[ | Previous issues 06- June,May| Apr | Mar| Feb|Home| ]
Biology of the disease: Myeloma, also known as multiple myeloma or myelomatosis is a type ofcancer affecting plasma cells, which are usually found in the bone marrow. Normal plasma cells are a type of blood cell that produces antibodies (also called immunoglobulins) to fight infection. Bone marrow is the ‘spongy’ material found in the centre of larger bones in the body where blood cell production including plasma cells occurs In myeloma, plasma cells are damaged causing them to become malignant orcancerous. These abnormal plasma cells are called myeloma cells. The myelomacells do not function properly and produce excessive amounts of an abnormal antibody, known as paraprotein or M-protein, which has no useful function. It is often through themeasurement of this paraprotein that myeloma is diagnosed and monitored. Unlike other cancers, myeloma does not exist as a lump or tumour. Instead, the myeloma cells normally divide and expand within the bone marrow and literally hollow out the bones. Myeloma can affect multiple sites in the body (hence multiple myeloma) where bone marrow is normally active in an adult. This marrow is in the bones of the spine, pelvis, rib cage, and the areas around the shoulders and hips. Common Symptoms of the disease : This is a disease that usually occurs in the elderly , in people more than 50 years of age. Most of the medical problems related to myeloma are caused by the high levels of myeloma cells overcrowding the bone marrow, and build-up of paraprotein in the blood or in the urine. Since they hollow out bones and backbone which caries our weight collapses easily. Many a patient presents with unrelenting backache. Fractures tend to occur easily . The high levels of the abnormal protein clogs the kidney leading to its failure. Tiredness due to anemia is also a common feature .In fact when an elderly person has persistent backache and anemia ,myeloma should be ruled out. The other features are due to abnormal plasma cell’s inability to combat infections. These persons can frequent and recurrent bacterial infections like pneumonia or urinary tract infections. Diagnosis
Symptoms as stated above combined with low hemoglobin and high ESR suggests the possibility of myeloma. This is confirmed by a Bone marrow aspirate study and finding a ‘M’ band in the serum protein electrophoresis study. X rays of the skull show a characteristic picture of hollowed out areas. Other tests are done to monitor the disease and assess the complications of the disease and organ involvement. Kidney failure and high levels of calcium are seen in many cases. Treatment Treatments for myeloma can be effective at halting the progress of the disease, controlling symptoms and improving quality of life, but they are not able to cure the disease. Even after successful treatment, regular monitoring is needed in case the myeloma comes back. There have been many new developments in the treatment of myeloma over the last few years, which have made significant change in the management of these patients. Treatment Options and Newer Modalities: There are various treatment options available for treatment of myeloma. This is a disease that can be well controlled for many years. The choice of drugs and duration of therapy will be individualized depending on the patient’s presentation and response to initial therapy. In these patients, the main goal of therapy is to prevent any myeloma related complications (such as bone fractures, infections etc as mentioned above). Once the disease is initially controlled, most of the patients benefit by an autologous stem cell transplant. In autologous transplants, the patients own stem cells are processed and given back after high dose chemotherapy. However, if myeloma occurs in younger age group (patients less than 50 years), which albeit is rare, the goal of therapy should be aimed at complete cure. This is possible with mini-allogenic stem cell transplant. Mini- allo transplant is a method of transfusing one of the matched sibling’s stem cells after administering immunosuppressive therapy to the patient. This has more safety profile compared to the standard transplants. One of the newer drugs which is very effective for myeloma is Thalidomide. This drug came into use in the 1960s to control excessive vomiting in pregnant women. Soon it was found to cause severe teratogenicity, the children born to mothers who have taken this drug had numerous physical deformities.About 2 decades later it found no use in patients with leprosy and in another decade it was found to play an important role in Myeloma. The drug has been marketed again since 2001, and is a breakthrough in the treatment of myeloma. Unlike chemotherapy, this does not cause any bone marrow suppression or hair loss etc. This can be conveniently taken as an outpatient. In addition to thalidomide steroids and various other chemotherapeutic drugs are also effective against myeloma. Another group of drug which has been introduced since 2004, is a drug called Bortezumab, which is useful even in patients who relapse after transplants. Bortezomib, (also called Velcade) is the first of a new category of drugs called “proteasome inhibitors” that work in a different way to other antimyeloma treatments such as chemotherapy. The proteasome is present in all cells and works by breaking down the many different proteins that control the cells lifecycle. Bortezumab works by temporarily blocking the function of the proteasome in all cells (normal and myeloma) resulting in a build-up of proteins that confuses the cell and causes it to die. (see Figure 1) Myeloma cells are 100 - 1000 times more sensitive to Velcade than normal healthy cells which recover their function in less than 72 hours. The quick recovery of normal healthy cells can prevent certain side-effects such as hair loss from occurring. As Velcade works differently from chemotherapy it can be used alongside it or instead of it when chemotherapy stops working. Those affected by myeloma also require a variety of supportive measures.
The commonly affected bones are those of the vertebral column( backbone).Merely
carrying body weight can collapse them. To prevent this, the affected
persons are advised to wear jackets that spare the backbone from transmitting
bodyweight. Agents are used remineralize the bones rapidly preventing
their breakage. At times kidney failure is severe and dialysis support
becomes necessary. When myeloma affected bones collapse in the spine,
the nerves can get compressed causing paraplegia ( paralyzed from waist
downwards). At such instances radiotherapy is given to the spine to
bring in rapid control in that area so that the persons recovers quickly
from the paralysis. Radiotherapy is also used when the disease presents
as a localized tumour (Solitary plasmacytoma) Dr.R.Suthanthirakanan Forty years after the report of a successful liver transplant in the US, India has now emerged as a chosen destination for liver transplantation in Asia. This was achieved in a short time span of four years. Now the transplant program in New Delhi which is one of the few centers in Asia, boasts of 75,liver transplants for adults and children, for cirrhosis and fulminant hepatic failure, using both techniques of whole cadaver organ as well as that of partial liver donated by live related donors. But there is still a very long way to go. For starters the number of patients who many need and afford liver transplantation in a given year in India is likely to be at least 15000. The acute shortage of cadaver organ in the country would mean, most of them would need live donors. Since the technique of live donor transplantation in adults is relatively new and extremely challenging, there will be fewer centers that will emerge to offer this service. To compound it all the rampant increase in alcohol abuse, prevalence of hepatitis – C, and B, lack of universal immunization of hepatitis B and lack of screening of blood products for hepatitis – C, in majority of blood banks are bound to increase the number of productive youth in our country with end stage liver disease. The patients in India are extremely malnourished from poor dietary advice and vegetarianism. They also tend to have concomitant infections such as candidiasis and urinary infections more often Nearly 40% have co – existing renal dysfunction and diabetes. Since most patients report very late to the transplant center, they do not have adequate time to undergo adequate rehabilitation prior to transplant. Indications and contraindications to liver transplant Most patients with acute fulminant liver failure and almost all patients with cirrhosis need liver transplantation. The upper limit for transplant is 70 years and there is technically no lower age limit. Patients with HIV, advanced liver cancer with cirrhosis, secondary or primary cancer in the liver without cirrhosis, advanced coronary artery disease, moderate / severe pulmonary hypertension, advanced Coronary artery disease and Porto mesenteric venous thrombosis are essentially absolute contraindications for liver Transplant. When is liver transplant recommended? Timing of referral is the key to good survival after liver transplant. Generally patients who show early signs of functional decompenstation of the liver have a median survival of 18 months only. Hence it makes sense to start sensitizing the patient to his/her disease and prognosis at this stage. Clearly none of these patients stand a chance to survive without liver transplant beyond 18 months after onset of synthetic dysfunction. The biochemical evidence of decompensation is apparent from blood tests that include albumin levels and prothrombin time. Physically it shows as recurrent loss of blood from gut like vomiting blood or repeated accumulation of fluid in the abdomen. Liver transplant is also indicated in early stages of liver cancer. However this rule does not apply to cholestatic liver disease patients like Primary biliary cirrhosis, where the bilirubin level and onset of ascites alone are considered grave prognostic indicators and one should not wait for onset of synthetic dysfunction, to consider for liver transplant.
Techniques of liver transplant A candidate for liver transplant undergoes a mandatory and complete evaluation by multidisciplinary approach. The waitlisted patients then can either opt to stay on the cadaver organ Waitlist or choose to have a live donor partial liver transplant. Patients with more urgent clinical need have to opt for live donor transplantation. The standard operation involves hepatectomy and removal of the diseased liver. This is also the most difficult phase wherein in the blood loss can be high. Once haemostasis (control over bleeding ) is achieved a new whole cadaver organ is transplanted in the place of the diseased one by re-connecting the blood vessels. Once the perfusion of the organ and haemostasis is satisfactory the bile duct is reconstructed usually by end-to-end connection. In the case of liver donor-left or right lobe liver transplant the steps are slightly modified in that the liver is removed, leaving the Vena Cava, intact. The venous drainage is created by connecting, the end of the hepatic veins with cava. Further the reconstruction may be more complex as multiple portal veins, hepatic veins, hepatic artery as well as the bile duct may be encountered. The right lobe reconstructions are more complex than the left lobe. The procedure may require up to 10, different intricate anastamoses, ( joining of blood vessels or tubular structures) some of which require microsurgery. The live Liver donation This is now a standard operation in selected center like ours. Nearly 65% of all transplants done at our center are using live related donors. The potential donors should be weight and blood group matched with the recipient. All liver donors are stringently screened were rejected based on volumes or other criteria of suitability. Donors with graft weight to recipient weight ratio of > 1 are usually selected for donation. Of course due consideration should be given to volume of the residual left lobe of the potential donor. The complete regeneration of the residual liver is achieved in 3 months. Live related liver donation has now come to stay in India as a standard life saving option for most patients requiring liver transplantation. Disease recurrence after liver transplant This is an issue that needs to be addressed with every potential candidate for liver transplant. Both hepatitis- B and C known to recur after the transplant. Nearly 40% of patients who undergo LT have either on of these causes. Hepatitis – C recurrence is almost universal and the current practice in our unit is to treat all patients with hepatitis-C after LT, with Alpha interferon and Ribavarin. This therapy may eliminate the virus in 30 – 40 % and in the rest help in delaying the progress of hepatitis and onset of full blown chronic liver disease. One can expect a good quality of life for 15 years or more after transplant for hepatitis – C induced liver failure. Economics of liver transplant Though liver transplantation is very expensive in most parts of the world, it can be carried out for 10 lakh rupees, due to lower health care coasts in India. The pre-operative expense is around 1 lakh rupees and the monthly expense after liver transplant is around seven to eight thousand rupees. It is a price well worth paying for a disease that has certain mortality. Result of liver transplantation 75 %of patients are live and well 5 years transplant at our center. This is a combined result of patients in all categories such as adults, children, acute liver failure and sick chronic liver failure patients who were on ventilator. A segregated analysis of outcome of liver transplantation at my center reveals that patients who are referred early and who are also the fittest have 85 % Survival. Dr.M.R.Rajasekar MS, FRCS 27.9.06 The L&T health centre in association with Prem Darshan
and the Trust had organized a cancer screening camp for the women in
and around Juhu at the St. Joseph’s church between 2.00 p.m. to
5.00 p.m. 37 ladies were screened and none of them had frank cancer.
The trust would like to thank Dr. Inamdar , the sisters of Prem Darshan
and the L&T health centre for the same.
A cancer awareness program for the workers of VVF Ltd.,
Sion was held at their canteen. More than 150 workers assembled for
the power point presentation. Many in the crowd were Gutka users and
smokers. A handful of them admitted usage and none of them wanted to
ask any questions during the session. A few came to clarify after the
session was over .One of them had bleeding gums and enquired whether
that was a sign of cancer. He was assured that it wasn’t and was
it was due to poor dental hygiene and a visit to dentist would solve
the problem. The trust would like to thank Mr. Vikas, Mr. Sandeep and
Ms. Ann for organizing this talk.
At the Shirodkar Hospital, Vile Parle 70 people assembled
to hear the talk on breast cancer basics. The talk was given by Mrs.Karthika
and was organized by the L&T Health Centre. When the risk factors
said late marriage a lady from the crowd said she has got married late
or will she definitely have cancer. The speaker assured her that it
is only a risk factor and she should undergo regular screening.. Mrs. Karthika Raju, a volunteer of the trust is also a volunteer of the L&T health centre and has been giving breast cancer awareness talk for quite sometime now. The Prerna Mahila Samaj Vikas Sangh, an organization had arranged a talk in the slums of Milind Nagar, Powai. More than 80 people who had gathered there listened to the signs and symptoms of breast cancer dumbfounded. They never wanted to ask questions despite the speaker willing to clear any small doubt. Cancer of cervix was also touched upon and then many ladies came forward with gynaec problems. They were asked to come to L&T Health centre on Friday at the Well woman clinic, and were assured that if it any of them had early signs of cancer, the trust would take care of them. 12.10.06 – Bandra 15.10.06
Giants Group of Powai had organized a medical camp at the Powai English High School wherein the Trust took up the task of cancer screening. Between 10 am to 2 pm people thronged to get examined in dental and eye departments but very few walked in to get examined for cancer. As usual the fear of being detected with cancer was the deterring factor. After volunteers provided counseling the response was better. A total of 30 men and 30 women were screened for cancer on that day. Fortunately none of them were detected to have frank cancer. The trust would like to thank Mr. Apukutan from Giants group and the Drs. Padma Ramakrishnan, Anupama Rao, Deviprasad Giani and Jiten Chowdhry for the smooth conduct of the camp. . Stalls in syntel
17.10.06 - Chennai
It was already 4 in the afternoon; she had to complete the shirt she was sewing the last half hour. Her children would be back from school and she had to make tea for them. She ran the machine faster, completed the shirt, shut the machine and involuntarily her hands folded to bow at it. Yes it was like a god to her, the machine had supplemented the family income and thanks to it the five children were studying in good schools. Her husband had worked very hard to own the small 2-room house that they were staying in, a great luxury in the city of Mumbai. A loan was taken which had to be repaid and she chipped in by exploiting her talent in sewing and hand embroidery. Praising the lord she got from the stool and a violent spasm rocked her abdomen. She just collapsed on the floor. When she recovered she realized that she had developed uterine bleeding. Only the previous week she had completed her periods, then how come again. Something is wrong! Late that evening she consulted her neighbours, some remedies were suggested and she took them.. Few days passed the bleeding did not abate and she went on to developed foul smelling discharge. This got her worried further. She related this to another neighbour who narrated the story of one of her relatives who was discovered to have cancer when she had such symptoms. Cancer! I will get it sorted, she decided. Next morning she was at the Tata memorial Hospital with her husband. Out there they examined her, conducted several tests and confirmed the diagnosis of cancer. All the courage that she had built up, suddenly vapourized. The fear had become a reality, which was difficult to accept. Eyes welled up with tears and body trembled with fright. Nothing could comfort her, not even the soothing words of the doctor and the fact it was confined to small area in her uterus and she could be easily cured. If death is inevitable let it be now, was last thought when she blacked out. When she awoke, she found herself in the bus, her husband by her side eagerly look it at her. “Kiran tumhe jeena hai, hamare liye … ( Kiran you have to live , you have to live for us ) “. I will she said and a smile fought its way out on her face. The very next morning they were at the hospital. The doctor said that she needs a few cycles of chemotherapy after which she will be operated upon. The costs and other details were explained to them. It seemed that it was going to be an expensive affair. But they were sure that they would find to way get the resources. I will stitch more clothes added Kiran. Sure said her husband and signed the consent form. The treatment would begin the following day. While waiting for chemotherapy the next day, she noticed the odd dress of the patient beside her. She got curious and asked the lady why she had dressed so. The lady let out a wail. “My fingers have become numb after they injected those drugs to cure my cancer and now I can’t even wear my sari “, she said. This shocked her. If she is unable to drape her sari, then where is the question of sewing or embroidery? Kiran did not want to burden her husband and drive him to bankruptcy. It is better that I am dead. That was irrational said her husband. But who was listening .She took hold of her husband and staged a run outside the hospital and nothing could stop her. The family of kiran was not willing to give up .Her husband made attempt after attempt to convince her. At times he would bring their only son in front of her and say “ for his sake kiran “. After several pleas and persuasion, she agreed to a treatment with an ayurvedic physician whose medicine was cheap and that would not numb her fingers. She took them religiously, but there was no sign of getting better. Instead the bleed continued and one day in a state of shocked she rushed to a hospital nearby. She was revived with few units of blood. And her uterus was removed shortly after that. The near death experience had softened her attitude to treatment and she agreed for Radiation but not chemotherapy. The cost was again an issue. Fortunately the hospital authorities promised heavy discounts. Yet they required finances for the ancillary care and to keep the home fires burning. The house was already in mortgage and whatever the jewels they had were sold off to pay for the previous treatment. And they had no one to look forward to other than the neigbours. They too distanced. One by one the household articles were finding a place at the pawnshop. On one not so fine morning the only thing that seemed disposable was the sewing machine. The sacrifice of a life giver to sustain life in her! That is when somebody informed her about our Trust and our rehabilitation program. The trust immediately intervened and prevented the sewing machine from being sold off. The further treatment would also be taken care off it was assured. It was like a messiah handing over life back to her sans the guilt of murder. An equipment which gave birth to numerous episodes of happiness, an equipment which bailed them out off several crises and an equipment which promised many more moments of joy was ready to be sacrificed to retain life in her body. When such mishap was averted the joy knew no bounds in her. She completed her treatment in few days and her home was soon whizzing with noise of the sewing machine. And when that stopped its motion her hand would thread needles and weave beautiful designs on handkerchiefs. Each day she embroidered at least 20 kerchiefs! For the trust it was a state immense satisfaction looking after Kiran Singh. For the little help it had done the reward was huge. A life leased, a guilt expelled and a family rejuvenated The happiness in the eyes of kiran, her husband and her 5 children and the happiness in the numerous eyes of persons who purchase the embroidered kerchiefs catapults us to a state of absolute bliss. Believe us, it has been such state since we began our cancer survivors rehabilitation program this February.
Since February 2006 , under the banner of Cancer survivors Rehabilitation Fund , the trust has given pensions , unemployment allowances, taken care of education and given vocational support . This program received a big impetus on the 12th Oct 06. ROSHNI, an organization run by a few illumined minds from a suburb in Coimbatore, Vadavalli , contributed 3 lakh rupees towards this fund. In a special function Mr.Krishnaraj Vanavarayar , Chairman , Coimbatore Kendra of Bharatiya Vidya Bhavan ,presented this cheque on behalf of ROSHINI. The trust is immensely thankful to Mr. R. S. Raman and his colleagues for their sincere effort to raise such a huge sum in short period of 6 months! Like ROSHNI many of you can join in our effort to make a survivors life as beautiful as before the cancer and perhaps more worthy. You may contact the trust offices for further details.
|
