The Indian visionaries has rightly identified the vast potential and scope of nuclear energy long back and the Indian Atomic Energy Programme was well conceived and conceptulised for the effective exploration of the peaceful uses of the atomic energy for societal benefits. Besides the main stream objective of the nuclear energy based power generation stations to meet the galloping energy demand of a developing economy, the non-power applications employing radiation are also equally rewarding. Medical applications of radiation or more precisely use of radioisotopes in human healthcare is one of the major non-power utilization of atomic energy for peaceful applications. It is interesting to note that radioisotopes are finding equally important applications in both diagnostic as well as therapeutic fields as in-vivo and in vitro radiopharmaceuticals.

Nuclear Medicine and Healthcare

Radioimmunoassay

The Radiation Medicine Centre (RMC) of BARC in Mumbai has become the nucleus for the growth of nuclear medicine in India. RMC is engaged in activities which involve research and development in nuclear medicine and allied sciences as a major activity followed by patient services as well as human resources development in nuclear medicine. It is also the premier teaching center of nuclear medicine in this country and has been a WHO and IAEA referral center.

It has the distinction of being the largest center in the world for the diagnosis and treatment of benign and malignant thyroid disorders. Each year 6000 new thyroid cases register with the RMC and it has 5500 cases of thyroid cancer in its rolls, diagnosed and treated, the largest single institutional volume anywhere in the world. The first PET scanner of the country was installed in the RMC and with this it is on par with the major nuclear medicine centers of the world. The Radiation Medicine Center has a three pronged mandate: Diagnosis of disease. 2. Treatment of disease. 3. HRD.

Diagnosis of disease

The RMC is the largest center in India devoted exclusively to nuclear medicine practice and teaching. With three gamma cameras, (two dual heads and one single head, all capable of SPECT) two rectilinear scanners and a profile scanner the RMC performs every conventional nuclear medicine test of all the major organs of the body and has a very busy thyroid and cardiac clinic as well. The cardiac lab performs stress tests on a treadmill and bicycle ergometer and also with pharmacological agents like adenosine, and dobutamine. Two more dual head gamma cameras are to be installed in the forthcoming year.

Teletherapy

The diagnostic investigations were related to almost all organs of the body like thyroid, heart, bone, kidney, lungs, GI bleed, hematology, etc. Radiation Medicine Centre is providing Clinical services and treatment to a large number of patients referred to RMC from various parts of the country routinely besides a great deal of R&D work in the field of Nuclear Medicine.

  Positron Emission Tomography

PET set up in RMC, Mumbai

The majority of patients who come for the FDG scans are patients of cancer, usually of the lung, breast, GI tract, lymphomas and a host of less frequent cancers. A great deal of research studies get done in collaboration with the neighboring Tata Memorial Hospital for cancer.

FDG PET in Psychiatry

In the three years of its existence at the RMC, FDG PET scanning has, in addition to providing service to a large segment of cancer patients used FDG PET in a large number of areas including psychiatry where studies carried out in schizophrenia and drug abuse have demonstrated hitherto unknown facets of these conditions. Currently research is going on in OCN, Bipolar Depression and in Epilepsy.

 

FDG PET in Cardiology

FDG PET scanning has already established itself as an important diagnostic test in determining living muscle in heart attacks. The conventional myocardial scanning will show which part of the heart muscle has been affected by the ‘heart attack’. If substantial muscle is alive and capable of repair to a normal state, there is at present no means of knowing this and cardiologists may give up the case as not salvageable. If however it can be shown that there is life in the muscle still, the cardiologist can make attempts to re establish normal blood flow to the muscle and revive it. This is what FDG PET scanning shows by demonstrating that the muscle is still capable of using glucose.

Thyroid cancer expertise and other cancers

Radio iodine treatment of thyroid cancer is a specialty of the RMC. The RMC has the largest single institution number of treated patients of thyroid cancer. Patients are referred from all over India for this treatment. The RMC also offers four-week long training courses in the management of thyroid cancer with 131-I to nuclear medicine physicians in January and July. This training helps them establish treatment facilities in their parent institutions.

In addition, treatment is also offered with 131-I MIBG for neuro endocrine tumors, P-32 for bone pain palliation and P-32 samarium colloid for intraarticular use in painful joints.

Radiation Medicine Centre being one of the largest centers for teaching and training is contributing a lot to Human Resources Development in Nuclear Medicine. This center has got Cyclotron and Positron Emission Tomography (PET) facility, which is first of its kind in India. In the field of radiodiagnosis and therapy, RMC is a regional referral centre of the World Health Organization for South East Asia. At RMC about 3.3 TBq of Tc based radiopharmaceuticals are dispensed and 8000 radio diagnostic investigations and 9000 radio-immuno assays (RIA) are carried out annually. BARC supplies reactor produced radioisotopes and radionuclides for medical use. The radioisotopes processed and supplied by BRIT (Board of Radiation and Isotope Technology) to medical users across the country, include radiopharmaceuticals, brachy-therapy wires, radio-immunoassay (RIA) kits and various other products, and services.

Human Resource Development :

The Diploma courses in nuclear medicine and nuclear medicine technology.

Since 1973, two courses have been conducted at the RMC for doctors and science graduates namely DRM and DMRIT. The DRM is a two year course and the DMRIT is a one year course. Ten students are taken for each course from a pan India applicants list. No stipend is being paid but then there is no tuition fee. From this year 2006, the two courses have been transferred to the newly created deemed University of the DAE called the Homi Bhabha National Institute or HBNI.

Smaller two week and four week long courses are held for students of Bio Medical Engineering from colleges in Bombay.

The RMC is also a training hub for fellows from the IAEA for varying periods from three months to a year. Doctors and scientists of the RMC serve as experts for the IAEA and are frequently on its RCA’s and Coordinated Research Projects.

Radioisotopes and Radiopharmaceuticals

The accelerator at VECC (Variable Energy Cyclotron Centre) manufactures radioisotopes, which are processed for medical applications. The Regional Radiation Medicine Centre (RRMC) meets the requirements of the Eastern Region of the country for radiodiagnosis and therapy. The Centre provides therapy and scanning services using a 4 MeV Linear Accelerator and the radio-immunoassay services. BRIT supplies annually over 45,000 consignments of different radiopharmaceuticals, cold kits and radioimmunoassay kits to nearly 120 nuclear medicine centres and 650 RIA laboratories in the country. Based on the products supplied by BRIT, yearly an estimated 2.5 lakh to 3 lakh diagnostic imaging studies are performed and a few thousand patient treatments using radioiodine are carried out for thyroid disorders. About 5 lakh patient sample analysis are carried out every year using immunoassay kits. BRIT’s regional centres at Bangalore and Delhi provide Tc-99m radiopharmaceuticals for use in hospitals of their regions. The centres at Dibrugarh and Bangalore offer radioimmunoassay service to local hospitals.

BRIT also supplies cobalt-60 teletherapy sources to 170 teletherapy units in 62 cities in India and cesium-137 and iridium-192 brachytherapy sources for cancer treatment. The other supplies include phosphorus-32 injections for pain palliation in severe bone cancer cases.

TATA MEMORIAL HOSPITAL

Cancer care and Research

Tata Memorial Hospital (TMH) established in 1941 , is a comprehensive cancer care centre for diagnosis, treatment, research and education of cancer. TMH is fully supported by Department of Atomic Energy, Government of India. Over 16,000 cancer patients are seen every year at this hospital.

These patients come for the treatment from various parts of India and neighbouring countries . TMH is committed for research in cancer and has an active Cancer Research Secretariat (CRS). The CRS supports multicentric National and International research studies.

Cancer Research Institute was established in early 50’s and merged with the Tata Memorial Hospital to augment the government commitments for the Service, Education and Research in Cancer .

Linear Accelerator

Every year nearly 30,000 new patients visit the clinics. Nearly 60% of these cancer patients receive primary care at the Hospital of which over 70% are treated almost free of any charges. Over 1000 patients attend the OPD daily for medical advice, comprehensive care or for follow-up treatment. During the year 2003, over 20000 new cases were registered in addition to over 13000 Referral Cards issued for only special investigations.

Nearly 8500 major operations are performed and 5000 patients treated with Radiotherapy and Chemotherapy annually in multi-disciplinary programmes. At the TMH, Evidence Based Medicine is the keystone. Apart from the patient care and service, clinical research programmes and randomized trials contribute increasingly to improved delivery of care with highest standards of work ethics.

The strategies for early diagnosis, treatment management, rehabilitation, palliative care and terminal care have been established in a comprehensive and multidisciplinary approach for a total cancer care programme. In surgery, concepts have changed taking into account the biology of cancer. Radical surgeries are replaced by more conservative surgery with objectives of quality of life, conserving function and organ without compromising overall survival outcomes.

Radiation therapy has also made rapid advances with high technology, precision, computerisation and newer isotopes for therapy. Chemotherapy has played a very major role, with new drugs and clinical protocols investigated in clinical trials. The TMH was the first Centre in the country to initiate Bone Marrow Transplant in 1983. A "first in India" PET - CT scanner has been procured to make this cutting edge technology available for cancer management.

Cancer Prevention: Preventive Oncology has a very major and important role to play for early diagnosis, screening and down staging of cancer. Department of Preventive Oncology was commissioned in the year 1993, which give special focus on education in cancer prevention and early detection. Of the 2 to 2.5 million cases of cancer in the country over 70% of cases are detected late and report for treatment in advanced stages. The emphasis on early detection would go a long way to dealing with the large numbers as well as to mitigate avoidable suffering and a financial burden.

Clinical Research: A Scientific Review Committee critically reviews the proposed research programmes and projects in detail and ensures that the research effort is at the cutting edge of an international standards . The Hospital Ethics Committee critically evaluate the research and medical practices followed in the Hospital. A separate Data Monitoring and Safety Committee, in addition, monitors all officially sanctioned research programmes.

Education: The Tata Memorial Centre is a recognised training centre for cancer education and research by national and international organisations such as WHO, IAEA and UICC. Tata Memorial Hospital is a post-graduate teaching centre and is affiliated to the University of Mumbai, National Board of Examinations and Maharashtra University of Health Sciences. Every year over 80 post-graduate students, register with the Centre for doing their Master's or Doctorate courses. There are about 400 students undergoing training every year in medical and non-medical fields in long and short term courses

Telemedicine and Telepathology

Telepathlogy service was established starting with the rural Cancer Hospital at Barshi. This service is now utilised by several other hospitals as well. A telemedicine service facility has been set up linking Dr B Borooah Cancer Institute at Guwahati and the Dr Walawalkar Hospital at Dervan, Chiplun. Six Hospitals in the North - East and Regional Cancer Centres will be networked to enable patients to access comprehensive cancer care from all over the country.

Teletherapy Machine

The indigenous Telecobalt Machine for cancer treatment has been installed and commissioned at Advanced Centre for Treatment, Research & Education in Cancer (ACTREC), Navi Mumbai. It is a state-of-the-art machine, which incorporates world class features like, 250 RMM Cobalt-60 source capacity, minimum couch height and noise free movement at par with any imported machine of same category. In addition, the machine has zero-zero collimator closing for radiation safety, lower penumbra for better beam quality, total digital controls with self-calibration of motions and controls, single cable communication between machine and control console, computer controlled couch, total treatment data acquisition and data analysis.

Blood Irradiator

Irradiation of blood & blood products by gamma rays is a proven and safe method to eliminate the risk of post transfusion graft versus host disease. Gamma irradiation of cellular blood components is the best current technology to reduce such risks to the recipients as confirmed by research, and therefore being widely practiced world over in hospitals and blood banks as a life saving approach to this problem. Blood is usually irradiated in standard blood bags in dedicated blood irradiators using cobalt-60 or caesium-137 radioactive source .

Blood Irradiator is a self shielded and versatile Gamma Irradiator which can house Cobalt-60 source up to 25TBq which provides a dose rate of about 11Gy/minute inside sample chamber . BRIT has designed and developed a dedicated blood irradiator called Blood Irradiator-2000 (BI-2000). The irradiator provides a dose rate of about 11 Gray/minute approximately inside the sample chamber. It is incorporated with a sample rotating mechanism to obtain better uniformity of dose to the products. The control system is a programmable logic controller based with touch sensitive color screen using user-friendly software and a printer for data recording. The unit can be installed in a room without any additional shielding. Its design conforms to all relevant national and international standards and safety codes. One newly designed and developed Gamma Chamber 1200 unit housing 148 TBq of Co-60 source was supplied to Tissue Bank, Tata Memorial Hospital, Mumbai.

A number of technologies and products have emerged from the biomedical research carried out in the DAE research centres. Radiation processed hydrogels for treatment of burn injuries, skin patches for treatment of superficial cancers, preparation for palliation of pain due to bone metastasis and radiolabelled preparations are some of the innovative products developed at Trombay. CAT has developed lasers for medical applications

which includes carbondioxide laser based system for a range of surgical modalities. These systems have been supplied to various hospitals in the country. Nitrogen laser radiation exposure has been found to help in drug penetration in the lungs of a tuberculosis patient, and has also been found to accelerate burns healing. CAT has developed nitrogen laser units with fibre optic beam delivery systems. Some such units are in use in hospitals at Indore and Patna.

Clinical Research Secretariat (CRS)

A unique centre ‘Clinical Research Secretariat’ was commissioned in 1997 to temper the vast data generated from clinics/laboratory and draw meaningful conclusions with clinical endpoints.

The CRS offered a wide range of services from collection, maintenance, quality control & analysis of data to design & execution of prospective trials of importance to the institute and nation. The primary aim was

• To generate easily testable hypothesis from focused retrospective analysis/ laboratory studies.
• To test novel avenues with survival/quality of life in observational studies or randomized trials.
• To support mega-trials from multiple centres spread all over India.
• To improve in patient care and appropriate clinical studies.
• To collate published evidence by Meta-analysis to define the state of art treatment.

Majority of the studies have been either presented or published in peer reviewed journals.

DAE Clinical Trial Centre (DAE-CTC)

A national centre for clinical trials has been established At Tata Memorial Hospital not only to initiate clinicians in the concept of scientific and evidence-based medicine but also to address burning medical and epidemiological questions.The scientific community and other funding agencies and ultimately patients may benefit from testing the efficacy of newly synthesized biological products such as engineered enzymes, genetic materials and other substances emanating from laboratories. The testing of a new vaccine for common diseases such as cervical cancer (caused by the human papilloma virus) is one such example. Other examples could include whether many of the commonly used indigenous herbal products are truly beneficial or even superior to conventional allopathic remedies. Recent research in India in animal systems suggests that 'haldi' or its active ingredient curcumin helps to prevent oral cancer. This, however, has not been confirmed in humans in the absence of a large well-conducted randomized clinical trial.

ACTREC

The Advanced Centre for Treatment, Research and Education in Cancer (ACTREC) is a new state-of-the-art R&D satellite of the Tata Memorial Centre (TMC). It has the mandate to function as a national centre for treatment, education and research in cancer.

TMC is an autonomous grant-in-aid institution of the Department of Atomic Energy (DAE), Government of India. It is registered under the Societies Registration Act (1860) and the Bombay Public Trust Act (1950). It is governed by a Governing Council chaired by the Chairman, Atomic Energy Commission, Government of India.

ACTREC comprises of 2 arms – a basic research arm constituted by the erstwhile Cancer Research Institute (CRI) and a Clinical Research Centre (CRC).

Cancer Research Institute

Research investigations have focused on molecular mechanisms responsible for the causation of the major human cancers relevant to India in parallel with studies in animal models and cells in tissue culture.

Ongoing investigations on oral cancer have focussed on global analysis of gains and losses of chromosomal regions, gene and protein expression, alteration in genes regulating DNA repair and xenobiotic metabolizing enzymes, role of intermediate filament proteins in epithelial cell transformation, presence of novel HPV, preparation of gene therapy reagents against oral cancer, understanding the molecular mechanisms in immune surveillance and development of single chain antibodies against antigens from oral tumor cells.

With respect to breast cancer, studies are carried out on the importance of HLA in breast cancer predisposition in specific ethnic groups and their relation to age of onset of the disease. Epigenetic mechanisms regulating genes involved in cell proliferation have also received attention. In-depth studies are on to understand the molecular mechanisms of hepatitis B virus infection leading to hepatocellular carcinoma. The utility of the viral mRNA for HBx gene, and circulating antibodies towards the HBx protein are being assessed as markers for viral infection.

Analysis of cytokine profiles and the role of antibodies to the viral proteins E6 and E7 in cervical cancer, cytokine imbalance in lung cancer patients, and the role of urinary cytokines in intravesical BCG therapy in superficial bladder cancer are also undertaken. The biology of HIV-2, the virus which has spread only in India and Africa is being studied in-depth. Having an Indian isolate of HIV-2 has also provided the impetus to develop an indigenous retroviral vector for gene transfer.

The first transgenic mouse in the country, which was made at the Institute, hosts a gene for a growth modulator. This mouse is being developed as a model for squamous cell carcinoma. In parallel, newer cell lines useful for cancer research and an expression system for the E6 protein of HPV are being developed.

Clinical Research Centre

The Clinical Research Centre comprises of a 50 bed hospital which is devoted to clinical research in the field of Cancer. In the first phase, the focus will be on Pediatric Oncology and emerging therapies, including Gene Therapy. Besides full support of the Tata Memorial Hospital at Parel, the hospital at ACTREC is also fully equipped with all required diagnostic and therapeutic facilities. The Radiotherapy at ACTREC is equipped with state-of-the-art dual energy Linear Accelerator, IMRT, Stereotactic therapy and HDR HDU -Brachytherapy units. The Centre is committed to carry out clinical trails under GCP conditions, including Phase I / II trials for investigational new drugs. In addition, the Centre would specialize in Cancer Genetics.

With full government support and in collaboration with the International Atomic Energy Agency (IAEA), a number of multiple scientific studies have been conducted. Head and Neck, Breast and Cervical cancers are common cancers in India and various scientific studies are being conducted at Tata Memorial Hospital with National or International collaboration. (In collaboration with IAEA, at Tata Memorial Hospital, a randomized study based on evaluation of Low Dose Rate (LDR) versus High Dose Rate (HDR) intracavitary brachytherapy for carcinoma cervix). It has got high implications on the future practice of radiotherapy in Gynaecological cancers. Fractionation study in Head and Neck cancer will direct towards the appropriate use of radiotherapy fractionation to achieve optimal response rate.

Tissue Bank

The Tata Memorial Hospital Tissue Bank was started in 1988 in collaboration with the International Atomic Energy Agency (IAEA) as part of the Regional Co-ordination Agreement (RCA) programme to promote the use of atomic energy with particular reference to upgrading health care systems in Asia and the Pacific Region. It is the first multi-Tissue Bank in the country. Over the past decade it has developed into a well equipped facility that complies with good manufacturing practice. Most important, it offers a viable alternative to expensive imported grafts bringing allografts within easy reach of all. The TMH Tissue Bank has helped to initiate Tissue Banks by training staff and providing technical assistance at various hospitals in the country.

Distance Assisted Training

The distance assisted training (DAT) and the distance learning (DL) programmes recommended by the Regional Advisory Board in radiotherapy, diagnostic radiology, nuclear medicine, and Tissue Banking, has become an essential national need in view of the large number of patients and hospitals spread all over the country.

Medical Physics

The project "Strengthening Medical Physics in the Asia & Pacific Region" aims at improving the medical physics capability and capacity through the establishment of regional approaches on education and training. The direct beneficiaries will be medical physicists working in radiotherapy, radiology and nuclear medicine.