Liver Cancer Treatment Surgery Chandigarh

What are the symptoms of liver cancer?

Symptoms of liver cancer vary widely and may include

  • Fatigue
  • Jaundice (yellowness of the skin)
  • Pain
  • Easy bruising or bleeding
  • Swelling of abdomen
  • Weight loss.

    • What are the risk factors for liver cancer?

    • Viral hepatitis such as hepatitis B and C
    • Regular alcohol consumption
    • Cirrhosis – cirrhosis due to any cause increases the risk of liver cancer
    • Diabetes – It can result in fatty liver disease and thus leading to hepatitis and predisposes to cancer.
    • Non alcoholic fatty liver disease – it can lead to inflammation of liver cell thus predisposing to formation of cancer.
    • Hereditary conditions like hemochromatosis( iron deposition in liver), Wilson disease ( copper deposition in liver)
    • Aflatoxins – consumption of food product infected with fungus producing aflatoxins can also produce liver cancer

    How can liver cancer be prevented?

    Prevention is very important when it comes to a disease like liver cancer. The underlying cause of liver cancer is often liver inflammation and the development of a condition called Cirrhosis.  In addition to avoidance of drugs and alcohol, infection (such as Hepatitis B or C) and obesity can contribute to the development of liver cancer.

    Steps to minimize these risks include

    • Vaccination against hepatitis B for those at risk,
    • Prompt treatment for patients infected with hepatitis C,
    • Maintaining a healthy weight through diet and exercise.
    • Avoidance of alcohol
    • Good control of diabetes.

    How is liver cancer detected?

    Patients diagnosed at an earlier stage have better outcomes. There are many strategies that are used to detect liver cancer, including.

  • Frequent imaging studies (ultrasound, computed tomography scan, magnetic resonance imagining) in high risk patients.
  •  Routine physical exams with blood testing in high risk patients.

    • Several researchers are looking to find the one blood test that will help identify liver cancer much sooner. Until that time, we continue to remain vigilant and screen with a variety of methods to try to catch this disease as early as possible.

    Are fatty liver disease and liver cancer related?

    Fatty liver disease progressing onto non-alcoholic fatty liver disease(NAFLD) and non-alcoholic steatohepatitis(NASH) can result in cirrhosis of the liver. Cirrhosis of the liver predisposes the patient to liver cancer. The fatty liver itself does not predispose a patient to cancer however if it is controlled at an early stage before it progresses onto cirrhosis then the risk of liver cancer is negligible.

    What is the optimal treatment of liver cancers?

    In general, the basic approach of any cancer therapy can also apply to liver cancer. The treatment of the local disease. In liver cancer, we often address the local disease with:

  • Surgery (removal of the tumor) – treatment of choice for patients
    without cirrhosis of the liver.
  • Liver transplantation – it is the treatment of choice in patients with
    cirrhosis provided tumor size and number criteria are met. It takes
    care of cirrhosis of the liver also.
  • Radiation therapy
  • Local ablation of the tumor by radiofrequency
  • Catheter-directed chemotherapy or embolization.

    • Are herbal medicines recommended to treat liver cancer?

    The term ‘herbal medicine’ can represent thousands of compounds. Unfortunately, most are not rigorously tested or regulated by the companies that produce them, so real evidence of any benefit is not known. In fact, they may have harmful side effects that one comes to know only after using them.

    Should I be worried if I have a cyst on my liver?

    There is often nothing to worry about with simple cysts in the liver. They can be quite common. When we find cysts that are growing, we will often take extra care to ensure that

    • There is not an associated tumor causing the growth
    • That cyst is not causing problems.

    This is often discussed over time with your hepatologist and/or liver surgeon who can help in differentiating malignant ( cancerous) cysts from nonmalignant ones.

    What should I do if some lesion is found in the liver on a regular check-up?

    Lesions in the liver on ultrasound can be of many types

    Non-cancerous

    • Hemangioma ( abnormal formation of blood vessels)
    • Abscess ( pus collection in liver)
    • Granulomas in liver- because of TB , Sarcoidosis etc.
    • Cysts of liver – that can be simple cyst or hydatid cysts ( worm infestation)

    Cancerous

    • Primary liver cancer
    • Metastatic tumor from some other organ- liver is most common site of spread of tumors from other abdominal organs.
    • Neuroendocrine tumor of liver
    • Malignant cysts of liver

    A hepatologist or liver surgeon can help you in guiding you towards diagnosis and treatment by carrying out relevant investigations.

    If a parent had/has liver cancer, are their children at greater risk of getting it?

    In some cases, yes, a parent with liver cancer can raise your personal risk e.g in hereditary disease as Hemochromatosis, or Wilson’s disease. However, this is not true for the majority of patients. It’s always good to talk to your primary care doctor about your concerns or questions.

    Gall bladder Cancer

    1. What are causes of gall bladder cancer?

    Known causative factors for gall bladder cancer are

    • Gall Stones
    • Gall bladder Polyps
    • Porclein gall bladder
    • Obesity
    • Old age
    • Choledochal cyst
    • Abnormalities of union of bile and pancreatic duct
    • Primary sclerosing cholangitis
    • Ethnicity
    • People residing in high-risk area eg., Chile, along plains of river Ganges etc.

    2. What are signs and symptoms of gall bladder cancer?

    Gall bladder cancer can present with very non-specific signs and symptoms. Majority times it is
    detected incidentally on imaging. Patient may present with

    • Pain
    • Jaundice
    • Loss of weight
    • Loss of appetite
    • Distension of abdomen

    3. How can gall bladder cancer be detected?

    Gall bladder cancer usually are detected on imaging. Ultrasound abdomen is first lie of
    investigation that can show irregular thickening of gall baldder wall. These findings are
    confirmed by multiphasic CECT abdomen that can show condition of gall bladder and
    surrounding enlarged lymph nodes.

    4. Are gall bladder polyps cancerous?

    Small gall bladder polyps are non cancerous. Any polyp larger than 1 cm in size harbour
    higher chances of malignancy and is an indication of surgery.

    5. How can gall bladder cancer be prevented?

    Gall bladder cancer cannot be prevented . There are no ways by which gallbladder cancer can be prevented except for prophylactic cholecystectomy in area of high endemicity eg., Chile ,
    where prophylactic cholecystectomy had been shown to decrease incident of gall bladder
    cancer.

    6. What is treatment of gall bladder cancer?

    Main treatment of gall bladder cancer is surgery is it is feasible. Complete resection of gall
    bladder cancer is the only chance of providing long term survival. Usually majority of patients
    present with advanced disease that cannot be resected and can be offered palliative treatment
    only. Resectability if usually assessed best by liver/gastrointestinal surgeon who is experienced
    in liver surgery. Assessment by liver surgeon can make advanced disease resectable by proper
    planning with help of interventional radiologist. Chemotherapy has a role in pallative setting or
    after resection of tumor by surgery.

    Colon and Rectal Cancer

    1. What is colon?

    A colon, also called the large intestine or large bowel, is part of the body’s digestive system. The colon is a muscular tube about five feet long and three inches wide. During digestion, food moves from the stomach to the small intestine and then to the colon. The colon absorbs water and nutrients from the body’s waste, creates stool and then pushes that stool into the rectum.

    2. What is the differences between colorectal, colon and rectal cancer?

    Colorectal cancer is the term used to describe cancer of the colon and/or rectum. The two cancers are grouped together because they share many common characteristics. Together, the colon and rectum make up the large intestine, a question mark-shaped bowel four feet in length. Colon cancer develops in all but the last few inches of the large intestine, between the appendix and rectum. Rectal cancer develops in the rectum, the last few inches of the large intestine that attaches to the anus. Colon cancer is more common.

    3. What are polyps?

    A polyp is a clump of cells that forms on the lining of the colon giving rise to swelling that project from wall of colon into lumen of colon. Most polyps are not harmful, but some may develop into colon cancer. Colonoscopies can help detect pre-cancerous polyps

    4. What are sign and symptoms of colon cancer?

    Colorectal cancer may develop when benign polyps in the large intestine grow and become cancerous. If early-stage colorectal cancer does cause symptoms, early warning signs may include sudden weight loss and/or narrow, ribbon-like stools. Other common early warning signs of colorectal cancer include:

    1. Rectal bleeding, either bright or dark red in color
    2. Tenesmus, which is the feeling that you have to empty your bowel but nothing passes
    3. Anemia caused by iron deficiency
    4. Persistent abdominal pain

    As the cancer grows, symptoms may include:

    1. Abdominal pain or cramps
    2. Constipation
    3. Diarrhea
    4. Blood in your stool
    5. Bloating or a sense of not feeling empty after a bowel movement
    6. Flat or ribbon-shaped stool
    7. Unexplained weight loss
    8. Fatigue
    9. Loss of appetite

    5. What are risk factors for colon cancer?

    A risk factor is something that increases your chances of getting a disease. Having a risk factor does not mean that you will definitely get a disease, only that you and your doctor should watch more carefully for warning signs. Some risk factors can be avoided through lifestyle changes and some cannot. Some of the risk factors for colon cancer include:

    1. Age 50 or older
    2. Type-II diabetes
    3. Personal or family history of colon cancer or polyps
    4. Personal history of inflammatory bowel disease
    5. Some inherited genetic syndromes
    6. Diet high in fat and/or low in fiber or calcium
    7. Obesity
    8. Smoking
    9. Heavy drinking
    10. Physical inactivity

    6. How is colon cancer diagnosed?

    Doctors use many tools and techniques to diagnose colon cancer including:

    1. History and physical examination by a physician
    2. Testing blood and stool
    3. Performing colonoscopies
    4. Performing CT scans, PET scans, MRIs, endoscopies, and ultrasounds

    7. How can we prevent / decrease risk of colon cancer?

    The risk factors for colorectal cancer may be reduced with regular checkups and lifestyle changes. In western countries it is recommended that men and women have a colonoscopy beginning at age 50 as the rates of cancer are higher in west. If you have a family history of colorectal cancer, you should get screened 10 years earlier than when your family member was diagnosed. For example, if your father was diagnosed with colon cancer at 48, you should talk to your doctor about getting a colonoscopy at 38. Talk to your doctor about how often you should get a colonoscopy. The procedure may be able to help your doctor spot cancer in its early stages. Pre-cancerous polyps are removed and biopsies are performed during the procedure, if necessary.
    Changes in your lifestyle may also help you lower your risk and prevent colorectal cancer from developing. Obesity, smoking, alcohol, diet and a sedentary lifestyle have been linked to an increased risk for colorectal cancer

    8. Is colon cancer hereditary?

    Colorectal cancer isnt always passed down in families, but it can be. If someone in your family has had colorectal cancer, you may be more likely to develop it.

    Colorectal cancer can sometimes be caused by Lynch syndrome, a genetic condition also called hereditary nonpolyposis colorectal cancer (HNPCC). About one in 30 colorectal cancer cases are a result of Lynch syndrome. Patients with Lynch syndrome tend to get colorectal cancer at a younger age than others, with a higher likelihood of developing other types of cancer as well, such as:

    • Stomach cancer
    • Liver Cancer
    • Ovarian Cancer
    • Uterine Cancer

    9. How is colon cancer treated?

    Surgery is the most common form of treatment for colorectal cancer. Surgery is used to remove the tumor and surrounding tissue. A portion of the colon or rectum may need to be removed, and a colostomy( part of colon is brought out through abdominal wall and bag if fixed over it in which stool gets collected) may be required—permanently or temporarily, depending on the extent of the cancer and how much of the colon or rectum is removed. Other treatment options include chemotherapy and/or targeted therapy drugs, which may also be used in addition to surgery. Radiation therapy is usually an option only for rectal cancer, not colon cancer.

    10. What types of doctors will I see during my treatment?

    Your colorectal cancer care team may include one or more of these doctors:

    • A gastroenterologist, who specializes in the digestive system and performs colonoscopies
    • Surgical gastroenterologist/ GastroIntestinal Surgeon – who performs surgery to remove tumors and provide best functional outcome e.g pouch formation in case of hereditary cancers. If disease is early only surgery can be curative.
    • A radiation oncologist, who uses radiation therapy to treat cancer
    • A medical oncologist, who treats cancer with drug therapies.

    Surgery is the mainstay of treatment in colon cancer. Preoperative chemoradiation is used in rectal cancer in locally advanced cases. Surgeon can assess the local stage of disease on scans and thus can plan upfront surgery or chemoradiation. Postoperative chemotherapy/radiation therapy is decided after final stage of disease is determined after examining removed specimen.

    Liver cancer

    Liver cancer is increasing day by day. Its probably due to increase in incidence of cirrhosis of liver that predisposes to liver cancer. Causes of cirrhosis of liver –

    1. Alcohol
    2. Viral hepatitis’
    3. NASH – Non Alcoholic Steatohepatitis
    4. Toxins
    5. Autoimmune conditions- PBC, Autoimmune Hepatitis etc.

    Above are main conditions that cause cirrhosis and predisposes to liver cancer. As the rate of obesity and Diabetes Mellitus is increasing all over world so is the rate of fatty liver and steatohepatitis (injury to liver) that predisposes to cirrhosis and thus liver cancer. So it becomes imperative for allpatients having above mentioned factors to be utmost careful in monitoring the progression of theirdisease to detect cancer at early stage.

    FAQs

    1. How can liver cancer be prevented?

    Liver cancers can be prevented by keeping high risk patients under regular follow
    with tumor markers and ultrasound examination. Patient at high risk of getting liver cancers
    are mentioned above. So patients with above risk factors who have not progressed to
    cirrhosis should be treated according to cause e.g; stopping alcohol, decreasing weight, good
    control of diabetes, treating viral hepatitis etc.

    2. What is peculiar about liver cancer and its treatment?

    Liver cancers usually arise in patients with cirrhosis. This presents peculiar problem
    as these patients have damaged liver in addition to tumor. Damaged liver further shrinks
    treatment options for such patients. Moreover majority of these patients are unfit for any
    form of treatment due to damaged liver. So treatment is tailored according to status of liver
    disease and tumour size and location.

    3. Is there any medical treatment of liver cancer?

    Mainstay of treatment is surgery. Medical treatment is offered to only those cases that
    cannot be offered any surgery


    4. How can liver cancers be treated?

    Best way to treat liver cancer is by surgery. Surgery can be

    • Resecting tumor or tumor bearing liver
    • Liver transplantation

    First option is feasible only in normal livers or in cirrhotic with small tumours. In patients
    with cirrhosis best treatment option is liver transplant provided tumor load is within one specific
    range. Liver transplantation takes care of diseased liver and tumor simultaneously and thus provides best chances of prolonged life.


    In cases of tumor deemed unresectable or patient is unfit for transplant, interventional
    radiology provides solution for tumor treatment by

    A. Radiofrequency ablation that has same results as surgery in cirrhotics,
    B. Tumor chemoembolization
    C. Internal tumor radiation by TARE

    5. Which specialist is best to treat liver cancer?

    Before starting any treatment liver or liver transplant surgeon must be contacted. Liver
    surgeon is best person to evaluate patients fitness and tumour resectability and can provide
    tailored approach that is best suited for patient’s condition as mentioned above.

    Esophagus Cancer

    1. What are causes of esophagus cancer?

    Risk factors for esophagus carcinoma are

    • Alcohol consumption
    • Smoking
    • Gastroesophageal reflux disease
    • Obesity
    • Barrett esophagus

    2. What are types of esophagus cancer?

    There are predominantly two types of esophagus cancers based on microscopic examination of tumor sample

    • Squamous cell carcinoma
    • Adenocarcinoma

    Few other types of carcinoma can affect esophagus but are uncommon -e.g, smallcell carcinoma, neuroendocrine tumor, sarcomas etc.

    3. What are symptoms of esophagus cancer?

    Usual presenting symptoms are

    • Difficulty in swallowing
    • Stickiness of food while swallowing
    • Retrosternal discomfort
    • Pain chest
    • Chronic cough especially while swallowing
    • Weight loss
    • Hoarseness of voice

    4. How can esophagus cancer be detected?

    First line of investigation for diagnosis are

    • Barium swallow
    • Upper GI endoscopy and biopsy

    These two tests not only provide us diagnosis but also tells us about location of tumor that will further decide future course of action for treatment. Biopsy provides us with tissue diagnosis regarding type of cancer as mentioned above.

    5. What are tests to be done before starting any form of therapy?

    After diagnosis staging investigation are required to grossly stage the disease and planfurther treatment

    • CT scan of chest and upper abdomen
    • Endoscopic ultrasound (EUS)
    • Whole body PET Scan
    • Bronchoscopy depending upon location of tumor

    6. What is treatment of esophagus cancer?

    Surgery has been mainstay of treatment for carcinoma esophagus. But long term survival was poor. With recent advent of few chemotherapeutic agents along with radiation the rapyhas really improved overall survival and outcomes. Even in patients with locally advanced disease chemoradiation has resulted in down staging of tumor and increased resection rate as well as survival rates. So now according to protocol patient usually under goes chemoradiation first followed by surgery.

    7. What if the type of surgery done for esophageal cancer?

    Esophagus cancer is treated by minimally invasive methods now. Thoraco- laparoscopi cresection of esophagus with reconstruction by stomach tube is method of choice for cancer of esophagus. Robotic surgery is further advancement in surgical armamentarium that increases safety of surgery and improves outcome. With minimally invasive methods side effects of surgery has been reduced to minimum and patient’s recovery is enhanced.

    8. What are side effects of treatment of esophagus cancer?

    The patient can have side effects due to radiation, chemotherapy or surgery. Side effects due tochemoradiation are

    • Nausea /vomiting
    • Difficulty in swallowing
    • Chest pain
    • Loss of appetite
    • Decreased cell counts
    • Mouth ulcers

    Complications after surgery can be

    • Hoarseness of voice due to nerve injury- its usually temporary and recovers with time
    • Swallowing problems due to uncoordinated effects of swallowing reflex
    • Injury to trachea, blood vessels, thoracic duct (incidence has reduced considerablyafter using minimally invasive methods)
    • Lung complications (reduced significantly with laparoscopic approach)

    Stomach Cancer

    1. What are causes of stomach cancer?

    Causes of stomach cancers are

    • Alcohol consumption
    • Smoking
    • Diet high in salt and processed meat and low in vegetables
    • Any previous stomach surgery
    • Conditions decreasing acid secretion in stomach
    • H.Pylori infection
    • Hereditary conditions like multiple polyps throughout GIT

    2. What are the symptoms of stomach cancer?

    • Early satiety
    • Anemia
    • Recurrent Vomiting or blood in vomiting
    • Loss of appetite
    • Abdominal distension
    • Passing black-colored stools
    • Unexplained weight loss

    3. Does cancer of stomach run in families?

    Yes cancer of stomach can run in families especially in patient having multiple polyps
    throughout gastrointestinal tract e.g, FAP, Lynch syndrome etc. first degree relatives of
    these patient should undergo prophylactic screening endoscopy at young age.

    4. How is stomach cancer diagnosed?

    Stomach cancer is usually diagnosed by Imaging or endoscopy and biopsy. To establish
    diagnosis endoscopy and biopsy is done. For staging purpose following investigations are
    advised –

    • CECT Scan of abdomen
    • PET Scan of whole body
    • Endoscopic ultrasound

    5. What is treatment of stomach cancer?

    Treatment of stomach cancer depends upon stage of cancer and presentation of patient. In
    case of patient who is unable to eat, surgery would be mainstay of treatment. While in patients with locally advanced disease chemoradiation followed by surgery is the treatment of choice. Surgery remain mainstay of treatment for stomach cancer.

    6. What type of surgery is best for patient?

    With advancement in technology and staplers stomach cancer is managed these days with
    laparoscopy. Laparoscopy has been used widely for total or partial removal of stomach and
    has been found to provide equal results with improved quality of life and early recovery in
    these patients.
    Robotic surgery is further advancement in surgical armamentarium that increases accuracy
    of dissection thus improving results.