HPB ONCOLOGY – Vibrant and rapidly evolving Subspeciality

How are cancers of the liver pancreas and bileduct (HPB CANCERS) different?

Most of abdominal cancer are readily diagnosed by symptoms such as vomiting, gastrointestinal bleed and basic investigations such as endocscopy, colonoscopy and ultrasound..by virtue of their unique anatomical location liver and pancreatic tumors are usually missed by these investigations and need specific tests like MRCP, ERCP and endoscopic ultrasound. Their symptoms are also subtle and diagnosis needs a high degree of suspicion and expertise.

What are the usual symptoms?

Symptoms of early cancer are usually subtle include anorexia, vague abdominal discomfort and by the time overt symptoms develop cancers are usually in an advanced stage. Jaundice can be presenting symptom in HPB cancers but many patients reach referral centres late after several trials of native medicine without diagnosis. It is not un common to find a patient who has had several ultrasounds and endoscopies for abdominal pain and told that he only ‘Acid” or ‘Gas and by the time he reaches a specialist the imaging shows advanced pancreatic cancers

How do we arrive at diagnosis?

Mostly diagnosis is arrived at by Triphasic CT scan with liver and pancreatic protocol and MRI with MRCP. In cases with diagnostic dilemma Endoscopic ultrasound and EUS guided biopsy is needed. In bile duct and pancreatic cancers spyglass cholangioscopy is needed to confirm diagnosis. Many patients have jaundice that needs relief through ERCP stenting or PTBD stenting. Some patient undergoing a major liver resections need a preoperative portal vein embolisation to shrink one half of the liver, Most of these facilities are available only at specialised HPB centres

Are there any risk factors for liver and pancreatic cancer?

Patients with Hepatitis B, Hepatitis C and alcoholic liver disease (ALD) have a high risk for liver cancer and need 6 monthly imaging and blood tests to detect early cancer. Patients with BMI more than 30, diabetes and fatty liver are at a higher risk for liver disease and liver cancer. Smoking, Obesity, fatty liver and sedentary life style predispose to pancreatic cancer. Chronic pancreatitis secondary to alcoholism and tropical pancreatitis common in India also increases risk for pancreatic cancer.

What is the need for a HPB oncology sub specialty?

Surgical management of HPB cancers carries a higher morbidity and mortality rates than most regular surgeries. Liver and pancreatic surgery is complicated and requires vast experience. In addition to the usual CHOP CUT STICH approach the HPB surgeon needs an understanding of their complex physiology as well as expertise in vascular surgery. This is especially important in the postoperative period in this high risk group. It has been scientifically proven that centres with focussed and high volume care in HPB oncology achieve best results. Most cancer centres in India have a jack of all trades approach offering treatment for cancers from head to toe. Specific focussed expertise is lacking due to low volumes. In HPB centres surgical expertise in benign and malignant liver conditions and specialised diagnostic expertise leads to higher volumes and expertise with better results

Are there options other than surgery at an HPB oncology centre?

In patients who are not fit or cancers too advanced for surgery the standard oncological approach is chemotherapy and radiotherapy . These treatments are virtually useless for liver cancer and patients are often misguided that situation is hopeless. In specialised HPB centres treatment options such as radiofrequency ablation, trans arterial chemoembolisation , transarterial radioembolization, liver transplantation for liver cancer are added to the armamentarium leading to better results. Likewise in pancreatic cancer laparoscopic pancreatic resections, EUS guided diagnosis and ablations, pancreatic and bileduct stent and endo- RFA are available in specialised centres.

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