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15 - Image-guided therapy of intrahepatic cholangiocarcinoma
- from Section III - Organ-specific cancers – primary liver cancers
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- By Michael C. Soulen, University of Pennsylvania, William S. Rilling, Department of Radiology
- Edited by Jean-Francois H. Geschwind, Michael C. Soulen
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- Book:
- Interventional Oncology
- Published online:
- 05 September 2016
- Print publication:
- 22 September 2016, pp 134-138
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Summary
Our understanding and management of intrahepatic cholangiocarcinoma have evolved substantially over the past 5 years, leading to a new staging system distinct from that used for primary hepatocellular carcinoma (HCC), and identification of prognostic imaging and histologic phenotypes which provide more sophisticated guidance for triage.
While primary liver cancer is recognized as among the most deadly malignancies on the planet, approximately 10% of primary hepatobiliary tumors are cholangiocarcinomas. Ninety percent of these originate in the extrahepatic ducts, leaving about 10% as intrahepatic cholangiocarcinomas. These relatively rare tumors account for less than 10,000 new cancers in the USA annually and about 3% of gastrointestinal cancers worldwide. The incidence appears to be increasing globally; however, this is associated with an improvement in immunohistochemical diagnosis, with more tumors previously categorized as adenocarcinoma of unknown primary now recognized as being of pancreaticobiliary origin, likely cholangiocarcinoma.
Unlike HCC, most patients with intrahepatic cholangiocarcinoma have no known risk factors. Recognized risks include conditions associated with chronic inflammation or infection of the biliary tree, such as sclerosing cholangitis, choledochal cyst, biliary cirrhosis, parasitic infections, and hepatic cirrhosis. However, 90% of patients lack any predisposing condition, so routine surveillance is the exception and diagnosis is often delayed until symptoms develop in advanced stages. Early lymphatic spread, bone metastases, and intrahepatic liver metastases are more common than in HCC. Macrovascular invasion is seen similarly to HCC.
Diagnosis of intrahepatic cholangiocarcinoma can be challenging. Imaging appearance is variable, with three imaging phenotypes described as mass-forming, infiltrative, and intraductal invasion. Tumor vascularity is highly variable, with late enhancement a distinguishing feature from HCC. Thorough diagnostic imaging and endoscopy are necessary to exclude other primaries. Biopsy diagnosis can be difficult due to desmoplastic stroma and poorly differentiated histology. Immunohistochemical stains can suggest a biliary origin, while negative stains help to exclude other tissues of origin such as primary liver or metastasis from pancreas, colon, breast, or lung cancer. Tumor markers can be helpful to distinguish cholangiocarcinoma from HCC. A CA-19-9 level > 100 U/mL (normal up to 37 U/mL) is 68% sensitive and 96% specific for intrahepatic cholangiocarcinoma in patients without sclerosing cholangitis. Less-specific tumor marker elevations include carcinoembryonic antigen, CA-125, and alpha-fetoprotein, with 10% having a mixed hepatocholangiocarcinoma histology.
29 - Palliative care and symptom management
- from Section X - Specialized interventional techniques in cancer care
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- By Drew A. Rosielle, University of Minnesota Medical Center, Melissa Atwood, Children's Hospital of Wisconsin, Milwaukee, WI, USA, Sean Marks, Medical College of Wisconsin, William S. Rilling, Medical College of Wisconsin
- Edited by Jean-Francois H. Geschwind, Michael C. Soulen
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- Book:
- Interventional Oncology
- Published online:
- 05 September 2016
- Print publication:
- 22 September 2016, pp 294-314
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Summary
Palliative care and communication with cancer patients
Overview of palliative care
The World Health Organization defines palliative care as an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual. Palliative care is focused on symptom relief and maximizing function, without necessarily impacting the natural history of the underlying illness. Bereavement support is integral to its mission as it views the patient and his or her loved ones as a unit of care. Palliative care is interdisciplinary, involving not only nurses and physicians, but chaplains, psychologists, social workers, and speech, physical, occupational, and other therapists. While palliative care has historic roots in the terminal care of cancer patients, its scope encompasses a wide variety of patients with non-malignant diseases. These include neurodegenerative disorders; advanced organ disease; and patients in critical care units. Ideally, palliative care is provided to patients with severe illnesses early in the course of their disease, alongside disease-modifying or curative therapy. As an illness progresses, and as disease-modifying or even life-prolonging interventions become less available, a patient's entire care may become palliative-focused. While much of the care of patients with life-threatening illness can be described as palliative, many patients will not require specialist palliative care, and basic competency in palliative care is important for clinicians across a variety of specialties and practice types.
Palliative medicine describes the physician's role in the aforementioned care model. Besides expert symptom assessment and treatment, palliative medicine physicians offer subspecialty expertise in determining prognosis and communication encounters with patients and families involving breaking bad news, establishing goals of medical care, and planning for the future in light of a life-threatening illness. The scope of practice of palliative medicine physicians varies by location and institution. Common settings include inpatient consultative palliative care services, acute inpatient palliative care wards, outpatient palliative care clinics, cancer pain and symptom management clinics, emergency departments, nursing home palliative care services, and hospice settings. Palliative care is increasing by number of programs and prevalence among adult and pediatric hospitals such that many cancer care providers will have access to palliative care specialists if needed.
45 - Palliative Care and Symptom Management
- from PART IV - SPECIALIZED INTERVENTIONAL TECHNIQUES IN CANCER CARE
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- By Drew A. Rosielle, Assistant Professor, Medicine Palliative Care Program Medical College of Wisconsin Milwaukee, WI, David E. Weissman, Director, End of Life Palliative Education Resource Center Medical College of Wisconsin Milwaukee, WI, William S. Rilling, Professor, Section of Vascular/Interventional Radiology Medical College of Wisconsin Milwaukee, WI
- Edited by Jean-François H. Geschwind, The Johns Hopkins University School of Medicine, Michael C. Soulen, University of Pennsylvania School of Medicine
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- Book:
- Interventional Oncology
- Published online:
- 18 May 2010
- Print publication:
- 15 September 2008, pp 563-588
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Summary
PALLIATIVE CARE AND COMMUNICATION WITH CANCER PATIENTS
Overview of Palliative Care
The World Health Organization defines palliative care as care [T]hat improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual (1). Medical care is focused on symptom relief and maximizing patient function, without necessarily impacting the natural history of the underlying illness. The unit of care is defined as the patients, along with their loved ones, and bereavement support is integral to its mission. Palliative care is interdisciplinary, involving not only nurses and physicians but also chaplains, psychologists, social workers, and speech, physical, occupational and other therapists. Although palliative care has historic roots in the terminal care of dying cancer patients, its scope encompasses a wide variety of patients with non-malignant diseases. These include dementia and other neurodegenerative disorders; advanced organ disease such as lung, heart, liver and kidney failure; and critically ill patients in medical, neurological, surgical and trauma critical care units (2, 3). Ideally, palliative care is provided to patients with severe illnesses early in the course of their disease, alongside disease-modifying or curative therapy. As an illness progresses, and as disease-modifying or even life-prolonging interventions become less available, a patient's entire care may become palliative focused.