Is Hepatocellular Carcinoma?

Hepatocellular Carcinoma (HCC) is the most prevalent type of primary liver cancer. Primary liver cancer is cancer that starts in the liver, whereas secondary liver cancer is cancer that has metastasised or spread from another part of the body to the liver. 

Roughly 90% of all cases of liver cancer appear in this form. It is the 3rd leading cause of all cancer deaths worldwide and is particularly common in developing countries. It affects roughly 2.5 people for every 100,000 people in the population. It is more than two times more common in men than in women and is more prevalent in Eastern and Southern Asia, Middle and Western Africa. The median survival rate is approximately 6 to 20 months from the time of diagnosis.

Hepatocellular Carcinoma tends to have two distinct growth patterns; a single tumour that grows to a significant size before spreading or as many small cancer nodules throughout the liver.

What Causes Hepatocellular Carcinoma?

The exact cause of Hepatocellular Carcinoma is not known, but it is found most commonly in people with underlying liver conditions such as hepatitis B or C, hemochromatosis, biliary stent disorder or fatty liver disease. These conditions end up causing cirrhosis, which in simple terms is ‘liver scarring’. 

As the liver gets damaged by these conditions, scar tissue forms on the liver as it attempts to repair itself. Damage caused by cirrhosis is permanent, so the liver is forced to make new cells to improve overall liver function. 

There is a risk of these new cells mutating and becoming cancer cells. The more cells grown in this way, the higher the chances that a mutation can occur. 

What Are the Symptoms of Hepatocellular Carcinoma?

Hepatocellular Carcinoma will show up the same as many other conditions that indicate poor liver health, such as:

  • Abdominal pain, 
  • Ascites (abnormal buildup of fluid in the abdomen)
  • Bloating
  • Bone pain 
  • Nausea
  • Vomiting
  • A lump or mass under the ribs
  • Loss of appetite
  • Sudden weight loss
  • Shortness of breath 
  • Itching
  • Jaundice

How Is Hepatocellular Carcinoma Diagnosed?

There are three main ways in which Hepatocellular Carcinoma is diagnosed; Lab tests, Imaging Tests, and Biopsies. 

Lab Tests

  1. Alpha Fetoprotein Blood (AFP) Test

AFP is a protein that is found in healthy adults at very low levels. 

High AFP levels in adults indicate the possibility of liver cancer and is the most used tumour marker test for Hepatocellular Carcinoma. The test is typically carried out with several others.

  1. Liver Function Tests (LFTs)

As liver cancer is most often the result of an already debilitated liver, LFTs serve as a good indicator of liver health. They can help understand which parts of the liver have been damaged and to what extent. 

Typically, LFTs test for alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), serum bilirubin, prothrombin time (PT), the international normalised ratio (INR) and albumin.

  1. Des-Gamma-Carboxy Prothrombin (DCP) Test

The DCP test is another cancer marker lab test much like AFP. It is also known as protein induced by vitamin K absence-II (PIV-KAII). 

This test is used in conjunction with AFP tests as it tends to show elevated levels in individuals who have Hepatocellular Carcinoma but who do not show elevated AFP levels.

Imaging Tests

  1. Ultrasound

The ultrasound is usually the very first test used to check for tumours in the liver. It makes use of sound waves to create images on a computer. The tumours typically show up as dark grey (hypoechoic) masses.

  1. Computed Tomography (CT) Scan

Specialised X-ray equipment is used to conduct a CT scan to produce cross-sectional images of the liver. Specific information about the size, shape and location of possible tumours can be evaluated. 

Liver lesions typically show up as masses or areas of abnormal enhancement on multiphasic CT imaging, which in conjunction with blood markers and clinical history, can help the clinician come to a definitive diagnosis. 

  1. Magnetic Resonance Imaging (MRI) Scan

MRI Scans are typically ordered if the CT scan was unable to confirm the diagnosis. MRIs also produce cross-sectional imagery but make use of radio waves instead of X-rays. 

MRI scans can be more accurate and give better imagery in certain circumstances but usually are more costly. Identification requires a skilled assessment of the images.

  1. Positron Emission Tomography (PET) Imaging 

Positron Emission Tomography / Computed Tomography (PET/CT) imaging is a form of hybrid molecular imaging that uses radiotracers to detect and image molecular changes in the body. 

For liver tumours, the more commonly used radiotracers are Fluorodeoxyglucose and Acetate. These tracers are used in metabolic pathways found in hepatocellular carcinomas, and by means of such molecular imaging, we can pinpoint and detect active tumours. 

Biopsy

A biopsy is the most definitive diagnostic test that can be carried out for Hepatocellular Carcinoma. 

It is the process of the removal of a piece of liver tissue for laboratory testing. The removed tissue cells are studied under a microscope, whereby cell mutation can be confirmed as cancerous. 

What Are the Treatment Options Available for Hepatocellular Carcinoma?

Several different treatment options are available for Hepatocellular Carcinoma, and it is not a one-size-fits-all approach. Depending on the individual’s stage, severity, and overall health, different combinations of treatments may be recommended.

Hepatocellular Carcinoma can be somewhat challenging to treat because of how the disease presents itself, developing in a background of cirrhosis, making it difficult to target exclusively. 

1) Radiation

Radiation therapy is the use of high energy beams of protons. The beams are targeted and focused at the cancer cells to kill them while carefully avoiding damage to healthy liver cells. 

Radiation therapy is typically recommended when other treatment options are unsuitable. Radiation therapy also has been shown to play an essential role in downstaging patients who are not eligible for transplant due to the extent of their cancer, possibly improving their condition to make transplant a viable option for them.

Some of the more common side effects of radiation therapy include:

  • Diarrhoea
  • Fatigue
  • Loss of appetite
  • Nausea and vomiting
  • Radiation-Induced Liver Disease
  • Redness to blistering and peeling close to radiated location

2) Chemotherapy

Chemotherapy is the use of drugs that are taken orally or intravenously to kill cancer cells. The drugs can be administered systemically (when cancer has spread) or regionally (more targeted). 

The drugs can also be administered directly into the hepatic artery through a method called Hepatic Artery Infusion so that a higher dose of drugs can be issued. This form of receiving the drugs is done under general anaesthesia and requires an infusion pump.

Compared to radiation, it is considered a non-targeted form of treatment as the drugs affect more than just the cancer site and may result in many unwanted side effects.

The severity and type of side effects depend on the individual and the type and dosage of the drugs prescribed. The most common chemotherapy drugs used for treating Hepatocellular Carcinoma are:

  1. Gemcitabine (Gemzar)
  2. Oxaliplatin (Eloxatin)
  3. Cisplatin (Platinol)
  4. Doxorubicin (Adriamycin)
  5. 5-fluorouracil (Adrucil)
  6. Capecitabine (Xeloda)
  7. Mitoxantrone (Novantrone)

These drugs are often used two or three at a time in combination with each other to achieve the best results. 

Some of the more common side effects of chemotherapy include:

  • Diarrhoea
  • Easy bruising or bleeding 
  • Fatigue
  • Hair loss
  • Increased chance of infections 
  • Loss of appetite
  • Mouth sores
  • Nausea and vomiting

3) Targeted Therapy

Whereas chemotherapy is non-targeted, other drugs can be used for treatment that is targeted. These drugs target the liver specifically instead of being dispersed throughout the entire body and are known as Targeted Therapy. There are two main types of targeted therapies; small molecule medicines and monoclonal antibodies. 

Small molecule medicines enter into cancer cells and destroy them, while monoclonal antibodies work by attacking targets outside the cell to destroy them. 

Small molecule medicines can be identified via their generic names ending with -ib, while monoclonal antibodies have their generic names ending with -mab. 

These drugs work in a variety of ways and have many different mechanisms of action. Targeted therapy works in one of the following ways:

  1. Stopping the creation of new blood vessels that feed the cancer cell
  2. Activating the immune system to attack the cancer cell
  3. Altering proteins within the cancer cell
  4. Shutting down signals that inform the cancer cell to grow or divide
  5. Transporting toxins into the cancer cell

Popular small molecule medicines for early treatment of Hepatocellular Carcinoma are Sorafenib (Nexavar) and Lenvatinib (Lenvima), while Regorafenib (Stivarga) and Cabozantinib (Cabometyx) are used in more advanced stage treatment.

A popular monoclonal antibody for early treatment of Hepatocellular Carcinoma is Bevacizumab (Avastin), while Ramucirumab (Cyramza) is used in more advanced stage treatment.

Some of the more common side effects from targeted therapy include:

  • Bleeding
  • Diarrhoea
  • Headaches
  • High blood pressure
  • Loss of appetite
  • Low white blood cell counts
  • Mouth sores
  • Tiredness 

4) Immunotherapy

As the name suggests, immunotherapy is a treatment that uses the body to activate the immune system to combat cancer. 

Cancer cells tend to mask themselves by turning on proteins that are known as Immune Checkpoint Proteins. When cancer cells use these, they tell the body’s immune system to leave them alone. 

Most immunotherapy drugs work by blocking the binding of the cancer cells to these Immune Checkpoint Proteins and are called Immune Checkpoint Inhibitors. 

These drugs can be classified as either PD-1 and PD-L1 inhibitors or CTLA-4 inhibitors. Commonly used immune checkpoint inhibitors for Hepatocellular Carcinoma are Atezolizumab (Tecentriq) and Ipilimumab (Yervoy).

Some monoclonal antibody targeted therapies are also forms of immunotherapy. One example is Rituximab (Rituxan), which marks cancer cells so that the immune system learns to better identify them and destroy them. 

Some of the more common side effects from immunotherapy include:

  • Constipation or diarrhoea
  • Cough
  • Itching
  • Feeling tired or weak
  • Fever
  • Loss of appetite
  • Muscle or joint pain
  • Nausea
  • Skin rash

5) Surgery

Surgery is usually the best option to cure liver cancer as it is the total removal of the tumour and all cancer cells. The procedure is called a partial hepatectomy, which removes part of the diseased liver. 

The downside here is that only people with a relatively healthy liver with a single tumour and where the cancer has not metastasised into the blood vessels can have this operation. 

The feasibility of the procedure is evaluated via imaging tests. Still, it is also possible that during surgery, the cancer might be found to have grown too large or spread too much, resulting in the surgery being aborted.

Though it may be the best option, it does come with a lot of risks and side effects:

  • Bleeding during and after surgery
  • Blood clots
  • Complications from anaesthesia
  • Infection
  • Pneumonia

6) Liver Transplant

When removal of part of the liver is not an option, and other forms of treatment have proved unsuccessful, a total replacement of the liver via a liver transplant is the best way for a chance at being cured. 

The vast majority of liver transplants come from people who die in accidents or from a donor in the family. The liver has unique regenerative properties, and a portion of it can be donated from a living donor to someone in need of a transplant safely. 

Just like with partial hepatectomy, there are significant risks involved in a liver transplant:

  • Bleeding during and after surgery
  • Blood Clots
  • Complications from anaesthesia
  • Infection
  • Rejection of the new liver

7) Theranostics

Theranostics is the act of using a combination of radiation-based drugs to identify and then kill cancer cells. One drug is used for the identification, and another is used for the treatment – providing a 2 in 1 solution of Therapy plus Diagnostics or Theranostics. 

For treatment of Hepatocellular Carcinoma, in the diagnosis stage, a test study using Technetium 99m Macroaggregated Albumin (MAA) is done to determine the uptake of such particles. These are injected into the liver via the hepatic artery, and following the injection, a scan is done to determine the distribution of particles in the cancer and normal tissue. 

By means of such testing, we are then able to determine an appropriate radiation dose to treat the cancer and yet limit the amount of radiation to normal tissue. 

In the therapy stage, the therapy agent used is Yttrium-90 microspheres. The technique involves delivering Yttrium-90 infused microspheres via the hepatic artery, similar to the initial testing phase. 

The tumour then receives a highly concentrated dose of radiation while the surrounding healthy liver cells receive a much-reduced amount. 

Some of the potential side effects from Yttrium-90 SIRT include:

  • Gastritis/Duodenitis
  • Lethargy
  • Mild to moderate fever
  • Nausea
  • Radiation-Induced Liver Disease

Who Will Benefit from Treatment with Yttrium-90 Selective Internal Radiation Therapy (SIRT)?

The people who benefit most from Yttrium-90 SIRT are those with inoperable tumours that cannot be removed during surgery or where other treatment options have not proved to be beneficial. 

What Are Some Questions I Should Be Asking My Doctor When Considering Treatment Options for Hepatocellular Carcinoma?

  1. Has the cancer spread beyond the Liver?
  2. What stage of cancer do I have?
  3. What treatment options would you recommend?
  4. What are my chances of survival based on what you can see?
  5. How much experience have you had treating this kind of cancer?
  6. Should I consider getting a second opinion?
  7. Should I consider taking part in a clinical trial for new treatments?
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