At the recent 33rd Annual Scientific Meeting of the Society of Interventional Radiology held in Washington DC, researchers from Johns Hopkins University (JHU) and Wayne State University (WSU), USA, reported their results on the use of cryoablation for small kidney tumours. (Cryoablation is the destruction of tissue by freezing. This is the direct opposite of radio-frequency ablation (RFA) which destroys tissue by heating.) The JHU researchers treated 60 patients with primary renal cell carcinoma with cryoablation. At 1 year follow-up, the success rate for tumours that were 4 cm or smaller was 95%, and for tumours up to 7 cm, it was almost 90%. In 3 patients, the cryotherapy failed. The tumours in these 3 patients were large and measured > 7cm in size. Ninety patients, with a mean tumour size of 3.1cm (range 1.2 – 7.6 cm), were treated by the team in WSU. After a mean follow-up of 1.3 years, local recurrence was only detected in 6% of the tumours.

Local destructive therapy is appealing because you normally do not need to do it through a big wound. As the zone of destruction is limited, you hope to minimize the amount of good tissue being destroyed. So, in someone with only one kidney for example, cryotherapy is ideal because the freezing will only destroy the tumour together with an adjacent rim of normal kidney tissue. However, if you do not destroy all the cancer tissue, the cancer will come back. Hence, when using local destruction therapy, be it freezing or heating, the chance of the cancer recurring increases as the tumour gets bigger. The two studies above showed that size is the determining factor. Indeed, RFA has been used to treat kidney cancer (< 4cm in size) with similar results (Cancer Control 2007; 14: 205 – 210). The cryotherapy and RFA results for treating kidney cancer are no different from the experience of using RFA to treat liver cancer (hepatocellular carcinoma). There are a few small studies, published recently, on using RFA to treat small (< 3cm) liver cancer. The researchers found that the short term results were comparable to performing surgery. However, studies on using RFA for larger liver cancer have shown that the outcome is worse than surgery. (Surgery removes the whole tumour from the body and thus removes the chance of the cancer recurring in the same place.) At present, local destructive therapy is still considered a treatment for local control only.

Cryotherapy has been around for much longer than RFA. However, RFA has caught on rapidly because it is easier to use. Until the mid 1990s, cryotherapy was difficult to use because you need to put liquid nitrogen into the machine. (I tremble each time I have to top up the machine with liquid nitrogen.) Now, cryotherapy is very easy (and faster) because it is done with bottled helium and argon gas. With time, more studies will be performed to define the exact role of cryotherapy in kidney cancer, liver cancer and other cancers. The same will happen with RFA. At the end I have no doubt that studies will show that given a certain size cancer, some patients will be better treated with cryotherapy while in others, RFA will be more suitable. But, in some cases you will still need open surgery in order to cure. In treating cancer, there is no one method that fits all.

A patient of mine has inoperable pancreatic cancer which has spread to the liver. Despite 3 courses of chemotherapy, the tumour marker continues to climb, indicating that the medicine is not working. The oncologist suggested switching one of the drugs to Tarceva (erlotinib) and if the marker continues to climb, then he would substitute Oxaplatin for Tarceva. If this final change has no impact on the tumour marker, the doctor would recommend no further treatment. The patient is keen to follow the doctor’s suggestions. However, his daughter is wondering if her father should stop if Tarceva doesn’t work. She is in a quandary. She feels that if the chemotherapy is unlikely to work, she would like her father to enjoy life without the side-effects of chemotherapy. She wishes to take him to visit his ancestral home in China (which he has intimated) while he is still able to walk independently. On the other hand, she does not want to ask her father to stop treatment as that might be seen as non-filial. The business partner who is footing the bill is of the view that if chemotherapy is unlikely to work, he would rather give the residual money intended for further chemotherapy to the children than ‘waste’ it on more chemotherapy. I was asked for my opinion / advice.

For patients with inoperable cancer, systemic chemotherapy is probably the only avenue available to these patients. In most cases, the treatment is not to cure but an attempt to control. For the patient, family members and occasionally for the friend who is footing the medical bill, the question “Should we stop treatment now or should we try even more combinations of chemotherapy agents hoping that one of them might just work?” is always tough to answer. The answer to the business partner’s dilemma is relatively straight forward. As the kind partner has decided to set aside a sum of money for the patient, it is up to the children and patient to decide on its use. To them using the money for treatment, rather than keeping the money for rainy days, may be the most appropriate action. The kind partner should not feel that such action is ‘wasteful’. As for the daughter’s predicament, perhaps it is time for the doctor to help guide the family and patient in order to reach a decision most appropriate to them. At this juncture, the patient and family members must be made aware that any decision is the right decision. There are no wrong decisions. Why? Because any action that makes the patient feels most at ease is the right choice. The patient must not feel that he must go down the path which will make the family members happy and vice versa. The doctor’s role is to ‘give courage’ not only to the patient but also to the family members to take that first step in the crucial decision making process. I would actually ask my patient what, apart from being cured of his cancer, he would like to do / achieve most at this moment. He may say “To visit my home in China” or “To continue with chemotherapy” or “To take a break from everything”. From his response, we will then be able to negotiate towards the right choice.

Given time and a sympathetic ear, it is usually possible to arrive at a decision which is most acceptable to all concerned. To achieve this, the doctor involved must set aside enough time for the discussion. It is certainly not something you want to take on while you are ‘in between’ patients in a busy clinic.

A few weeks ago, a lady brought her 84 years old mother to see me because she had been found to have gallstones on ultrasound scanning recently. The family doctor had asked for the ultrasound examination because the mother had complained of a change in her bowel habit recently. This was associated with an occasional feeling of abdominal distension. The daughter was asking for the gallbladder to be removed just in case it might cause trouble in the future.

When I took a detailed history from her, she had no gallstone-related symptoms at all. Physical examination did not reveal any obvious abnormality in the abdomen. At the end of the consultation, I told the patient and daughter that since the patient is totally asymptomatic from her gallstones, she does not require a laparoscopic cholecystectomy (removal of the gallbladder by key-hole surgery). If anything, she should consider having a colonoscopy instead because of her recent history of change in bowel habit.

About 20% of people in the western world have gallstones. Up to 70% of these people with gallstones are totally asymptomatic at the time of diagnosis. The natural course of asymptomatic gallstone disease is a benign one. In 1982, Gracie and Ransohoff published a paper titled “The natural history of silent gallstones: the innocent gallstone is not a myth.” in the New England Journal of Medicine. In the study, they found that the risk of developing symptoms in those with silent gallstones was in the order of 2% per year (N Engl J Med 1982: 307: 798 – 800). Consequently, the recommendation that asymptomatic gallstones should be treated expectantly (that is with no surgical intervention) has been in existence since the 1980s.

With the advent of laparoscopic cholecystectomy, removal of the gallbladder is often done as a day case. Due to the much reduced discomfort and inconvenience of undergoing a laparoscopic cholecystectomy, some have advocated gallbladder removal laparoscopically for all patients with gallstones irrespective of symptomatology. One of the arguments for this blanket recommendation is that most gallbladder cancer cases are associated with the presence of gallstones. Thus removal of the gallbladder with its stone(s) will prevent gallbladder cancer. The risk of developing gallbladder cancer has been estimated to be 0.01%. The rate of accidentally cutting the bile duct during laparoscopic cholecystecomy is greater than 0.01% and this is well known to cause a significant reduction in quality of life and often requires quite extensive reconstructive surgery to repair the damage. A study titled “Asymptomatic cholelithiasis : is cholecystectomy really needed? A critical reappraisal 15 years after the introduction of laparoscopic cholecystectomy.” was published in May 2007 (Dig Dis Sci 2007; 52: 1313 – 1325). The authors concluded that “the vast majority of subjects with asymptomatic gallstones should be managed by observation alone. Selective cholecystectomy is indicated in defined subgroups of subjects, with an increased risk for the development of gallstone-related symptoms and complications”.

Gallstones can give rise to gallstone-related complications such as cholecystitis (inflammation of the gall-bladder), acute pancreatitis due to the migration of a gallstone into the distal common bile duct, and jaundice due to a gallstone migrating into and blocking the common bile duct, to name a few. However, the majority of patients rarely develop gallstone-related complications without first having at least one episode of biliary pain or colic. In those with symptomatic gallstones disease, the advice is to have the gallbladder removed.

If you accept the argument that all people with silent gallstone(s) should be operated on just in case one might develop gallbladder cancer or other gallstone-related complications, then, using the same argument, everyone should have their appendix removed just in case one might develop appendicitis or cancer of the appendix.

I am sure you can think of a few situations where you can apply the same argument. The question is “Where do you draw the line?”.