Hepatobiliary & Pancreatic (HPB) Oncology: A Vibrant & Rapidly Evolving Sub-Speciality

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 a presenting symptom in HPB cancers but many patients reach referral centers 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 ‘Acidity’ or ‘Gas’ and by the time he reaches a specialist the imaging shows advanced pancreatic cancers.

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 (EUS) 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 patients undergoing a major liver resections need a preoperative portal vein embolization to shrink one half of the liver or a 3D CT volumetry Most of these facilities are available only at specialized HPB centers.

Patients with Hepatitis B, hepatitis C, and alcoholic liver disease 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.

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 STITCH approach the HPB surgeon needs an understanding of their complex physiology as well as expertise in vascular surgery as these tumors often involve critical vascular structures. This is especially important in the postoperative period in these high-risk group. It has been scientifically proven that centers with focused and high-volume care in HPB oncology achieve best results. Most cancer centers in India have a jack of all trades approach offering treatment for cancers from head to toe. Specific focused expertise is lacking due to low volumes. In HPB centers surgical expertise in benign and malignant liver conditions and specialized diagnostic expertise leads to higher volumes and expertise with better results.

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 specialized HPB centers treatment options such as radiofrequency ablation, trans arterial chemoembolisation, trans arterial radioembolisation, liver transplantation for liver cancer are added to the armamentarium leading to better results. Like wise in pancreatic cancer laparoscopic pancreatic resections, EUS guided diagnosis and ablations, pancreatic and bileduct stent and endoscopic radiofrequency ablation are available in specialised centers.