Case Study
Efficacy of
Panchakarma and Ayurvedic Herbo-mineral Preparations in the Management of
Renal Cell Carcinoma with Bone Metastasis – a Case Study
Authors: Dr.
Sawant Prashant M.D. (Ayu),
Dr. Jagtap Reshma M.D. (Ayu.), Dr. Kadam Sandhya M.D. (Ayu), Ayurlife
Positive Health Centre and Research Institute, Chembur, Mumbai - 71
Introduction:
Bone metastases in
patients with renal cell carcinoma (RCC) are associated with a
high risk of skeletal complications. About 40% of patients with RCC develop
bone metastases. RCC is the fourth most common metastatic
tumor of the spine and the most common cancer to present as
a neurologic deficit secondary to an undetected primary malignancy.
Chemotherapy and hormone therapy are ineffective, making radiation and
surgery the mainstays of treatment. Failure to respond to or
relapse after radiotherapy is common (American Journal of Neuroradiology
22:997-1003 (5 2001)
The median survival
time with distant metastatic RCC is around 6 months, and few cases survive
beyond 2 years. The incidence of spontaneous regression of metastatic renal
cell carcinoma is thought to be less than 1% of all cases. It is reported
that complete regression is even rarer than partial regression
We present a case of
RCC with bone metastasis, whose bone lesions completely resolved after the
ayurvedic multi-modality treatment.
Case Report:
Mr. D. S, male, age
41 years, a known case of right renal cell carcinoma (RCC) Grade II, with
multiple bone metastases, approached the centre on 26/11/2004. He had
complaints of severe pain in the upper back, pain in the right flank and
right side of the chest over mid-axillary line, since 15 – 20 days, which
increased on cough impulse. He had painful body movements and pain in the
left knee joint. He also complained of cough and throat irritation.
History of
Presenting Complaint:
Mr. D. S had pain in
the ribcage, bilaterally, since December 2001. His physician advised him
some NSAIDs. However, even after 2 months of treatment, the pain persisted.
He was then advised bone scan.
Bone
scan on 21/2/2002, revealed focal lesions on the costochondral junction of 1st
rib (both sides), 4th, 5th ribs (right side), 3rd
rib (left side) and on D10, L1, L2, L3 vertebrae.
(Click on image to view larger image)
The
MRI of L.S. Spine was done on 23/2/2002, which revealed definite lesions on
spine, involving the D10 pedicals and D9 body. A mass was also seen in the
right kidney (3.5 cm x 3 cm), strongly suggesting of a renal cell Ca. A
small focal lesion was seen in the LT kidney, probably a small cyst.
(Click on image to view larger image)
CT
abdomen done on 26/2/2002 was suggestive of a solid space occupying lesion
(SOL), involving the posterolateral aspect of right kidney (4.0 x 3.9 x 3.5
cm) suggestive of Neoplasm.
(Click on image to view larger image)
FNAC
of the right kidney was done on 27/2/2002, which was negative for Ca.
However a repeat FNAC from the lesion, done on 6/3/2002 confirmed RCC.
(Click on image to view larger image)
On 11/3/2002, right
radical nephrectomy was done. The histopathology report confirmed Renal Cell
Ca Grade II, Stage I
The following
treatment was advised by the oncologist:
Inj. Intreferon
thrice a week, Inj. Disodium Panindronate – once a month and Inj Prolukin-
once a month for 6 months
Follow-up after conventional treatment:
8.05.02
Bone scan
Shows active lesions
on the costochondral junctions of 4th, 5th rib right
side , 1st rib both sides, D10, L2, L3 vertebra. These lesions
were visualized on the previous study and have remained unchanged. The 3rd
rib left side anterior and L2 vertebral lesions appears to have resolved on
the present study.
1.11.02
Bone scan
Show abnormal tracer
uptake– lateral end of left clavicle, right 10th rib postero
laterally, L2 vertebra, tarsal region of the right foot and right calcaneum.
The rest of the skeletal system shows normal tracer uptake. Left kidney is
normal. Above mentioned osseous abnormalities appear like metastatic
lesions. The right tarsal region abnormality most likely represents trauma
induced changes.
18.06.04
Bone scan
Right 5th
rib at the costochondral junction (marginal), Rt calcaneal appear less
intense then before, 10th rib laterally posterolaterally, D4 to
D10 dorsal vertebral region is diffuse in nature.
The L2 vertebral
lesion and the left clavicular lesion seen on the previous bone scan done in
Nov 02 shows complete resolution.
(Click on image to view larger image)
13.11.04
Whole body Bone scan
SPECT
images shows increased tracer in D5 to D10 vertebral bodies. D8 and D6
vertebra appear partially reduced in size. Multiple skeletal metastasis.
Fresh lesions in 7th
rib left tibial tuberosity on right side, left navicular bone and lytic
lesion of the 11th rib are seen in addition to lesion reported
earlier studies.
(Click on image to view larger image)
At this stage, as the prognosis of the disease, according to modern
medicine, was not promising, Mr. D. S approached “Ayurlife” for ayurvedic
treatment.
On examination
(24/11/2004):
Complaints of : Sever
pain and tenderness over rib cage, more on right side of chest, cough ++,
fatigue ++, appetite- markedly decreased, anxiety ++
G. C.- fair, Pulse=
84/ min, B. P.= 110 / 90 mm of Hg., RS = rales right upper zone, CVS- NAD,
CNS = NAD, Weight = 61 kg.
Family History–
Insignificant
Ayurvedic
treatment:
Thirty ‘Rajayapan Basti’ (RYB) (a
multi-ingredient generic formulation administered as an enema) were
administered consecutively from 15th Dec 2004 to 22 Jan 2005.
Herbo-mineral formulation, containing
generic ayurvedic medicines, namely, Vajra bhasma, suvarna bhasma, sahastraputi abhrak bhasma, Bruhat vata chintamani rasa, tamra
bhasma, Makardhwaja rasa, guduchi ghana and Calcipral (P & P medicine), in a
prescribed dose, was administered orally.
Results:
From the second week
of treatment the pain and tenderness in the rib cage gradually reduced and
was completely relived at the end of first cycle of Rajayapan Basti (15th
Dec 04 to 24 Jan 05). His appetite was improved, fatigue decreased, anxiety
reduced markedly, cough relived, sleep improved, wt - 62 kg.
22.03.05
Whole body Bone scan:
Multiple skeletal
metastasis. Lesion in left 7th rib, L2 vertebra, medial
tuberosity of right Tibia are not visualized suggestive of regression of
disease.
(Click on image to view larger image)
26.08.05
Bone scan:
No area of abnormal
tracer uptake suggestive of metastasis seen in the skeletal survey.
No scintigraphic evidence of skeletal
metastasis.
(Click on image to view larger image)
31.08.05
PET scan:
Hyper-metabolic foci
in the neck region represent uptake in the tense musculature. Rest of the
whole body survey is unremarkable.
(Click on image to view larger image)
18.07.06
Whole body PET scan:
No definitive suggestion of any active disease on the present whole body
(Click on image to view larger image)
18.07.06
Bone scan
There is no definitive suggestion of osteoblastic metastatic disease on the
present bone scan.
(Click on image to view larger image)
Discussion:
(The conventional
approach:
In metasatic bone
cancer, Pamidronate (‘Aredia’) is used, along with cancer therapy. The dual
benefits of Aredia are delay and reduction of bone complications, such as
fractures, and the possibility of reducing bone pain. It is the only
medication approved for the treatment of bone metastases. This medication
acts on bone to help regulate blood calcium levels. It is used to treat
Paget's disease of bone and to treat high blood calcium levels. The
medication has also been used in the treatment of osteoporosis, to reduce
bone pain associated with certain illnesses and to treat bone loss due to
breast cancer.
Immunotherapy was
first introduced in the 1980s, and it provided another therapeutic
alternative for distant metastatic RCC. The current regimens of immuno-therapy
for distant metastatic RCC vary greatly but the main regimens are based on
interferon alpha and interleukin-2. In comparison to cases without immuno-
therapy, interferon alpha can prolong the median survival time by 2.6
months.
Interleukin-2 is one
of the activators between T cells and natural killer cells. The overall
survival time with interleukin-2 based adjuvant immunotherapy after a
cytoreductive nephrectomy was 16.7 months in one study.
To conclude,
previously, the median survival of patients with distant metastatic RCC was
only 6 months. Adjuvant immunochemotherapy can increase the median survival
time to more than 20 months.)
The Ayurvedic
approach:
According to ayurved, regeneration of cells
is carried out by ‘shukra dhatu’ and its division and multiplication
is controlled by ‘vata dosha’. The uncontrolled cell division is a
result of imbalance of ‘vata dosha’, which results into neoplasm (the
hypothesis of cancer).
As ‘shukra dhatu’ is ‘sarvadehik’, every
cell in the body has an inbuilt potential of replication / reproduction, in
favorable situations. The ‘akasha’ provides space for accommodation of such
multiplying cells (as ‘garbhashaya’ – uterus provides space for growth of
embryo). Any space or ‘akasha’ (Kha) is therefore, a potential garbhashaya
(e.g. test-tube baby). However, if such a situation is created in space
other than the one designated for the purpose, it is abnormal- ‘Kha-vaigunya’.
Some of the cancerous cells may be carried
to the distant places with circulation, and if they find a suitable place
for harboring, they may replicate in that place if the condition is
favorable. This migration of
cancerous cells is carried out by vata dosha
Embryologically, the kidneys are created
from the essence essence of ‘Rakta dhatu’ and ‘Meda dhatu’ (Cha.
). In ayurvedic therapeutics, this reference needs to be viewed in terms of
probable mode or route of samprapti (etio-pathology) and its reversal (chikitsa-
treatment). Medicines which act on rasa dhatu and meda dhatu would
therefore, probably be helpful in treating any pathology of Kidney.
In the hierarchy of production of dhatu,
asthi dhatu is produced from meda dhatu by removing ‘sneha’ from it through
process of ‘khara paka’ with the help of vata dosha (Charak Chikitsa
15/30-31). As meda dhatu is also responsible for the formation of kidneys, 'asthi
dhatu', being genetically similar, is the most favorable site of metastasis
of Renal Cell Ca. Therefore, rasayana treatment directed at meda dhatu
should benefit in treating primary renal cell Ca.
Asthi dhatu and vata dosha have ‘ashraya-
ashrayee’ (interdependent) relationship.
‘Basti’ is an ideal treatment for ‘vata dosha’ related diseases. Therefore,
‘basti’ is an ideal procedure to treat ‘kha vaigunya’ in asthi dhatu.
‘Rajayapana basti’ is a type of
‘basti’ in which a specific formulation, as described in treaties of ayurved,
is administered per rectum. It is useful in controlling the cell division
and act as a rasayana and improves longivity.
The herbomineral formulation used
internally, is a combination of generic formulations described in ayurvedic
treaties. Each of these formulations has a specific role in the management
of neoplasm and prevention of its relapse.
Important
properties of the ingredients used:
|
Medicine |
Main Properties |
|
Vajra bhasma4
|
Yogawahi (reaches in to
the smallest part), Rasayana, Lekhana |
|
Suvarna bhasma5
|
Vayasthapana (enhances
quality of life, increases ‘oja’, asthikshata hara, asthi shosha hara.. |
|
Bruhat Vata Chintamani
Rasa6 |
Fast acting, vata dosha
balancing |
|
Abhrak bhasma7 |
Promotes strength,
|
|
Shankha bhasma8 |
Lekhana, Useful in
reducing ‘arbuda’ (mass / tumor) |
|
Tamra Bhasma |
Lekhana |
|
Makaradhwaja
|
Rasayana |
|
Guduchi Ghana |
Rasayana |
|
Calcipral (P & P
medicine) |
Asthi poshaka |
Hypothesis:
Conclusion:
The treatment
protocol based on ayurvedic hypothesis used to treat this particular case
has yielded positive outcome. However, the usefulness of this therapy for
metastsatic bone cancer has not been established and the hypothesis needs to
be extensively evaluated
References:
-
Charak Samhita / Siddhishtana / XII / 16.)
- Ashtanga Hrudaya /
Sutra / 20 /1
- Rasatantra sara
- Rasatarangini / 23 /
25-26
- Rasatarangini / 15 /
69-80
- Bhaishajyaratnavali /
Vatavyadhi Chikitsa / 91-94
- Rasatarangini / 10 /
72-73
- Rasatarangini / 12/
20-21,29
