HepatoPancreato Biliary (HPB) Surgery
Liver Tumours
Tumours can form in the liver. It can come from the liver itself (primary liver cancer) or cancer from other areas may spread to the liver (liver metastasis).
Primary liver tumours include hepatocellular carcinoma (HCC) and cholangiocarcinoma. Tumours that may spread to the liver include colorectal cancer, neuroendocrine tumours, breast cancer and melanoma.
What symptoms might I experience?
Tumour of the liver may not cause any symptoms. They may be picked incidentally on imaging done for other reasons.
When symptoms occur, regardless of the type of liver tumour, the symptoms are similar. These include right-sided upper abdominal discomfort/pain, yellowing of eyes (jaundice), itch, pale stools and dark urine along with generalized symptoms of loss of weight and loss of appetite.
Tumours from other sites of the body may also cause symptoms related to that specific body site.
How is it treated?
Liver tumours are managed in a multi-disciplinary team along with oncologist, radiologist and other surgical specialties as required.
Treatment of liver tumours is dependent on the type of tumour and extent of liver involvement. It may be removed surgically (liver resection), which can be done keyhole (laparoscopic) or open. Other treatment options for liver tumours include transarterial chemo-embolisation (TACE), radiofrequency ablation (RFA), microwave ablation (MWA) as well as radiotherapy.
Your surgeon can provide a thorough assessment and facilitate multi-disciplinary team discussion and approach to your care.
Pancreatic cysts
Pancreatic cysts can form throughout the pancreas. True cysts of the pancreas include intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), serous cystadenoma (SCN) and soilid pseudopapillary neoplasm (SPN).
Majority of the cysts do not cause symptoms and are often picked up incidentally on various imaging modalities, such as a CT scan. Once detected, dedicated high quality imaging of the pancreas is performed (CT pancreas or MRI pancreas). Endoscopic ultrasound (EUS) and fine needle aspiration (FNA) may be required. Pancreatic cysts are managed in a multi-disciplinary team with radiologists and gastroenterologists as diagnosis can sometimes be difficult.
Treatment is based on the nature of pancreatic cysts.
Serous cystadenoma – no treatment required typically
Solid pseudopapillary neoplasm (SPN) – pancreatic surgery
MCN & IPMN – observation or pancreatic surgery depending on the risk of developing or harbouring cancer
The type of surgery performed is dependent on the location of the cyst.
Tail of pancreas - Distal pancreatectomy
Head of pancreas – Pancreaticoduodenectomy (Whipple’s procedure)
Whole pancreas – total pancreatectomy
Cancers of the Pancreas
Cancers can develop within the pancreas. This includes pancreatic adenocarcinoma (colloquially known as pancreatic cancer) and pancreatic neuroendocrine tumour.
Tumours from other body sites can also spread to the pancreas. These tumours include breast cancer and renal cell carcinoma. However, spread to the pancreas from other body sites is not common.
Pancreatic adenocarcinoma
Pancreatic adenocarcinoma is the 8th most common cause of cancer in Australia. 5 year over all survival is approximately 6 – 7 %.
What symptoms might I experience?
Pancreatic adenocarcinoma may not cause any symptoms initially. This is why it is often diagnosed late.
Local symptoms may occur when it pushes on or involves nearby structures. It can cause yellowing of the eyes and skin (jaundice), itch, pale stools and dark urine when it blocks the bile duct (drainage tube of the liver). Early satiety, nausea and vomiting may occur when it presses on the stomach. Upper abdominal discomfort/pain and back pain may also be experienced. Systemic symptoms of loss of weight and loss of appetite may also occur.
Diagnosis
Once pancreatic cancer is suspected, whole body high resolution CT is performed especially of the pancreas. Endoscopic ultrasound and fine needle aspiration of the area of concern is typically performed to confirm diagnosis.
How is it treated?
Treatment of pancreatic cancer is tailored to the fitness of the individual as well as the staging of pancreatic cancer. It is managed in a multi-disciplinary team with HPB surgeons, oncologists, radiologists and gastroenterologists.
ERCP and biliary stenting may be required to relieve blockage of the bile duct caused by the tumour prior to any intervention.
Further treatment options include surgery and chemotherapy alone or in conjunction with surgery.
Type of surgery required is dependent on where the cancer is located:
Tail of pancreas - Distal pancreatectomy
Head of pancreas – pancreaticoduodenectomy
Pancreatic neuroendocrine tumour (pNET)
Pancreatic neuroendocrine tumours arise from a subset of cells in the pancreas called Islet of Langerhan. It is a rarer form of cancer accounting for up to 1 – 2% of all primary pancreatic tumours.
What symptoms might I experience?
pNET may not produce any symptoms and may be picked up incidentally. It can produce a range of symptoms including upper abdominal pain, yellowing of eyes/skin, itch, pale stools and dark urine. pNET may produce hormones (functional tumours) and symptoms can result from high hormone levels. For example, excess insulin production can result in low sugar levels that are difficult to treat.
Diagnosis
As part of workup for pNET, your surgeon will organize for you to have blood tests including a tumour marker, chromagranin A. Neuroendorcrine tumour specific whole body imaging is also performed (DOTATATE PET scan). Further scans may be required, such as FDG PET scan and MRI pancreas. Endoscopic ultrasound (EUS) and biopsy (FNA) may also be performed.
How is it treated?
Not all pancreatic neuroendocrine tumours require treatment. Treatment is typically based on the size of tumour, symptoms and the grading of the tumour.
When treatment is required, treatment options include surgery of the pancreas and medications targeting tumour cells, such as Octreotide.
Your surgeon will discuss with you and your family treatment options available specifically for you.
