Nuclear Medicine Therapy for Cancer Treatment in India

Nuclear medicine is a specialized branch of radiology that involves the use of radioactive materials (radiopharmaceuticals) for diagnostic and therapeutic purposes. Nuclear medicine imaging is used to examine the structure and function of the internal organs and help diagnose an abnormality or disease at an early stage. This branch of medicine is also being used to treat certain forms of cancer and diseases.

Nuclear-Med-India

Nuclear medicine imaging

For diagnostic procedures, a relatively small amount of radioactive materials is used to help visualize the organs which helps the doctor locate and identify the abnormality, size of any tumors and other physiological or functional problems of an organ.

The doctor can also monitor the disease progression and response to treatment using this technique. During the procedure, radiopharmaceutical agents are injected into the patients and PET (Positron Emission Tomography) or SPECT (Single Photon Emission Computed Tomography) cameras are used for imaging. These techniques can read the emission spectra produced by the radiopharmaceutical agents used.

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Nuclear Medicine Therapy

Nuclear medicine is a technique that uses a small dose of radioactive material for the diagnosis and treatment of various types of abnormalities. Use of nuclear medicine in the treatment of diseases is typically offered to patients with Thyroid Cancers or overactive thyroid gland, Neuroendocrine tumours, Prostate cancers, Lymphomas and Liver tumours.

This targeted therapy approach uses a small amount of radioactive material or radioisotope, called Radiopharmaceutical, to damage the cancer cells. The radioactive compound is conjugated with a tumour-targeting agent to deposit lethal radiation into the tumour. It can be administered in the form of a drink, injection or capsule.

How does Nuclear Medicine therapy work?

Nuclear Medicine Therapy is an upcoming field of medicine in which precision treatment methods are used in combination with molecular imaging techniques. It uses molecular diagnostic techniques for the identification of the disease, uses the same method to deliver a dose of radiation specifically to the affected site (abnormal tissues).

It is based on the concept of “Theranostics” – a revolutionary field that focuses on delivering the right treatment at the right time and with the right dose for every patient.

Some examples of this approach include Iodine-131 to treat an overactive thyroid gland and thyroid cancer, PRRT for neuroendocrine tumors and PSMA therapy for prostate cancer.

The radiation from the radioactive material affects the cancer cells or other disease cells more than normal cells. The radiopharmaceutical compound can eventually kill the cancer cells or shrink the tumor.

This works by –

Radioactive material is a naturally occurring or man-made compound that releases radiation energy. The radioactive material or radiopharmaceutical compound can be used to kill cancer cells or help control the disease progression. The material can be in the form of solid, liquid or gas, and can be delivered to the target cells in different ways for different parts of the body.

For instance, radon is in gaseous form and can be inhaled for treatment whereas radioiodine is given as a capsule or liquid and is swallowed. Every type of radioisotope has its own half-life, which determines when it will stop being radioactive.

Popular Nuclear Medicine Therapies in India

Lu PSMA Therapy

Lutetium Prostate-Specific Membrane Antigen (Lu-PSMA) therapy is a treatment for patients with advanced-stage prostate cancer or those who have become refractory to standard treatment approaches. The therapy is a high precision treatment that can help prevent damage to healthy surrounding tissue while delivering high dose radiation to the tumour cells.

The therapy aims to:

  • Stop multiplication of tumour cells or slow their growth
  • Reduce tumour size
  • Provide relief from symptoms such as pain caused by cancer and improve the quality of life of the patients

How does it work?

Prostate-Specific Membrane Antigen (PSMA) is a unique receptor present on the surface of cells of the prostate gland. PSMA is overexpressed in prostate cancer cells and increases with tumour progression. If cancer spreads to the other parts (metastasizes), the PSMA receptor also appears on the sites where cancer has metastasized. Therefore, this receptor is an excellent target for nuclear imaging as well as treatment for prostate cancer.

The radionuclide therapy uses a molecule that can attach to the PSMA receptors present on the cancer cells in the body. Lutetium-177 is a radioactive element that emits low-energy beta radiations that can damage or kill the cancer cells when in close proximity. In Lu PSMA therapy, the radioactive substance is bound to a small protein molecule that can attach to the PSMA receptor on prostate cancer cells. This Lu-177 – PSMA complex targets the prostate cancer cell specifically and emits radiation to destroy these cells. As the penetration of the emitted beta radiation is low, it does not affect the healthy normal cells near the tumour.

Who are the suitable candidates for Lu PSMA?

Currently, the therapy is being offered to patients with advanced castration-resistant prostate cancer that is metastatic and has evidence of cancer progression.

Tumour progression can be determined by:

  • High serum PSA levels
  • Increase in the tumour size or number of the metastatic lesions as seen by CT/MRI scan or Ga68 PSMA scans
  • Worsening of pain or other symptoms

Contraindications

  • High-grade renal insufficiency
  • Bone marrow depletion
  • Acute haematological problems

Lu PSMA therapy is not contraindicated to patients having subsequent chemotherapy or radiation therapy if needed.

Procedure: 

  • The patient is admitted to the hospital for 24 hours and has to stay in a Specialised High Dose Radioisotope Therapy Unit for radiation protection.
  • Lu177-PSMA compound is administered intravenously as an infusion.
  • MAG3/EC scan, a kidney function test, is done before Lu177 PSMA is administered.
  • Usually, patients are hydrated with intravenous fluids and an amino acid solution before and after Lu177 PSMA administration. This is to protect the renal functions.
  • Most patients need 3-4 treatment cycles with an interval of 8-12 weeks. The number of cycles, as well as interval duration, varies on the basis of the patient’s response to the treatment and medical assessment.
  • The average dose of the Lu 177 PMSA is in the range of 5.5 – 11GBq per treatment cycle. Required doses for every patient is determined on the basis of pre-treatment dosimetry (calculation of the ionising radiation dose absorbed by the human body).

Outlook 

Lu PSMA Therapy is a highly specific and precise therapeutic technique that has been showing great potential for the management of metastatic prostate cancer especially when other types of treatment methods fail to show improvement.

After Lu177 PSMA therapy, Over 70% of patients have experienced a reduction in Prostate-Specific Antigen (PSA) level and a reduction in tumour size. Almost all the patients had a reduction in pain and an overall improvement of health following the second dose of therapy.

Side effects

Lu PSMA is typically well tolerated by patients and does not have any significant adverse effects following the injection.

Some common side effects include a slightly dry mouth, tiredness and nausea. There may be a small drop in the number of white blood cells and platelets around 2 – 3 weeks after the Lu177 PSMA therapy. The side effects are usually mild and temporary. Patients recover soon without any treatment and the risk of serious or life-threatening complications is very low.

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PRRT – Peptide Receptor Radionuclide Therapy

Peptide Receptor Radionuclide Therapy is a radioisotope therapy (also called molecular therapy) that is used for the treatment of certain types of cancer called Neuroendocrine Carcinoma or Neuroendocrine Tumours (NETs). The therapy is approved by the U.S. Federal Drug Administration (FDA) for the treatment of NETs that originate from the stomach, intestine or pancreas (carcinoids and islet cell carcinomas of the pancreas). Other types of NETs that can be treated with PPRT are pheochromocytoma, a rare tumour of the adrenal glands and rare thyroid cancer that does not respond to treatment with radioiodine.

Suitable candidates 

The treatment with PRRT is offered to patients who –

  • Have advanced stage (metastatic) or progressive NETs
  • Are not eligible for surgery
  • Fail to show improvement with other treatment options

How it works?

For PRRT therapy, a cell-targeting protein or peptide molecule (octreotide) is attached with a radioactive compound, also called a radionuclide. This results in the formation of a special type of radiopharmaceutical known as a Radiopeptide. This radiopeptide is injected into the patient and it reaches the neuroendocrine tumour and binds itself to the cancer cells. The radiopeptide then delivers a high dose of radiation to these cells. The most commonly used radionuclides in PRRT are Yttrium 90 (Y-90) and Lutetium 177 (Lu-177). The peptide molecule, octreotide, is a laboratory synthesized version of a hormone (somatostatin) that binds to a specific receptor present on most neuroendocrine tumours.

The aim of PRRT is to:

  • Provide relief from the symptoms
  • Stop or slow the progression of tumour
  • Improve overall survival

Procedure 

The number of sessions and procedure details depend on several factors such as the type of cancer and the hospital facility. A patient usually needs four to six sessions but may vary up to 10 PRRT sessions, given a gap of two to three months.

  • The treatment is usually done as an outpatient procedure but may require hospitalization for a few days, depending upon the type of radionuclide used.
  • A session takes approximately four hours.
  • Patients are given an Amino Acid Solution intravenously before each PRRT session, to protect the patient’s kidneys from the radiation effects.
  • The radiopeptide material is then injected into the patient’s bloodstream.
  • An additional Amino Acid Solution is also administered at the end of the session.
  • Sometimes, Molecular Imaging Scans may be done during and after the treatment process to follow the path of injected radiopeptide inside the body.

As a small amount of radiation may remain in the body after the therapy, the patients are advised to follow precautions post-treatment, especially for the first few days. After discharge, the radiation safety protocol provided by the doctor has to be followed. This includes maintaining a safe distance from other people for some days post PRRT therapy. It is also important to take care of the bathroom hygiene as per FDA recommendation as the remaining radionuclide leaves the body through urine and faeces.

Outlook 

While PRRT has been reported to be an effective treatment option for controlling advanced progressive Neuroendocrine Tumours, it is not a cure. Patients with Gastroenteropancreatic NETs who cannot undergo surgery are typically treated with hormone therapy. But when tumours still continue to grow despite this treatment, PRRT therapy is offered to control symptoms and tumour growth.

Advantages of PRRT

Molecular therapies such as PRRT provide more personalized and precise cancer treatment. The radionuclide can be customized to the specific biological characteristics of a patient and molecular properties of the tumour.

PRRT is a targeted therapy as the radiopeptides selectively attach and damage the neuroendocrine tumour cells. This limits radiation exposure to the healthy tissues around the tumour.

As the surrounding healthy tissues are not affected, the therapy has fewer side effects in comparison to chemotherapy.

Risks and Side effects of PRRT

The major risks associated with PRRT arise from radiation toxicity. This may affect the production of Red Blood Cells, White Blood Cells and Blood Platelets, and kidney functions as well as liver functions.

Some common side effects of the PRRT for neuroendocrine tumour treatment include:

  • Nausea
  • Vomiting
  • Abdominal discomfort or pain

The less common side effects of the treatment include subacute haematological toxicity and temporary hair loss. Although serious hematologic toxicity is rare, some patients may have delayed toxicity to the kidneys and develop renal insufficiency.

I-131 MIBG Therapy

Meta Iodo Benzyl Guanidine (MIBG) therapy is a novel method of treatment for patients with high risk advanced neuroblastoma including relapsed or refractory tumours. Neuroblastoma is a cancer of nerve tissue that mostly affects infants and young children. 

 

This is a precise treatment that uses radiopharmaceuticals – radioactive iodine (I-131) to deliver radiation specifically to the tumour cells. MIBG therapy is a novel method that is more effective, less painful and less time-consuming (hospital stay) than other therapies.

 

How does it work?

MIBG is a complex that can be absorbed by some type of nerve tissue and neuroblastoma cells. This happens because MIBG is very similar to norepinephrine/noradrenaline, the neurotransmitter chemical, that is normally taken up by nerve cells. 

The therapy combines MIBG with beta-emitting isotope I-131 to selectively target the tumour cells and deliver the killing radiation to these cells. I-131 MIBG aims to damage the cancer cells precisely and prevents harm to the surrounding healthy tissue. 

 

Procedure 

  • The patient is admitted to the special Nuclear Medicine Therapy Room or Radioisotope Therapy Isolation Room. 
  • The I-131 MIBG is a clear fluid that is administered through an IV or a central venous catheter over a period of three to four hours. 
  • The patient will be simultaneously given fluids for hydration and other medications if required.
  • The hospital of the three to five days is usually required for the therapy. Sometimes, the child may have to stay longer so that the radiation level comes down to the safe level. 
  • The radiation level is checked every day at the hospital by the Radiation Safety Officer (RSO)

The patient will need to take oral medication to prevent thyroid damage caused due to the radioactive iodine in the I-131 MIBG. The medicine will be given before the treatment begins and will be continued for three weeks.

 

Caution 

While most of the radioactive drug concentrates in the tumour cells, it also travels to bodily fluids such as sweat, spit, and urine – and still remains radioactive. People around the patients such as the caregivers are vulnerable to radiation exposure and need to take certain precautions. The patients are admitted to the specialized high-dose radioisotope therapy isolation room which is designed with lead walls and floors to minimize radiation exposure. The caregivers are supposed to stay behind the portable lead sheets surrounding the patient’s bed. As the patient’s bodily waste such as urine is also radioactive, special lead pipes are used to discard it and stored in a special waste storage facility. The waste in kept here for three months, after which it can be disposed of as normal medical waste

The radiation safety officer and doctors work closely with the parents of the children receiving the therapy to provide the day-to-day care.

 

At home:

A small amount of radioactivity still remains in the body even after the levels come down to a safe mark. Therefore, after discharge from the hospital, the doctor provides safety instructions that should be followed at home. 

The caregiver has to ensure that the post-discharge follow-up is implemented after the discharge. This includes:

  • The child continues to take the Thyroid Protecting Agent for four weeks, as instructed by the doctor.
  • Having a Complete Blood Count (CBC) at least twice a week after leaving the hospital.
  • The patient will most likely require platelets and red blood cell transfusions for a few weeks post-therapy.
  • If the Neutrophil count falls below 0.75, the patient may need GCSF (Granulocyte Colony Stimulating Factor), a type of growth factor to help the white blood cells recover from the treatment. Depending on count recovery, the child may require reinfusion of his/ her stem cells.
  • A follow-up MIBG Scan to be done 9-12 weeks post-treatment.

Outlook 

About 30-40% of children with refractory or relapsed neuroblastoma have shown improvements in I-131 MIBG therapy. This makes it one of the most active agents for relapsed disease. The therapy may not cure the disease but it allows the patients to have more control over their condition and makes it possible to have a prolonged disease stabilization.

 

Potential risks and complications

Common side effects include nausea, dry mouth, irritation in salivary glands and reduced number of blood cells (red and white) and platelets produced by the bone marrow. The patient may need transfusions for blood and platelet as well as stem cell infusions.

 

Some less likely side effects include a decrease in thyroid function. This leads to problems such as fatigue, weight gain, and constipation. Patients may also require lifetime treatment with a supplement for the thyroid gland. Other problems such as infertility, high or low blood pressure, thinning of hair, infection because of low white blood cells. Patients may also have bleeding or bruising due to low platelets along with loss of appetite.

Vanshika Rawat

Written By Vanshika Rawat

Vanshika Rawat is an experienced content developer. She is very knowledgeable in the field of science and healthcare and has worked under brilliant scientists during her higher education. Vanshika obtained her degrees in Masters in Science and Bachelors in Science (Microbiology with Hons.) from renowned institutions - Panjab University and University of Delhi.
Dr. Surbhi Suden

Verified By Dr. Surbhi Suden

Dr. Surbhi Suden is one of the founders of Lyfboat and a doctor with a renowned name in the Medical tourism industry. She has been working with international patients since 2008 and is a deeply committed professional with a long term vision of transforming the current healthcare scenarios.

India’s healthcare industry is a highly advanced sector that offers treatment with the latest technology available in the medical field. Nuclear medicine therapy is a novel approach for treatment of advanced stage cancer that is refractory or relapsed or treatment of diseases that are fail to be managed with other methods. These therapies are delivered at sophisticated medical facilities that are specifically designed to use radioactive material for treatment.

Nuclear medicine therapy in India is offered by the top hospitals such as Fortis Memorial Research Institute. The department of Nuclear Medicine at FMRI is a dedicated unit equipped to perform different types of Radioisotope therapies. It is the referral centre for Iodine therapy for thyroid cancer in the country and a pioneer centre in Lutetium therapies for Neuroendocrine tumour. It is the first-of-its kind centre in India for Lutetium PSMA therapy and has been treating many patients with this therapy. FMRI’s Nuclear Medicine department is currently the only centre in India to offer myeloablative MIBG therapy for high risk neuroblastomas for paediatric cases and the first centre to offer Targeted alpha therapy for neuroendocrine tumours, prostate cancer and certain brain tumours.

The best Nuclear Medicine therapy hospitals in India maintain high safety and quality standards to ensure reliable treatment. A team of dedicated radiation specialists and nuclear oncology experts along with Radiation Safety Officer provide effective care to the patients. Each step of the therapy is monitored by the team to ensure stringent quality protocols are in place.

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