Embryonal Tumor Treatment for International Patients in India

Embryonal tumor treatment

Embryonal tumors are rare, and aggressive childhood brain tumors, which develop in undeveloped (embryonal) cells in the brain or spinal cord. Treatment is based on the type of the tumor, its location and stage as well as upon the age of a child and requires a multimodal approach of surgery, radiation and chemotherapy. This is a summary of embryonal tumor treatment:

Surgery

• Objective: Maximal safe removal (resection) of the tumor.
• Neurosurgeons attempt to excise as much of the tumor as is possible without injuring important brain structures.
• In certain instances, where it is not totally possible, surgery is followed by other line of treatment.

Radiation Therapy

• It is also effective in treating cancer cells left after an operation.

Techniques include:

• Craniospinal irradiation (CSI) - involves the treatment of the brain and spinal cord because such tumors may be spread using the cerebral spinal fluid.
• Proton beam treatment - becoming more popular in children because it is less likely to have long-term side effects.
• In small children, radiation can be delayed or reduced because they can be damaged in development.

Chemotherapy

• Plays a very important role in children below 3 years where the radiation is risky.

Delivered:

• As an IV dose and orally (IV/oral)
• Administered intrathecally (into CSF) to kill cancer cells residing in spinal fluid
• In aggressive cases then high dose chemotherapy with stem cell rescue can be an option.

Targeted, Novel Therapies (Clinical Trials)

• Tumor molecular profiles (e.g., subgroups of medulloblastoma, ATRT mutations) are used to determine personalized treatment.
• Current trials assess the effect of the virus on humans.
• Drugs of a selective action (e.g. SMO inhibitor in SHH-subtype medulloblastoma)
• Immunotherapy approaches
• CAR-T cell therapy (preliminary research phase)

Rehabilitative Support

• They use steroids to lower the swelling of the brain.
• Shunts or endoscopic third ventriculostomy (ETV) for hydrocephalus.
• Long-term therapy: speech, motor and cognitive therapy.
• Hormone replacement where there is impaired pituitary functioning.

Embryonal brain tumor diagnosis

Embryonal brain tumor diagnosis is comprised of clinical assessment, imaging analysis, pathology and molecular studies to adequately diagnose the tumor type and advise therapy. This list is a detailed one:

Medical History and Physical Exam

Symptoms review:

• Headache, nausea/vomiting (in the morning, usually especially bad)
• Problems with balance and coordination
• Changes in Sensory underdevelopment
• Irritability, Behavioral changes and developmental regression (in children)
• Neurological assessment: Neurological assessment of reflexes, muscle strength, eye movement, sensory, and co-ordination.

Imaging Studies

• MRI (Magnetic Resonance Imaging) - standard imaging issue in brain tumor diagnosis.
• To get the size, location and extent of the tumor using contrast and without using contrast.
• MRI spine will be performed to ensure that there is no Cerebrospinal fluid spread.
• CT Scan - occasionally done in emergent cases, can be used to determine hydrocephalus or bleeding, but is not as much information than MRI.

Spinal Tap or Lumbar Puncture

Looks at cerebrospinal fluid (CSF) to:

• To investigate the tumor cells (to detect metastasis via the CSF routes).
• Biomarkers.
• This is usually performed post-surgery, to avoid the possible risk of herniation in cases where there is high pressure inside skull.

Biopsy / Surgery

• Tissue diagnosis is imperative

Either through:

• Surgery (removal of the maximum amount of possible tumor).
• Stereotactic biopsy (tiny sample when undertaking resection of tumor may prove hazardous).
• The pathologists can then classify the tumor according to WHO classification of embryonal tumors of the CNS.

Molecular Testing & Histopathology

• Microscopically, embryonal tumor characteristics (small, round undifferentiated cells) are seen.
• Subtypes can be differentiated using IHC.    

Molecular/genetic profiling (extremely significant in the diagnosis recent times):

• Subgroups of medulloblastoma (WNT, SHH, Group 3, Group 4).
• TERT (ERCC4/XP8) (loss of SMARCB1 or SMARCA4 genes).
• C19MC amplficaton.
• Molecular classification has an effect on both prognosis and the form of treatment to be used.

Additional Tests

• Blood tests- general check-up, eliminating metabolic causes.
• Neurocognitive testing - trailer prior to treatment
• Genetic counselling- in case of suspicion of an hereditary cancer syndrome (e.g. Li-Fraumeni syndrome, Gorlin syndrome).

Best hospitals for embryonal tumor treatment

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Embryonal tumor symptoms and therapy

Signs of Brain Tumor of the Embryonal Type

Given that these tumors can develop quickly and hence commonly impede CSF circulation, symptoms tend to surface abruptly and vary according to location (they commonly occur in the cerebellum, brainstem, or supratentorial areas). Common Symptoms:

Elevated pressure in Intracranial

• Headaches seen in n the morning
• Nausea/vomiting
• Excessive sleepiness in youngsters or temperament in children

Coordination and Balance Problems

• Difficulty in the walking or clumsiness
• Loss of fine muscles

Eye sight and hearing problems

• Doubling of vision, loss of clarity of vision, jerking of eyes (nystagmus)
• The deafness in certain types of tumor

Scientific or behavioural modifications

• Decreased school grades
• Mood or character change

Seizures (seen more frequently in embryonal tumors of the supratentorial part). Hydrocephalus (accumulation of fluids because of CSF obstruction) 3- Increased head circumference in infants.

Embryonal Tumor Treatment (Therapy)

Treatment is multi modal and consists of surgery, radiation and chemotherapy individualized by age, tumor type and molecular characteristics.

Surgery

• Primary treatment: look for maximum safe resection.
• It decreases pressure (hydrocephalus) and supplies tissue to be diagnosed.

Radiation Therapy

• Administered post-surgery in the majority of the patients (with the exception of very young children).
• Craniospinal irradiation (CSI) targets possible disease spread and tumor.
• It facilitates less late-term effects in children using proton beam therapy.

Chemotherapy

Frequently used with surgery and/or radiation.
Specifically, it is important in children under the age of 3 years at which point avoidance or delay of radiation is of importance.

May as well as given:

• Intravenously (systemic)
• Into the CSF (intrathecally)
• High-dose chemotherapy and stem cell rescue as a treatment of aggressive disease.

Targeted / New Treatments

On molecular subtype:

• Medulloblastoma (WNT, SHH, Group 3, Group 4) have different prognoses and therapies.
• TRTD BLINDTT implemented successfully.
• TMR -> very aggressive, clinical trials normally will be taken into regard.

Supportive Care

• Use of steroids to curb brain swelling.
• Surgery to treat hydrocephalus Placement of shunts or ETV.
• Physical/speech/cognitive therapy: physiotherapy, neurocognitive support.
• Endocrine treatment when pituitary / hormonal functions are impaired.

Advanced embryonal tumor treatment in India

High-risk (advanced), metastatic, or recurrent disease includes the use of a more intensive and experimental treatment approach, as compared to the standard therapy. These are aggressive tumors, and they have a higher likelihood of either spreading because of cerebrospinal fluid (CSF) or symptoms recurrence after initial treatment. Here is summarised advanced embryonal cancer treatment:

Surgery

• The initial complement maximally safe resection although in advanced disease.
• Recurrent tumours can be operated again, provided it is possible.
• Surgery is also effective in reducing tumor bulk prior to an aggressive adjuvant therapy.

High-dose Chemo-therapy with Stem Cell rescue

• Chemotherapy with high doses are able to be used in case of aggressive or recurrent cases.
• These doses kill bone marrow, and to reestablish marrow function, autologous stem cell transplant (HSCT) is completed.
• Primarily in Atypical Teratoid/Rhabdoid Tumors (ATRT) and in recurrent medulloblastomas.

Radiation Therapy (Advanced Methods)

• Standard treatment CSI is to be applied in case of metastatic disease.
• The use of proton beam therapy is the more preferable method in children to minimize the long-term toxicity.
• Recurrence in a few cases can be sent to focal re-irradiation.
• SRS of small recurrences.

Molecular based (Targeted Therapy)

On the basis of the tumor genetic/molecular profile:

Medulloblastoma subtypes:

• NTC -> usually good prognosis
• SMO- HH (may respond to SMO inhibitors e.g. vismodegib, sonidegib).
• Group 3/ 4- still in clinical trials.
• SMARCB1/SMARCA4: mutations-driven: new and emerging therapeutics under investigation include EZH2 inhibitors and aurora kinase inhibitors.
• There is a very aggressive, clinical trial-based approach to TMR.

Immunotherapy (Emerging)

• In some subtypes, immune checkpoint inhibitors also (PD-1/PD-L1 inhibitors) are used in trials.
• CAR-T cell therapy (genetically modified T cells that are directed against target cancer antigens encompassing preclusion clinical trials appear promising.
• Oncolytic viruses- experimental therapy where viruses select avoid kill tumor cells

Clinical Trials

• Advance embryonal tumors will often require enrolment in a clinical trial to gain access to therapy of the cutting edge.

The trials may include:

• New combinations of chemotherapy
• Targeted drugs
• Immunotherapy approaches
• Cutting pulsed photon and proton radiation

Supportive and Palliative Care

• Treatment of hydrocephalus: stake or endoscopic third ventriculostomy.
• Anti-inflammatory steroids.
• Physical, speech, and occupational therapy.
• In 4th stages, support and quality of life management are very important.

Embryonal tumor specialists in India

• Dr. Mukesh Patekar
• Dr. Ashok Kumar Vaid
• Dr. Kunjahari Medhi
• Dr. Vedant Kabra
• Dr. Niranjan Naik
• Dr. Ramandeep Singh Arora

Embryonal tumor treatment in India by GetWellGo

GetWellGo is a medical tourism service provider that assists foreign patients to avail the amenity of the high end brain and neuro-oncology at India. They collaborate with other hospitals and professionals who are well-known to ensure that they treat brain tumors such as embryonal types. They offer services in cost estimation, travel organisation and hospital facilitation.

How GetWellGo Can Help (particularly in the case of embryonal tumors)?

Embryonal tumors such as medulloblastoma, ATRT or ETMR are aggressive and frequently require multi-modality treatment including:

• Maximal safe tumor removal neurosurgery
• Radiotherapy (usually craniospinal radiotherapy, perhaps proton beam)
• Chemotherapy may be high-dose with the use of stem-cell rescue
• And more to the point, molecular diagnostics to inform therapy

India possesses:

• High-tech imaging (MRI, functional MRI, CT, spectroscopy)
• Expert multidisciplinary teams in top hospitals
• More cost effective than most of the Western countries

Why Choose GetWellGo for Embryonal Tumor Treatment?

GetWellGo is regarded as a leading supplier of healthcare services. We help our foreign clients choose the best treatment locations that suit their needs both financially and medically.

We offer:

• Complete transparency
• Fair costs.
• 24 hour availability.
• Medical E-visas
• Online consultation from recognized Indian experts.
• Assistance in selecting India's top hospitals for Embryonal Tumor treatment.
• Expert oncologists with a strong track record of success
• Assistance during and after the course of treatment.
• Language Support
• Travel and Accommodation Services
• Case manager assigned to every patient to provide seamless support in and out of the hospital like appointment booking
• Local SIM Cards
• Currency Exchange
• Arranging Patient’s local food