Liver, Pancreas and Bile Duct Cancers
Liver cancers, pancreatic cancers and bile duct cancers are collectively known as hepatopancreobiliary cancers (HPB cancers).
Hepatopancreobiliary Services in the Belfast Trust are provided in Belfast City Hospital, the Royal Victoria Hospital and the Mater Hospital. The HPB cancer Multi- Disciplinary Team is the team of specialists who care for and treat patients with liver, pancreatic and bile duct cancer. The team consists of:
- Specialist HPB Surgeons
- Clinical Nurse Specialists (CNSs)
- Palliative Care team members
- Ward & Outpatient Nursing staff
- Allied Health Professionals (AHPs): Physiotherapists, Occupational Health specialists and Social Workers
- Administration Staff
Please note that this section details services provided to adult patients. Information on Children’s Cancers.
If a GP suspects a patient has cancer of the liver, pancreas or bile duct, the patient will be referred to one of the hospitals in the Belfast Trust. Patients will be contacted regarding an appointment.
There are several main types of liver cancer:
- Hepatocellular carcinoma (HCC) is the main type of primary liver cancer. Approximately 85 out of every 100 (85%) primary liver cancers are this type.
- Metastatic Carcinoma is a cancer that has spread to the liver from a primary tumour of the rectum or bowel.
- Benign liver tumours are non-cancerous tumours that do not spread to other parts of the body. They are usually small and have no accompanying symptoms.
Investigations and Diagnosis
Patients will be seen by a specialist Consultant when they are referred to the hospital. The doctor will ask the patient about their symptoms and general health before doing a physical examination. A blood test may be required to assess a patient’s general health.
Patients may then be sent for tests to find out the cause of their symptoms. Investigations include:
- Liver ultrasound scan
- Abdominal CT (computerised tomography) scan
- MRI (magnetic resonance imaging) scan
- PET CT Scan
If a patient has confirmed liver cancer the type of treatment they have will be based on individual circumstances. The patient’s doctor will discuss the various treatment options available and give advice on the treatment decision. Before patients can have any treatment they must give their consent.
Chemoemobilisation treatment aims to get rid of the cancer by giving chemotherapy directly into the affected part of the liver and by cutting off the blood supply to the tumour. Chemotherapy drugs are injected directly into the tumour in the liver. The chemotherapy drugs will be mixed with a substance called lipiodol that helps the chemotherapy stay in the liver for longer. This makes the treatment more effective.
Chemoemobilisation is carried out in the x-ray department in the Royal Victoria Hospital by Consultant Radiologists who are specially trained for the procedure. Patients undergoing chemoembolisation will usually need to stay in hospital overnight and possibly longer. The treatment can be repeated several times.
Depending on their circumstances, patients may also undergo chemotherapy in the Northern Ireland Cancer Centre.
Patients who require radiotherapy as part of their treatment will do so under the care of an oncologist in the Radiotherapy Department of the Cancer Centre.
Ablation is a process used to destroy primary liver tumours. Primary liver tumours can be ablated, using either alcohol (also known as a percutaneous ethanol injection) or heat (also known as radiofrequency ablation or RFA).
Surgery aims to completely remove the cancer completely with an operation.
Very small cancers can often be treated with a simple surgical operation under local or general anaesthetic, or with laser surgery. There is often no need for patients being treated in this way to stay in hospital overnight.
If the cancer is larger, surgery will often involve a hospital stay and an operation under general anaesthetic.
If only certain areas of the liver are affected by cancer and the rest of the liver is healthy, it may be possible to remove the affected part. This is called a liver resection.
If the operation involves the removal of a whole lobe of the liver, it is called a hemi-hepatectomy.
The liver has an amazing ability to repair itself. Even if up to 80% of the liver is removed it will start to re-grow very quickly, and may be back to normal within a few weeks.
Patients will most likely have their surgery as an inpatient in the Mater Hospital.
It may be possible to remove the whole liver and replace it with a liver from another person – a donor. In the treatment of Hepatocellular carcinoma (HCC) a liver transplant can only be done if patient has:
- a single tumour that is between 3–5cm
- a single tumour that is between 5–7cm that hasn’t changed in size for six months
- a maximum of five tumours, all smaller than 3cm in size.
Patients may also have a liver transplant if they have cirrhosis of the liver. However, patients with severe cirrhosis may not be well enough to go through this major operation.
Patients from Northern Ireland, under the care of the Belfast Trust, who require a liver transplant will travel to England to have their operation. This will be arranged by the Belfast Trust and patients will discuss this with their Consultant.
There are five main types of pancreatic cancer. These are:
- Ductal Adenocarcinoma: This is the most common type of pancreatic cancer. It begins in the pancreatic duct and can spread from there to other parts of the body.
- Neuro-Endocrine Tumours: These begin in the endocrine cells where insulin and other hormones are made.
- Cystic tumours: These are fluid-filled sacs in the pancreas.
- Acinar cell carcinomas: These start from the cells that make pancreatic juice.
- Lymphoma: This is a cancer of the lymphatic tissue in the pancreas.
Investigations and diagnosis
Patients referred to the Belfast Trust who are suspected of having a pancreatic cancer will be seen by a specialist Consultant at their first appointment. The consultant will ask about the patient’s symptoms and general health before doing a physical examination. Patients may have blood taken for testing.
Patients may undergo a number of tests and scans to find out the cause of their symptoms. Theses investigations include:
- EUS (endoscopic ultrasound)
- CT scan (computerised tomography)
- MRI scan (magnetic resonance imaging)
- PET CT scan
There are a number of treatments used to treat pancreatic cancer. The type of treatment a patient will have depends on their individual circumstances. They will make their decision to treat after discussion with their Consultant. Patients must give their consent before they can have any treatment.
Surgery aims to completely remove the cancer with an operation. Surgery to remove pancreatic cancer usually involves a procedure known as Whipple’s Procedure. Patients undergoing this treatment may have part of the stomach removed.
A Consultant or Surgeon will provide patients with a information leaflet about the operation which details the nature of the surgery including complications.
Prior to surgery to remove pancreatic cancer patients may have a small tube known as a stent inserted. the stent relieves common symptoms of jaundice. Jaundice is caused by a blockage of the flow of bile through the common bile duct into the intestine.
Jaundice is common in pancreatic cancer, and its symptoms can make patients feel very ill. Occasionally, the Surgeon may suggest the patient has a bypass operation to get round a blockage in the bowel and to keep the digestive system working.
Bile Duct Cancer
What is Bile Duct Cancer?
Bile ducts are tubes that transport fluid (bile) from the liver to the small intestine. They are part of the biliary system. Bile duct cancer develops from the cells in the lining of the duct. At first, the cancer usually grows along the walls of the ducts before growing into the walls. Left untreated, the cancer will spread and is life-threatening.
The cancer may spread by growing through the bile duct wall and spreading out into surrounding tissue, usually the liver and nearby lymph nodes. It may also spread to other parts of the body via the blood stream. When cancer cells from a bile duct tumour settle in another part of the body and start growing there, it is called secondary cancer or metastasis.
Bile duct cancer is also known as cholangiocarcinoma. When patients are diagnosed with bile duct cancer, their doctor will examine the lymph nodes around the biliary system in order to ‘stage’ the cancer.
The stages are as follows:
- Stage 1A – the cancer is contained within the bile duct.
- Stage 1B – the cancer has spread through the wall of the bile duct, but hasn’t spread into nearby lymph nodes or other areas.
- Stage 2A – the cancer has spread into the liver, pancreas or gall bladder or to the nearby blood vessels, but not the lymph nodes.
- Stage 2B – the cancer has spread into nearby lymph nodes.
- Stage 3 – the cancer is affecting the main blood vessels that take blood to and from the liver, or it has spread into the small or large bowel, the stomach or the abdominal wall. Lymph nodes in the abdomen may also be affected.
- Stage 4 – the cancer has spread to distant parts of the body such as the lungs.
Investigations and diagnosis
Patients referred to the Belfast Trust with suspected bile duct cancer will be seen by a specialist HPB Consultant. The Consultant will ask the patient about their symptoms and general health before doing a physical examination. Patients may also have some blood taken for testing.
Patient may be referred for a number of scans and tests to find out the cause of their symptoms. These investigations include:
- Ultrasound Scan
- CT (computerised tomography) scan
- MRI (magnetic resonance imaging) scan
- Endoscopic retrograde cholangio-pancreatography (ECRP)
- Endoscopic ultrasound scan (EUS)
There are a range of treatments which may be used to treat bile duct cancer. Each patient has unique circumstances, so the kind of treatment they receive will be based on discussions they have with their doctor and the nature of their cancer.
Before a patient undergoes any treatment, they must give thier consent for the treatment to proceed. This is an important process to ensure that the patient understands the treatment they are being given.
Surgery is an important treatment that aims to completely remove the cancer.
If it isn’t possible to remove the tumour patients may have an operation to relieve the blockage. This is known as a bypass operation. This will help to relieve jaundice.
A list of surgical procedures used to treat Bile Duct Cancer have been outlined below:
- Removal of the bile ducts: If the cancer is at a very early stage (stage 1), just the bile ducts containing the cancer are removed. The remaining ducts in the liver are then joined to the small bowel, allowing the bile to flow again.
- Whipple’s procedure: If the cancer is larger and has spread into nearby structures, the bile ducts, part of the stomach, part of the small bowel (duodenum), the pancreas, gall bladder and the surrounding lymph nodes are all removed.
- Partial Liver Resection: A liver resection, or partial hepatectomy, is a surgical procedure to remove tumors in the liver. Removing the cancerous portion of the liver may help to prevent the disease from spreading more. In some incidences, it may also help to prolong the life of patients with metastatic colorectal cancer.
- Biliary Stenting / Stent insertion: A stent is a tube put into the bile duct to hold it open and allow bile to drain away. The tube is about as thick as a ballpoint pen refill and about 5–10cm (2–4in) long.
The Hepatopancreobilary (HPB) Cancer Mutli-disciplinary Team (MDT) meets weekly in the Royal Victoria Hospital to discuss patients with suspected and confirmed liver, pancreatic or bile duct cancer.
Detailed discussions between all the relevant specialists takes place, looking at all the available results for each patient to ensure that the best treatment plan for every patient is agreed.
A record of each patient’s discussion will be sent to their GP.
As part of their cancer review, patients are asked to return to the hospital to see a member of the specialist team following the completion of their treatment. The frequency of these review appointments will differ for each patient. The review appointments allow the team to assess each patient’s progress following treatment. The check-ups are also a good opportunity for patients to discuss any worries or concerns they may have.
Follow up appointments will be outpatient appointments and may take place at the Royal Victoria Hospital, Belfast City Hospital or Mater Hospital.
If patients develop any worrying symptoms following the completion of their treatment, they should contact their Consultant or local GP.
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