GASTROINTESTINAL CANCER PART-17
Welcome to the 17th part of educational series on GastroIntestinal Cancers. We learned in part 16 about surgical management of hepatocellular carcinoma.
Question: Dr. Chiragbhai, what treatment options exist for unresectable patient i.e. either patients with larger or more tumors or poor liver function?
Answer: These are difficult cases, with options which are not so great.
But carefully selected few patients still have a chance of curative treatment, i.e. liver transplant. If patient fits certain criteria, most widely used is UNOS guidelines, chance of long term survival is equal to partial hepatectomy i.e. 4 year recurrence free survival over 70-80%, which is almost equivalent to cure. One of the major advantages of liver transplant is its ability to replace cirrhotic liver, thereby preventing other complications.
Que: But doctor, what are the commonly available options?
Ans: I think it is important to note at this point that there is a significant increase in number of trained people who can perform hepatic resections now in India. Also, there is a marked growth in number of liver transplant centers across country. We should not be limited by old ideas of treatment options and the talk about lack of high-end treatments in our country any more. A number of patients in India now have resources and motivation to obtain these treatments, by going abroad or out of town or state. Growing affordability in country is obvious from number of luxury cars on the road.
Que: I agree with your idea, and referring patients to tertiary care centers will certainly increase proportion of patients who can benefit from curative treatments? What are the other treatment options for HCC patients?
Ans: Loco-regional (ablation or embolization) and Systemic.
Ablation can be done with RFA-radiofrequency, PEI-ethanol injection, cryoablation, microwave ablation. All these can be performed without laparotomy. Long term control rates of up to 50% have been reported, especially with tumors less than 3 cm size.
Embolization treatment can be done using bland beads or chemoembolization. Patients with portal vein obstruction, bilirubin more than 3 are not good candidates. Radioactive material embolization is another effective approach.
Systemic therapy includes an oral multikinase inhibitor Sorafenib which has modest improvement in survival, and is recommended as the preferred option for systemic therapy. However, this drug has been tested in Child Pugh class A and class B. PIAF is a combination chemotherapy regimen, which has shown some good results in some paitents, and occasionally converted patients to resectable stage.
For class C patients, options are practically none and best supportive care is what is advisable.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA),
Diplomate American Board of Oncology and Hematology.
Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. 079 26754001 www.shyamhemoncclinic.com