Gastrointestinal cancer-16-Liver

GASTROINTESTINAL CANCER PART-16

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:
Potentially resectable or Transplantable
Unresectable
Inoperable due to performance status, poor liver function, comorbidities
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.

Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA),
Diplomate American Board of Oncology and Hematology.
Ahmedabad. drchiragashah@gmail.com
Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. 079 26754001 www.shyamhemoncclinic.com