Welcome to the 16th part of educational series on GastroIntestinal Cancers. We learned in part 15 about risk factors for liver cancer and screening of high risk population. Also, we learned about role of AFP and radiology in diagnosis, without need for biopsy in many cases.
Question: Dear Dr. Chiragbhai, how do you manage a newly diagnosed HCC?
Answer: First of all, staging work up is required including a good CT scan of abdomen, and CT chest. Bone scan is required if there is bone pain or liver transplant is planned.
Another very important part of evaluation is about functional reserve of liver. This assessment is important in deciding type of treatment, and prognosis. Many different systems exist including Child-Pugh score, MELD score, Okuda, BCLS etc. Some of them combine stage and liver, kidney function.
Que: What are the treatment options?
Ans: Treatment options include surgery, liver transplant, other locoregional therapies, and systemic therapy. Based on evaluation mentioned above i.e. stage and liver function, there are 4 categories of patients:
1. Potentially resectable or Transplantable
2. Unresectable
3. Inoperable due to performance status, poor liver function, comorbidities
4. Metastatic disease
Once again, this is a team work and a number of specialists are often required to determine patient category and deliver defined treatment, including GI surgeon, gastroenterologist, medical oncologist, radiologist, interventional radiologist, intensivist, nephrologis and others.
Patients often have other issues like underlying cirrhosis, secondary renal dysfunction, Hepatitis B or C, portal hypertension, bleeding tendency, low albumin, encephalopathy etc which have a significant impact on decision making.
Que: This does seem quite complicated. How many patients are resectable?
Ans: Well yes, it is even more complicated than it seems e.g. assessment of liver function or tumor in relation to liver anatomy are more refined now, but still far from very accurate. Inspite of so many scoring systems, and advanced scans, in a small number of cases, nature still comes up with surprises intraoperative or postoperative. Therefore, one must insist on a multidisciplinary evaluation to minimize surprises and adverse outcomes.
Inspite of all of the above, a significant minority of patients do present to us at a stage when we have been able to resect them (one just last week – over age 60), or use other locoregional or systemic therapies to provide significant results.
In next part, we will talk about few details of the specific treatment modalities.
Wednesday, November 25, 2009
GASTROINTESTINAL CANCER PART-15
Welcome to the 15th part of educational series on GastroIntestinal Cancers. We learned in part 14 about treatment of pancreas cancer including surgery as the mainstay of treatment, with adjuvant chemotherapy and sometimes radiotherapy. However, most of these are diagnosed late and are treated with mainly medical management.
Question: Dear Dr. Chiragbhai, what are the risk factors for our next subsite hepatic cancer?
Answer: Hepatocellular cancer is a common cancer worldwide, with a very high incidence in Asia. Risk factors include:
1. Hepatitis B
2. Hepatitis C
3. Cirrhosis – secondary to hepatitis and other causes
4. Alcohol
5. Autoimmune hepatitis
6. Genetic disorders like hemochromatosis, primary biliary cirrhosis etc
7. Aflatoxin exposure in food
In Asia and Africa, Hepatitis B is the most common cause, whereas in north America, Hepatitis C is more common as cause of Hepatocellular Carcinoma-HCC. Effective immunization against Hepatitis B reduces rate of chronic hep B infection and hence HCC.
All health care workers, including doctors, nurses etc must take vaccine against hepatitis B. It is now part of childhood vaccination plan at most places in India as well. In Hong Kong, this strategy has shown significant reduction in incidence of HCC.
Que: If patients with cirrhosis or those with hepatitis B or C are especially at high risk for developing HCC, is there a screening tool?
Ans: Yes there is. It is not recommended for normal population, but it is worth considering in patients who have any of the above mentioned risk factors. A large randomized controlled trial involving over 18000 patients has shown improvement in survival with screening in patients with above noted risk factors.
This includes abdominal sonography and AFP level evey 6 months. It is shown to detect HCC cases early, thereby allowing surgical resection and increased survival.
Que: Why is this cancer generally detected late?
Ans: HCC mostly presents in very advanced stages, because of nonspecific symptoms like loss of appetite, upper abdominal pain, weight loss, jaundice. Sometimes it presents with paraneoplastic syndrome like hypercholesterolemia, hypercalcemia, erythrocytosis, hypoglycemia.
Diagnosis is made using Triphasic helical CT or MRI, with help of AFP. Classic signs on CT are diagnostic enough for tumors more than 2 cm. Biopsy is required when imaging and AFP are not showing classical findings. Biopsy is also required for non surgical management such as chemotherapy.
Question: Dear Dr. Chiragbhai, what are the risk factors for our next subsite hepatic cancer?
Answer: Hepatocellular cancer is a common cancer worldwide, with a very high incidence in Asia. Risk factors include:
1. Hepatitis B
2. Hepatitis C
3. Cirrhosis – secondary to hepatitis and other causes
4. Alcohol
5. Autoimmune hepatitis
6. Genetic disorders like hemochromatosis, primary biliary cirrhosis etc
7. Aflatoxin exposure in food
In Asia and Africa, Hepatitis B is the most common cause, whereas in north America, Hepatitis C is more common as cause of Hepatocellular Carcinoma-HCC. Effective immunization against Hepatitis B reduces rate of chronic hep B infection and hence HCC.
All health care workers, including doctors, nurses etc must take vaccine against hepatitis B. It is now part of childhood vaccination plan at most places in India as well. In Hong Kong, this strategy has shown significant reduction in incidence of HCC.
Que: If patients with cirrhosis or those with hepatitis B or C are especially at high risk for developing HCC, is there a screening tool?
Ans: Yes there is. It is not recommended for normal population, but it is worth considering in patients who have any of the above mentioned risk factors. A large randomized controlled trial involving over 18000 patients has shown improvement in survival with screening in patients with above noted risk factors.
This includes abdominal sonography and AFP level evey 6 months. It is shown to detect HCC cases early, thereby allowing surgical resection and increased survival.
Que: Why is this cancer generally detected late?
Ans: HCC mostly presents in very advanced stages, because of nonspecific symptoms like loss of appetite, upper abdominal pain, weight loss, jaundice. Sometimes it presents with paraneoplastic syndrome like hypercholesterolemia, hypercalcemia, erythrocytosis, hypoglycemia.
Diagnosis is made using Triphasic helical CT or MRI, with help of AFP. Classic signs on CT are diagnostic enough for tumors more than 2 cm. Biopsy is required when imaging and AFP are not showing classical findings. Biopsy is also required for non surgical management such as chemotherapy.
GASTROINTESTINAL CANCER PART-14
Welcome to the 14th part of educational series on GastroIntestinal Cancers. We learned in part 13 about treatment of anal cancer where chemotherapy combined with radiotherapy is standard treatment, and allows avoidance of permanent colostomy. Today we will discuss pancreas cancer.
Question: Dear Dr. Chiragbhai, is pancreas cancer very difficult to treat?
Answer: This is a cancer which mostly presents in very advanced stages, because of nonspecific symptoms like nausea, dyspepsia, depression, weight loss, jaundice. Also, apart from surgery, other modalities have limited activity.
Que: How is it treated then?
Ans: Once again, surgery is the primary treatment, but is often not possible because of advanced stage. Therefore, a very good evaluation is important to decide resectability, using at least a good CT scan, and a multidisciplinary evaluation. EUS and laparoscopy, where available, add to the decision making in some cases.
Que: What type of surgery is performed?
Ans: Whipple procedure or pancreaticoduodenectomy. This is a major surgery with significant risk of death or severe morbidity. Studies have indicated that centers performing more than 5 such surgeries per year, preferably over 20 per year, have the best results. This is similar to what we have discussed in earlier parts of this series with relation to other major surgeries. Mortality difference between centers could be as high as 20% vs 4%. Therefore, this issue should be considered strongly in choosing center.
Que: What other important issues should be evaluated?
Ans: Some of the patients are “borderline resectable”. Such patients should be considered for preoperative chemotherapy plus radiotherapy, as some of these patients can be converted to clearly resectable disease, providing long term survival.
One important point should be emphasized at this point: biopsy is frequently not easy or comes back as normal or inconclusive, when done as CT guided or EUS guided. If patient has potentially resectable disease and clinically and radiologically pancreas cancer is more likely, surgery should be done, without trying for repeated biopsies.
However, biopsy confirmation is a must for non surgical therapies e.g. chemotherapy.
Also, biliary drainage is required in most cases. However it is not urgent if patient does not have jaundice or signs of infection(cholangitis). It can be in form of a stent, generally placed by ERCP, or surgical.
Que: What about role of other modalities?
Ans: Unfortunately, role of other modalities at present is limited. Postoperative chemotherapy and possibly chemoradiotherapy adds somewhat to the results, and should be given to increase survival in this otherwise dreadful disease. However, many patients are not in a position to receive radiotherapy after this major surgery, which often takes long time for patient to recover. Chemotherapy alone is probably sufficient, based on some recent studies i.e. ESPAC-1 (for use of 5-FU) and CONKO-001 (for use of gemcitabine).
Addition of newer medicines and targeted therapies have shown no or very limited impact so far.
GASTROINTESTINAL CANCER PART-13
Welcome to the 13th part of educational series on GastroIntestinal Cancers. We learned in part 12 about treatment of rectal cancer, especially newer modalities which have led to improved outcome e.g. avoiding permanent colostomy. Also, how genetic testing has led to less side effects and more efficacy, and that most of such tests are available in India.
Question: Thank you Dr. Chiragbhai. What is the next sub site?
Answer: Next is Anal Cancer. This is a relatively rare cancer, which is divided into two: anal canal and anal margin(also known as perianal region). It is mostly squamous cell carcinoma.
It appears to be associated with HPV-16 infection, in majority of cases. This is similar to cancer of cervix, which is also associated with HPV infection. That is why immunosuppression, either in form of medicines or from HIV increases risk of anal cancer. This information becomes much more important now that we have a vaccine to prevent HPV infection.
Que: How does Anal cancer present?
Ans: Most patients present with bleeding per rectum, some with pain or mass. Most patients present in stage 1 or 2, as there is bleeding. However, one should not misinterpret this with piles. A careful examination is enough for diagnosis, to be confirmed by a biopsy. Staging work up includes CT scan of abdomen/pelvis and chest, or preferably PET-CT where available.
Patients should also undergo screening for cervical cancer with PAP smear, as there is known association, and a common risk factor i.e. HPV infection.
Que: How do you treat this disease?
Ans: In the past, surgery i.e. APR was the treatment. However, it is associated with permanent colostomy and a high failure rate i.e. about 50%.
Since early 80s, standard of care for anal cancer is chemoradiation, based on several randomized trials. All these studies showed that chemoradiation was better than surgery, with about 80% survival. Also, only a small number ultimately require colostomy, due to salvage surgery. Mitomycin and 5-FU is used with radiotherapy. Cisplatin appears to be of similar efficacy as mitomycin in phase 2 trials, but at least one randomized trial showed higher rate of colostomy with cisplatin compared with mitomycin.
Que: What about patients with HIV and Anal Cancer? Do they tolerate these treatments?
Ans: Good question. HIV infection incidence is high in India as well and is on a rapid rise. Therefore, we are all going to see HIV related diseases more and more commonly, including cancers. HIV infected patients have lower immunity, and use of chemotherapy is of concern. However, this has been studied, and patients with CD4 count over 200 can be safely treated with same regimen. Mitomycin is known to produce rare severe myelosuppression in otherwise healthy patients. One may use cisplatin in this group. They should be started on highly active antiretroviral therapy HAART to improve their immunity.
So, in summary, this is a comparatively rare cancer, frequently diagnosed early with careful examination, has very good rates of cure, good quality of life and better survival with use of chemoradiation rather than surgery, interesting association with HPV infection which may be of importance in era of vaccine, has rising rates due to rising HIV infection.
We will talk about hepatobiliary and pancreas cancers in upcoming parts of this series. Please feel free to send us your questions, at the email address noted.
Question: Thank you Dr. Chiragbhai. What is the next sub site?
Answer: Next is Anal Cancer. This is a relatively rare cancer, which is divided into two: anal canal and anal margin(also known as perianal region). It is mostly squamous cell carcinoma.
It appears to be associated with HPV-16 infection, in majority of cases. This is similar to cancer of cervix, which is also associated with HPV infection. That is why immunosuppression, either in form of medicines or from HIV increases risk of anal cancer. This information becomes much more important now that we have a vaccine to prevent HPV infection.
Que: How does Anal cancer present?
Ans: Most patients present with bleeding per rectum, some with pain or mass. Most patients present in stage 1 or 2, as there is bleeding. However, one should not misinterpret this with piles. A careful examination is enough for diagnosis, to be confirmed by a biopsy. Staging work up includes CT scan of abdomen/pelvis and chest, or preferably PET-CT where available.
Patients should also undergo screening for cervical cancer with PAP smear, as there is known association, and a common risk factor i.e. HPV infection.
Que: How do you treat this disease?
Ans: In the past, surgery i.e. APR was the treatment. However, it is associated with permanent colostomy and a high failure rate i.e. about 50%.
Since early 80s, standard of care for anal cancer is chemoradiation, based on several randomized trials. All these studies showed that chemoradiation was better than surgery, with about 80% survival. Also, only a small number ultimately require colostomy, due to salvage surgery. Mitomycin and 5-FU is used with radiotherapy. Cisplatin appears to be of similar efficacy as mitomycin in phase 2 trials, but at least one randomized trial showed higher rate of colostomy with cisplatin compared with mitomycin.
Que: What about patients with HIV and Anal Cancer? Do they tolerate these treatments?
Ans: Good question. HIV infection incidence is high in India as well and is on a rapid rise. Therefore, we are all going to see HIV related diseases more and more commonly, including cancers. HIV infected patients have lower immunity, and use of chemotherapy is of concern. However, this has been studied, and patients with CD4 count over 200 can be safely treated with same regimen. Mitomycin is known to produce rare severe myelosuppression in otherwise healthy patients. One may use cisplatin in this group. They should be started on highly active antiretroviral therapy HAART to improve their immunity.
So, in summary, this is a comparatively rare cancer, frequently diagnosed early with careful examination, has very good rates of cure, good quality of life and better survival with use of chemoradiation rather than surgery, interesting association with HPV infection which may be of importance in era of vaccine, has rising rates due to rising HIV infection.
We will talk about hepatobiliary and pancreas cancers in upcoming parts of this series. Please feel free to send us your questions, at the email address noted.
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