GOOD MORNING DOCTOR Prof. John Kurakar (a heart touching experience of cancer treatment) authored by Prof. John Kurakar CHAPTER 4 BEGINNING OF THETREATMENT

 

                     GOOD MORNING DOCTOR

Prof. John Kurakar

(a heart touching experience of cancer treatment) authored by Prof. John Kurakar

CHAPTER 4
BEGINNING OF THETREATMENT

In December 2021,on a Monday, we met with Dr. Sudheendra from the Gastrointestinal surgeryDepartment at Amrita once again. He thoroughly reviewed the biopsy report, CTscan, and CT scan CD. Our daughter, Dr. Manju Kurakkar, had arrived from Punefor the visit. Next, we consulted with the renowned oncologist Dr. Pavithran.He also examined the reports in detail and noted a small lesion in the thyroidgland. He recommended an immediate F.N.A.C. test. Subsequently, we met withRadiation Oncologist Dr. Haridas M. Nair, who spent over an hour explaining theseverity of the condition. He mentioned that surgery could only be considered if the size of the tumor near the throat and rectum was reduced, which wouldrequire both radiation and chemotherapy. He suggested that the course anddosage of radiation and chemotherapy could be discussed and finalized with him.That same day, we returned to see Dr. Sudheendra, who scan. PET scans are a type of imaging test that create three-dimensional of the inside of the body. PET stands for Positron Emission Tomography. A PETscan uses a small amount of radioactive material to highlight areas of the bodywhere cells are more active than normal, which can help in detecting conditionssuch as cancer. This scan is useful for identifying the location of cancer, aswell as determining if and where it has spread. A PET scan typically takesbetween 45 to 60 minutes, and you will need to be in the department for atleast one hour due to the radioactive liquid (radiotracer) injected before thescan. PET scans are often combined with CT scans to provide more detailedimages, resulting in a PET-CT scan. PET-CT scans help in determining whether amass is cancerous, deciding on the best treatment for cancer, and evaluatinghow well the treatment is working.PET scans aresometimes used to check for cancer in the lymph nodes located in the centralpart of the chest. Most PET scans require patients to refrain from eating forapproximately 4 to 6 hours prior to the procedure. Some individuals mayexperience claustrophobia during the scan. It is important to remove any metal objects such as hair clips, coins, belts, and underwire bras before the scan.While the procedure itself is painless, you will need to remain still, which may cause some discomfort. Additionally, you will hear continuous backgroundnoises during the scan. PET (Positron Emission Tomography) technique that provides unique insights into how an organ or system body is functioning. PET scans are primarily used to evaluate cancers, neurological (brain) disorders, and cardiovascular (heart-related) diseases. The PET scanner consists of a ring of detectors that encircle the patient, resembling a CT scanner in appearance. The scan is conducted by a healthcareprofessional known as a nuclear medicine scientist, in collaboration with anuclear medicine specialist. During a PET scan, a small amount of a‘positron-emitting’ radioactive substance, called a radiopharmaceutical, isinjected into the patient. This substance is painless and helps to highlightpecific areas within the body. The PET radiopharmaceutical, and a computer processes these emissions to createtwo-dimensional and three-dimensional images of the examined In PET scans, areaswhere the injected radiopharmaceutical accumulates—cells—appear 'brighter' on the images compared to normal tissues. Most modernPET scanners are integrated with CT scanners, allowing the PET and CT images tobe combined or fused. This fusion provides a more combining the structural information from the CT scan with the functional information from the PET scan, thus enhancing the accuracy of the diagnostictest. In these combined scanners, the patient passes through both the PET andCT scanners while lying on the same bed and maintaining the same position.


PET scans arehighly effective in early detection and monitoring of cancer. They can reveal changesin metabolism and the function of organs and tissues. PET scans often detectcancers before they are visible with other imaging techniques and can create awhole-body image to identify if and where cancer has spread. They are usefulfor distinguishing between malignant tumors and scar tissue. PET scans can assess brain function and detect abnormalities associated with neurological conditions. PET scans can evaluate heart function and identify issues related to cardiovascular health.The next morning, Iarrived at the hospital ready for the PET scan. The scan took about an hour and was completed by 9 AM. By around 10 AM, I met Dr. Haridas. He instructed me to return in two days to discuss the radiation plan and other details. By then, the PET scan report had arrived. The report indicated that there were some abnormalities near the lung in the chest area, so Dr. Haridas recommended a bronchoscopy before starting radiation therapy. Dr. Haridas discussed the matter in detail with Dr. Tinku Joseph from the Pulmonology Department. Dr. Tinku Joseph mentioned that he would be on leave for two weeks starting the following day and suggested performing the bronchoscopy after his return. Dr. Haridas emphasized that the patient's condition had progressed to a serious stage and recommended sending the patient to a nearby facility as it was very urgent. Given the urgency, I agreed to be admitted to the hospital immediately so that the bronchoscopy could be performed the following day.
Bronchoscopy is a diagnostic procedure used to examine the airways and diagnose lung diseases. It may also be employed during the treatment of certain lung conditions. A bronchoscope is the instrument used for this purpose and can be either flexible or rigid. The flexible bronchoscope, which is most commonly used, is a thin tube about half an inch (1 centimeter) wide and approximately 2 feet (60 centimeters) long. In rare instances, a rigid bronchoscope might be used. The procedure involves inserting the bronchoscope through the nose or mouth, down the throat, into the trachea (windpipe), and then into the airways (bronchi and bronchioles) of the lungs. I was taken to a specialized operating theater for the bronchoscopy. I remember being seated in front of a machine, receiving an injection in my arm, and having a liquid poured into my mouth before I lost consciousness. When I regained awareness, it was past 10 PM, and I found myself in a hospital bed. The next day, I was discharged and returned to the guest house. The following morning at 8 AM, I met Dr. Haridas M. Nair. He took me to the radiation room to prepare the radiation plan, marked my body, and completed other necessary tasks. After the examination and marking, I met with Dr. Haridas again. He recommended 25 sessions of radiation and 25 days of chemotherapy. This decision was made collaboratively by Dr. Haridas, Dr. Pavithran, and Dr. Sudhindran. Radiation and chemotherapy were to be administered 5 days a week. Following the sessions, I needed to undergo blood tests and present the results to the doctors. Only if the results were satisfactory would the next cycle commence. Each cycle required mandatory blood tests. I completed the radiation and chemotherapy over five weeks without experiencing hair loss.
Radiation therapy,or radiotherapy, is a cancer treatment method that uses high-energy radiationto destroy cancer cells. This therapy involves the use of X-rays and gamma raysto target and eliminate cancer cells.Radiation can be administered in primarilythree ways:Therapy: This method involves directing radiation from a large machine outside the body to a specific area of the body. Since the radiation comes from an external source, it is often referred to as "teletherapy."

2. InternalRadiation Therapy (Brachytherapy): In this approach, a radiation source isplaced inside or very close to the tumor. This allows for high doses of radiation to target the cancerous area directly.
3. SystemicRadiation Therapy**: This involves administering radioactive substances thattravel through the bloodstream to target cancer cells throughout the body.is an essential component of cancer treatment. It works by rapidly destroyingthe DNA (deoxyribonucleic acid) within cancer cells, thereby halting their abilityto reproduce. A combined approach involving surgery, chemotherapy, andradiation therapy is often used for comprehensive cancer treatment. The choice of treatment depends on the stage of the cancer and the overall health of the patient. In many cancers, radiation plays a crucial role in the treatment plan. Radiation therapy, or radiotherapy, is a treatment that uses high-energy radiation to destroy cancerous cells. It employs X-rays and gamma rays to target and eliminate cancer cells. The type and stage of cancer determine the dosage and duration of radiation therapy. Typically, radiation is administered once daily, five days a week. This treatment is generally quick and painless. There's no need to fear cancer or its treatment. The field of oncology has seen significant advances and discoveries, and each doctor will recommend the most suitable and safe treatment for each patient. By following the doctor’s recommendations with confidence and maintaining mental resilience, the treatment can be made comfortable and effective.
Chemotherapy is a treatment approach that uses medication to combat cancer. It involves the use of one or more chemical drugs, often classified as cytotoxic, to target cancer cells. Doctors may prescribe chemotherapy before surgery to reduce the size of a large tumor, slow down the growth of cancer cells, treat cancer that has spread to various parts of the body, or eliminate all rapidly growing and mutated cancer cells to prevent recurrence.
When the PET scan suggested a potential thyroid cancer, Dr. Haridas recommended the prompt removal of the thyroid gland. Despite multiple FNAC tests showing no signs of cancer, the PET scan's unusual findings led Dr. Haridas to strongly advise the excision of the thyroid gland. In Kerala, thyroid nodules are relatively common. Nodules in the neck are generally categorized as either benign or malignant. While malignant nodules may indicate cancer, most thyroid nodules are benign and do not necessarily signify the presence of cancer. The most important test for evaluating such nodules is the FNAC, or Fine Needle Aspiration Cytology. This test is crucial for assessing thyroid nodules, especially when combined with thyroid gland scans and hormone level assessments. FNAC helps determine whether a nodule is cancerous and identifies the type of nodule present. Removal of such nodules, followed by a biopsy, can confirm whether cancer is present. However, there is a rare possibility that some nodules may still be cancerous despite these tests. Following Dr. Haridas's recommendation, we consulted with Dr. Subramanyan Iyer from the Head and Neck Department.Dr. Subramania Iyeris currently the Professor and Chairman of Plastic and Reconstructive Surgery,Head and Neck Surgery/Oncology, and Craniomaxillofacial Surgery at the Amrita Institute of Medical Sciences. He completed his undergraduate medical education at Medical College Kottayam, followed by an MS from the All India Institute of Medical Sciences, New Delhi. He then pursued an MCh in Plastic Surgery from the University of Calicut. Dr. Iyer has extensive experience in the UK, having worked in various centers including Chepstow, Hull, and Liverpool, specializing in Plastic Surgery and Head and Neck Surgery for five years. Prior to joining Amrita in November 2003, he served as the head of the Division of Head and Neck Surgery and Reconstructive Surgery at Amala Cancer Hospital, Trichur.

In addition to hisclinical work, Dr. Iyer is a dedicated educator and researcher. He teaches and trains postgraduate students pursuing MCh in Plastic Surgery, MCh in Head and Neck Surgery and Oncology, and MS in Otorhinolaryngology at Amrita School of Medicine, Amrita Vishwa Vidyapeetham University. He is also an approved research guide at the Amrita Center for Nanosciences and Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram.
Dr. SubramaniaIyer, who has received numerous national and international awards, thoroughlyexamined me. He recommended that a tracheoscopy be performed on the same day. Tracheoscopy is a procedure that allows a provider to look inside the windpipe (trachea) and into the lower airways using a thin, flexible tube called an endoscope, which has a tiny camera and light at the end. This procedure is useful for evaluating conditions such as tracheal collapse, tracheal tumors, extramural compression, or tracheal foreign bodies. Following Dr. Subramania Iyer’s recommendation, junior doctors promptly took me to the scoping room. I was seated in a special chair and instructed to open my mouth and say "Ah." While doing this, a liquid was poured into my mouth. I was then asked to say "E," during which a very thin, flexible tube equipped with a small camera was inserted into my throat. After a brief period, the camera was withdrawn from my throat. Subsequently, several medical tests were conducted, and the date for the thyroid gland removal surgery was scheduled. On the same day, I visited the anesthesia department for a detailed examination and received clearance from there.
General Anesthesia is the technique used to induce loss of consciousness or sensation to enable surgical procedures. Various types of anesthesia are employed based on the nature of the surgery. These range from general anesthesia, which renders the entire body unconscious, to regional or local anesthesia, which numbs only the specific area where the surgery is performed. General anesthesia involves rendering the patient completely unconscious and is used for procedures requiring full-body sedation. Prior to administration, the patient undergoes a thorough assessment, including laboratory tests and a review of medical history, to determine the most appropriate anesthetic approach. In contrast, regional anesthesia includes techniques such as spinal anesthesia and epidural anesthesia, which numb only specific regions of the body. These methods are used to avoid the need for full-body sedation while ensuring the area of surgery remains insensate. Additionally, regional blocks can be applied to specific limbs or areas for localized numbness.
After examining the patient's condition, a tube is inserted into the airway through the mouth/nose. Once the tube is properly positioned, it is connected to an external machine. Through this tube, oxygen, nitrous oxide, and various gases for anesthesia are administered. Special medications are also given to prolong the anesthesia. Throughout the operation, the patient's respiration and the oxygen levels reaching the lungs are monitored using monitoring systems. After the operation, medications are given to help the patient wake up from the anesthesia. Once the patient is awake, the tube is removed. As the date of the operation approaches, there is considerable anxiety. Will there be loss of voice or breathing difficulties after the thyroid surgery? Manju Kurakar asked the doctor about these concerns. The doctor assured her that there is no likelihood of any complications.
The thyroid glands are located at the front of the neck. The thyroid gland is situated just below the larynx (voice box). It consists of two lobes located on either side of the trachea, which are connected by a narrow band of tissue called the isthmus. In adults, the thyroid typically weighs between 20 and 40 grams. On the upper part of the thyroid gland, there are four parathyroid glands located on either side. These parathyroid glands produce a hormone called parathyroid hormone (PTH). The primary function of the parathyroid glands is to regulate the levels of calcium ions in the body. The hormone produced by the thyroid gland is thyroxine. The thyroid gland plays a significant role in regulating metabolic processes in the body. Both the thyroid gland and the thyroxine hormone are crucial for the functioning of body cells.

If the body produces excess thyroid hormone, the condition is known as hyperthyroidism. Conversely, insufficient thyroid hormone production is termed hypothyroidism. Both conditions are serious and require medical treatment. The thyroid gland is crucial for regulating and maintaining various bodily functions, including heart rate, muscle function, bone health, digestion, and brain development. A tumor that originates in the thyroid gland is referred to as thyroid cancer. My thyroid surgery took place on February 10, 2022. I was admitted to Amrita Hospital on February 9 and discharged on February 12. On the morning of February 10, I was taken to the operating theater at 7 AM for the surgery, which was my first operation. After the procedure, I was transferred to the general ICU and monitored for four hours. Once I regained consciousness, I was given water and food, and shortly after, I was moved to a regular hospital room where I spent two days under observation. Dr. Subramanyam Ayyar led the surgery. I was discharged on February 12. Ten days later, during a follow-up visit, the biopsy report was reviewed. Dr. Ayyar recommended radioactive iodine therapy. Since an A.P.R surgery was scheduled for March 22, two injections were required to elevate my T.S.H. hormone levels, which was noted to be somewhat costly. For more detailed information and to proceed with the iodine therapy, I was referred to the Nuclear Medicine Department.
God is the ultimate source of all power and healing, often working through the hands of doctors and medical professionals to bring about restoration and recovery. While human skill and knowledge are crucial, it is divine intervention that ultimately guides and strengthens the healing process. Patience is key in this journey, as we trust in the timing and wisdom of a higher power. By maintaining faith and allowing the process to unfold, we open ourselves to witness the profound and miraculous ways in which God acts through the dedicated efforts of those who are committed to healing and care.