Topic: Can someone help me understand something please? SURGICAL OPTIONS?

Admittedly I have no medical training, so bear with my obvious ignorance, but I can't get an answer to this question anywhere and it's driving me absolutely nuts.  Anyone who can explain it in laymans terms PLEASE BY ALL MEANS DO!

I do not understand why cholangiocarcinoma is not able to be surgically removed at stage 3......I'm sure there's a reason, but nobody can explain it to me so far. What I mean is this......understood there is a tumor, got that. Understood there is backup of the bile and jaundice is a byproduct of that........have spent seems like the last month since we found out about my mother in law trying to learn everything I can about cholangiocarcinoma and here's what I've been told by the doctors
I am abbreviating here, so bear with me.....doctors don't seem to like my direct questions so far, so they aren't getting answered and it driving me NUTS!


Doctor " There is no way we can do surgery since we could not control the bleeding"
My Question:  In an age where we can remove a human heart, keep blood flowing mechanically while a new donor heart is installed, why is this a problem?

Doctor " If we remove the tumor there is too great a risk"
My Question: " At Stage 3/4 is it not worth a good element of risk in many people's mind"? Is anyone doing late stage portal vein resectioning in the US?


Doctor " If we removed a section there would be nothing to reattach the portal vein to"
My Question: I've found plenty of scientific research studies, especially in Japan that lead me to believe there is both man made portal vein material available and indications of quite a bit of portal vein resection. with, in one case a 5.9% operative dx rate..........compared to the alternative that sounds like PRETTY FREAKIN' GOOD ODDS TO ME!

Guess I'm grasping at straws maybe, but with all of the medical science out there is there not a single facility doing surgery on more advanced stages of CC? 

Below is one of several examples I've found from Japan.
http://www.pubmedcentral.nih.gov/articl … id=1356151

and after you go through the science and methodology, pay particular attention to the last 1 1/2 paragraphs where it says:

"Criticism is that most of surgeries in their series were palliative or R2 resection. However, Todoroki et al27 described that adjuvant radiotherapy for patients with stage IV hilar cholangiocarcinoma who underwent R1 resections significantly prolonged survival compared with resection alone. Thus, adjuvant intraoperative and/or postoperative radiotherapy may have potential survival benefit when macroscopically curative resection is possible. Now we are planning adjuvant radiotherapy for locally advanced disease.

In conclusion, combined portal vein and liver resection for hilar cholangiocarcinoma can be performed with acceptable mortality. Approximately one third of the resected portal veins have not been infiltrated microscopically; however, without portal vein resection, the dissection plane will be cancer-positive in most cases. Although portal vein invasion has a negative impact on survival, combined portal vein and liver resection can offer long-term survival to some patients with advanced hilar cholangiocarcinoma who were previously thought to have inoperable disease."

2 (edited by marions Thu, 20 Sep 2007 11:05:33)

Re: Can someone help me understand something please? SURGICAL OPTIONS?

Dear soninlaw,

Just wanted to share this with you.
Replacing a heart does not involve cutting in to the organ.  Here, we are talking about reattaching arteries and vessels and circulating the blood throughout the body while bypassing the heart during surgery.   

When looking at biological make up of the liver you will notice it containing thousands of blood vessels (the heart doesn't), which bleed profusely when cut although, liver resections and transplants are being performed fequently. 

CC is a different kind of monster.

Hoping for all of us to find more answers.

Marions

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER

Re: Can someone help me understand something please? SURGICAL OPTIONS?

Soninlaw,
I may have missed something but it doesn't sound like you have gotten a second opinion from a surgeon who has experience, preferably lots of experience, with CC surgery.
If this is accurate please considered having your mother in law (is she the patient?) evaluated by a surgeon with CC experience.
I have written a number of posts on this subject.  If you search on 'second opinion' you should find more thoughts and suggestions.   Note that it isn't necessary to travel at first to get more feedback.  Some surgeons will look at radiologist reports and imaging and let you know if it is worth your making a trip for them to evaluate you further for surgery.
Marion has done a tremendous amount of research on CC in the last couple of years and she sums up the difficulties well.
-Peter

Re: Can someone help me understand something please? SURGICAL OPTIONS?

Actually we have had 3 opinions at this point from 3 different hospitals including Shands and Moffitt Cancer Center. I have been on via email as far away as Germany and Japan looking for options and keep coming up empty. Frustrating to say the least.

Thanks for the suggestions/thoughts.

5 (edited by marions Mon, 05 Nov 2007 00:15:31)

Re: Can someone help me understand something please? SURGICAL OPTIONS?

Dear soninlaw,

Of course, you are frustrated, as we all are. We want an answer and a cure for this disease.

As you may have already learned, due to the rarity of the occurrence of this cancer studies are limited, and in my mind, inconclusive in their respective outcome when applied to this cancer.  Physicians, in most instances, heavily rely on the results of published studies in order to establish their treatment protocols as  medicine and science have simply become too complex for any one physician to be an expert at both.

Working through the maze of information on this site, several cancer centers and physicians will become apparent as will numerous treatment plans with varied outcomes. 
You will also notice the different approaches taken in the quest of treating this cancer may it be through surgery, chemo therapy; or alternative approaches, some with long lasting and positive results.

You might also want to target those physicians with a higher volume of bilary patients and those surgeons, who have performed a fair amount of resections associated with this cancer.

Foremost, don

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER

Re: Can someone help me understand something please? SURGICAL OPTIONS?

www.curelivercancer
Check this website out.  There is a doctor who is performing surgeries on CC patients.  His name is Dr. Jerome Canaday.

Let me know if you want more information.  My husband, Tommy, has been talking with this doctor.  We are sending all of Tommy's scans and reports to him to see if surgery is an option.  Tommy has two separate cancers:  esophageal and bile duct.

Keep the faith.
Laura West

Re: Can someone help me understand something please? SURGICAL OPTIONS?

www.curedoflivercancer.com
I gave you the wrong address... sorry.
Try this one to get in touch with Dr. Canaday.

Laura West

Re: Can someone help me understand something please? SURGICAL OPTIONS?

Laura.... I viewed your link  and wanted to say it appears  you have found yourself and Tommy an excellent surgeon with great credentials.  Hope and prayers headed your way for another miracle.

Jeff G.

Take it to the Limit,One More Time! (Eagles)

Re: Can someone help me understand something please? SURGICAL OPTIONS?

Thanks Jeff...
I will keep you posted.  I am overnighting all of Tommy's records tomorrow.  He wants to see Tommy this week or next.  We are praying that this is our answer!!
He seems to be such a caring doctor... an answer to our prayers.

Laura

Re: Can someone help me understand something please? SURGICAL OPTIONS?

Hi Jeff,

Tommy and I met with Dr. Jerome Canady.  Surgery is scheduled for November 13th.  Tommy will have half of his liver resected, part of his esophagus resected, his stomach, and part of his pancreas resected..  We are feeling very grateful that God led us to Dr. Canady.  He is an amazing person and doctor.  I have been praying for a miracle... I think we found it.

I will stay in touch.
Laura

Re: Can someone help me understand something please? SURGICAL OPTIONS?

DEAR LAURA,
THANK YOU SO MUCH FOR POSTING THE INFO/STORY ON DR. CANADY. I AM HOPEFUL HE CAN HELP MY FATHER. I SENT ALL MY FATHER'S INFO, AND HE WILL CALL LATER TODAY TO LET ME KNOW IF HE WILL BE ABLE TO DO SURGERY. IF YOU WOULDN'T HAVE POSTED THAT INFO, I WOULD NOT HAVE KNOWN ABOUT HIM.
THANK YOU AGAIN!
LANA

Re: Can someone help me understand something please? SURGICAL OPTIONS?

I praise Jesus that I am reading all these phenomenal posts!  My wife Cindy asked me back in March of this year that when she received her miracle to create for her a website to give people hope.  You are all part of God's answer to my wife prayer. "To give desperate people hope!"  Tomorrow, Cindy receives her final chemo!  Her last tumor marker reading 3 weeks ago was 19.  Back in March it was over 37,000.  You are now all part of Cindy's miracle.  If you truly want the same miracle Cindy received, please go to our second website www.cindysmiracle.com and watch it in its entirety! 

God is not a respecter of persons.  What he has done for Cindy he can do for you!

God Bless,
Neill Russell

13 (edited by marions Sun, 04 Nov 2007 22:29:38)

Re: Can someone help me understand something please? SURGICAL OPTIONS?

laurahw,
my best wishes to Tommy and to a successfull surgery. 
I was wondering, has Dr. Canady given you any information in re: to the risk factor?  Also, I would be interested  in knowing as to how many surgeries of this type he has performed and how people have fared with it. 
Hoping and wishing for the absolute best
Marions

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER

Re: Can someone help me understand something please? SURGICAL OPTIONS?

soninlaw

there are surgeons who are willing to do aggressive surgery (my dad had a resection see my other posts on Prof Lodge here in the UK).  Although aggressive surgery was previously frowned upon there seems to be a shift in opinion and I have found research supporting more radical surgery offering improved outcomes. 

eg:
[Radical surgery for hilar cholangiocarcinoma (Klatskin tumor).]

Cir Esp. 2007 Jul;82(1):11-5

Authors: Ramos Rubio E

In patients with hilar cholangiocarcinoma, long-term survival critically depends on complete tumor resection. Indeed, there are no long-term survivors with positive resection margins. Furthermore, hilar cholangiocarcinoma seems to have a low propensity for distant metastases and adjuvant therapy after surgery has not been shown to have clear clinical benefits. This evidence should be regarded as arguments for extended resections. The question remains of how to achieve an R0 resection. In the last few years greater use of major hepatectomy has increased resectability and has improved long-term results. Concomitant resection of the caudate lobe is recommended as this site is a prime area of local recurrence. Frozen sections should be routinely used to assess the remnant proximal and distal ductal stumps. However, if the proximal remnant is positive, additional ductal resection at the separating limits is not always feasible. Gross portal vein invasion has a negative impact on survival, but should not be a contraindication to resection. Hepatectomy with portal vein resection can offer long-term survival in some patients with advanced hilar cholangiocarcinoma. The incidence of nodal involvement in resected specimens has been reported to range from 30% to more than 50% and there is a correlation between primary tumor extension and nodal involvement. Lymphatic metastases from hilar cholangiocarcinoma appear to spread first to pericholedochal nodes in the hepatoduodenal ligament and then to spread widely toward the posteriorsuperior area around the pancreatic head, portal vein and common hepatic artery. Routine lymphadenectomy should include all these areas. The only factors precluding resection are involvement of celiac, superior mesenteric or para-aortic tumoral nodes. Survival is closely associated with the extent of nodal involvement. The no-touch technique including right trisegmentectomy combined with portal vein resection has been proposed as the surgical procedure of choice for a more radical approach, and as a measure to prevent dissemination of tumor cells during surgery.

PMID: 17580025 [PubMed - in process]

source:   http://news.rare-cancer.org/PubMed___Ch … a/2007/06/

Re: Can someone help me understand something please? SURGICAL OPTIONS?

Dear Laura,,
I hope you read this before the 13th . All I can tell you is please do not let that doctor operate on your husband . I know you want him to live but the surgery he is going to have is radical extreme and the cancer is going to be removed not gone. I am telling you Dr canady will tell you he can help  and he will operate on hime and he will make it through the surgery but in weeks to come he will be sick full of infectionand he will have to go back into the operating room over and over again . He will not be able to eat enjoy life the way he has . He will be sick on feedins inpain . All that you enjoy together now you will no longer enjoy . Look at the man now you will no longer see him after the 13th . I am sure DR canady has alaready befriended you . Had dinner with you shared his stories with you and thenhe will sit at the bedside day and night you will be so impressed at his dedication . However see beyond it .   He does not want your husband to die he wants him to live to promote him . He is all about himself. Cancel the surgery Laura please go to a respectable doctor .

16 (edited by marions Wed, 07 Nov 2007 00:38:57)

Re: Can someone help me understand something please? SURGICAL OPTIONS?

Jules,
great posting and an informative read.
In re: to Dr. Canady however, I believe we are trying to differentiate between "aggressiveness" and "recklessness".
Marions

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER

Re: Can someone help me understand something please? SURGICAL OPTIONS?

truth4u

I would just like to ask you for some factual evidence to substantiate your claims against Dr Canady.  I think that you should bear in mind that successful surgical resection offers alot of hope to cc sufferers in the fight against this horrendous disease.  Of course, it should be stressed that this surgery is no small undertaking and that does carry risk and that the recovery may not be smooth (indeed it rarely ever is).  I am sure that any good surgeon would explain clearly the risks and prepare their patient fully for the operation.

I would urge anybody contemplating surgery to seek opinions from experienced liver surgeons only and to question them on experience with cc resections (how many have they performed?) - also consider researching into your surgeon (read published articles that he has contributed to for example). 

The debate concerning aggressive surgery rumbles on in the medical press.  However I have noticed a shift in opinion more recently and it would appear that it is more widely accepted that an aggressive technique offers improved patient outcomes. 

I do understand Neill's eurphoria concerning his wife's successful surgery and I wish her the very best for a speedy recovery.

Jules