PAGE 1 – (FRONT COVER) FEBRUARY 2020

WHAT’s INSIDE? 
1. About

2. Editorial

3. Case Review

4. Theme Based Case Discussion

5. The Journal Club

WHY THIS ISSUE? 

The very idea of a newsletter in HPB Surgery is to introduce our doctors
and allied professionals to the scope of work that is being performed. 

In addition to its academic approach, this newsletter lays down the

foundation for a Multidisciplinary practice involving multiple specializations
for the best outcomes in patients with HPB conditions. 

We hereby, take pleasure in presenting this edition of our Newsletter with a

theme of ‘Neoadjuvant Therapy in HPB oncology’. 

We hope that this move serves as a foundation for an integrated and

holistic practice that offers our patients the best chance at therapy. 

Dr Subash K.G,

Associate Consultant,

HPB Oncology & Liver Transplantation,

HCG Hospitals, Bangalore.

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EDITORIAL

The importance of HPB Surgery as an independent speciality has risen over the last two
decades in view of the advancements in the diagnostic and therapeutic modalities. A
large number of previously ‘untreatable’ conditions affecting the liver and pancreas are
now amenable to therapy and by far, surgery provides the best chance for cure in
majority. Specific areas of progressive interest in the HPB Surgery domain include HPB
Oncology, Genomics, Organ Transplantation and Interventional Radiology.

We have been attempting to focus on a multidisciplinary approach to the diagnosis and

treatment of these conditions including Robotic and laparoscopic surgery where
feasible, endoscopic procedures, interventional radiology maneuvers and a holistic
team based discussion involving the oncologist, hepatologist, pediatrics, vascular
surgery, etc.

Dr Raghavendra Babu J,

Consultant and Clinical Lead;

HPB Oncology and Organ Transplantation,

HCG Hospitals, Bangalore.

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CASE REVIEW
We present a 56 year old patient with pain abdomen and fatigue since 2 months, with an increase
in symptoms from 3 weeks, associated with one episode of mild fever 3 weeks ago which
subsided on medication.

He has a history of being diagnosed with carcinoma Right colon 9 years ago, and has undergone
Right Hemi colectomy with Ileo-Colic anastomosis for the same, in 2010. The HPE report
verified it as a Mucinous Adenocarcinoma (T3N0M0) – Poorly Differentiated. The surgery was
followed by 6 cycles of adjuvant chemotherapy following the surgery.

The patient recovered well after treatment, up until 2018, when he developed an anastomotic site
recurrence of the malignancy on the posterior wall of the Ileo-Colic anastomosis, for which he
underwent local resection of the lesion and followed it up with 6 cycles of adjuvant
chemotherapy (CAPOX + BEVACIZUMAB).

In addition to these findings, another observation that was made included a colonoscopy
performed in 2013 that had revealed a single recto-sigmoid polyp which was unchanged at repeat
colonoscopy in 2018. A UGI scopy demonstrated Duodenal Ulcer (Forest 3).

Up until now it is evident that a colonic adenocarcinoma had occurred and even recurred once
for which he received appropriate treatment. But currently, the patient is almost asymptomatic
and presents with mild dyspeptic symptoms with a febrile episode and mild abdominal pain that
occurs occasionally. Therefore, he was evaluated to rule out another recurrence.

He was confirmed to have a lesion in the first part of the duodenum (D1), extending up to the
second part (D2) and laterally infiltrating on to the liver (segment 5). An endoscopic biopsy
confirmed it as a mucinous adenocarcinoma along with PET-CT Scan which showed FDG
uptake by the lesion. Hence, a Whipple’s Pancreatico-Deodenectomy was planned in the
treatment of this metachronous metastatic duodenal adenocarcinoma.

The surgery was begun with the intention of a WPD but an attempt at mobilizing the duodenum
was made, so as to restrict the procedure to segmental deodenectomy with hepatic
metastatectomy, but due to dense infiltration of the tumor, this was not possible and the strategy
was changed and a Hepatico-Pancreatico-Deodenectomy was performed. This surgery is a rarity
in itself and is not commonly performed due to the associated complications like post-operative
Liver failure, pancreatic fistulae, and liver abscess, etc.

Our patient tolerated the procedure well and was in the ICU post-operatively for one day and
shifted to the ward on POD 2, and his recovery was uneventful with no complications. He was
given supportive care for the next 4 days and was discharged on POD 7. He was advised for a
medical oncology opinion and a follow up with the team.

HPD has its reservations as a standard operative procedure because of concerns over morbidity
and mortality, but it can be safely performed using the presently reported surgical strategy with
acceptable short and long-term outcomes. A precise assessment of the patient condition and the
tumor characteristics might improve patient outcome. Most importantly, as demonstrated in the
management of this patient, a multidisciplinary approach involving the Medical Oncology team,
colorectal surgery, HPB Surgery, MGE team has a large role to play in successful outcomes in
such challenging cases.

PICTURE 1

PICTURE 2

PICTURE 3
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THEME BASED CASE DISCUSSIONS

PATIENT 1:

This was a 49 year old female patient from Hubli, who presented with pain abdomen with
features and endoscopic findings suggestive of Gastric Outlet Obstruction, about 10 months ago,
in January 2019. She was evaluated thoroughly and a diagnosis of Duodenal Adenocarcinoma
was made. It was thereby decided for her to undergo Neoadjuvant Chemotherapy (NACT) to
downstage the tumor before a surgical attempt at complete excision was undertaken. Hence, she
was treated with 6 cycles of FOLFOX regimen based chemotherapy by our Medical Oncology
Team and the symptoms of GOO started subsiding immediately. Post NACT, evaluation of the
tumor showed a good response to NACT and she needed a segmental deodenectomy instead of
a complex, large volume visceral organ resection. She recovered well in a week and was
discharged in a hemodyanamically stable condition.

FIGURE 1 FIGURE 2

PATIENT 2:

This was a 24 year old male patient from Bangalore, with Bilobar, multicentric well
differentiated HCC in a non-cirrhotic liver. Management of this condition would involve
surgical excision of the tumor, but due to an extremely low FLR, a surgical attempt would do
more harm than good. He was advised to undergo Trans-Arterial Chemo Embolization (TACE)
at HCG Bangalore. A total of 3 sessions of TACE was performed by the Interventional
Radiology Team which eventually resulted in the lesions becoming amenable to surgical

PAGE 6
excision (Staged Hepatectomy) with an adequate FLR and a follow up revealed no recurrence
up to about a year now.

FIGURE 1 FIGURE 2

PATIENT 3:

This was a 58 year old female patient from Cameroon with HCV related HCC, diagnosed in
April 2018. A thorough evaluation showed that the liver mass was 10 cm large and was
involving segments 5, 6, 7, 8 of right lobe and thrombus extending on to the right hepatic vein
with multiple lymphadenopathies and a massive elevation of AFP was noted (10,300).
She was being treated with anti-viral’s for the HCV for about 3 months previously, as a result of
which, HCV-DNA was not detectable at the time of presentation.
The treatment plan included Cyber-Knife therapy and Immunotherapy to begin with and later
evaluates her again after a few months. Follow up imaging, 6 months later revealed the mass had
shrunk to the size of about 4 cm, AFP had dropped down to a large extent (300) and this aided us
in carrying out a right Hepatectomy succesfully and the patient returned to Cameroon a month
later and is doing well with no issues up to now, which is 6 months of follow up.

FIGURE 1 FIGURE 2
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PATIENT 4:

A 35 year old male with complaints of abdominal pain and dyspepsia of 3 months duration was
found to have a gall bladder mass on imaging. A tru-cut biopsy was reported as a poorly
differentiated adenocarcinoma. Hence, a diagnosis of locally advanced carcinoma gallbladder
infiltrating into segment 4 of the liver with lymph node metastasis was made and Neoadjuvant
Chemotherapy was suggested. He underwent 3 cycles of NACT with Gemcitabine and Cisplatin,
and showed a good response to it. The GB mass had decreased from 6.5 cm to 2.5 cm and the
lymph nodes had reduced from 4 cm to 2.3 cm. Thereby, a radical cholecystectomy was
sufficient to attain negative margin on all sides. Patient recovered well and was discharged on the
4th post-operative day.

FIGURE 1 FIGURE 2
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THE JOURNAL SCAN

1. Survival in Locally Advanced Pancreatic Cancer After Neoadjuvant

Therapy and Surgical Resection
Gemenetzis, Georgios MD*; Groot, Vincent P. MD*; Blair, Alex B. MD*; et al.

Annals of Surgery: August 2019 - Volume 270 - Issue 2 - p 340–347

doi: 10.1097/SLA.0000000000002753

RESULT: Surgical resection of Locally Advanced Pancreatic Carcinoma after

Neoadjuvant therapy is feasible in a highly selected cohort of patients and is associated
with significantly longer median overall survival.

EDITORIAL COMMENTS.

2. Chemotherapy after Portal Vein Embolization to Protect Against Tumor

Growth during Liver Hypertrophy before Hepatectomy.
Catha Fischer, MD1 Laleh G. Melstrom, MD1 Dean Arnaoutakis, MD1
;  ;  ; et al

JAMA Surg. 2013;148(12):1103-1108.
doi:10.1001/jamasurg.2013.2126

RESULT: Chemotherapy after PVE may prevent cancer progression and does not retard
growth of the liver. Thus, the combination of PVE and chemotherapy may enhance both
oncologic and operative safety.

PAGE 9-
 EDITORIAL COMMENTS.

3. Neoadjuvant chemotherapy in patients with locally advanced

gallbladder cancer.
Bhawna Sirohi, Abhishek Mitra, Palepu Jagannath, Ashish Singh, Mukta Ramadvar, Suyas
Kulkarni, Mahesh Goel& Shailesh V Shrikhande

FUTURE ONCOLOGY  VOL. 11, NO. 10 |

https://doi.org/10.2217/fon.14.308

RESULT: NACT increases resectability and survival in patients with locally

advanced GBC.
EDITORIAL COMMENTS.

PAGE 10-
DEPARTMENT OF HPB ONCOLOGY WITH LIVER TRANSPLANTATION

 Dr Raghavendra Babu J
Consultant and Clinical Lead

 Dr Subash K.G
Associate Consultant

 Dr Farman Ali
Post-Doctoral Clinical Fellow

 Ms. Keerthana
Transplant Co-coordinator