Whatsapp discussion series- 4 :CHOLANGIOCARCINOMA (CCC) Prof. S.N. Ojha & others

[20/03 7:43 AM] Prof. Satyendra ojha sir: CHOLANGIOCARCINOMA (CCC)

CCC typically refers to mucin-producing adenocarcinomas that arise from the bile ducts. They are grouped by their anatomic site of origin as intrahepatic, hilar (central, ~65% of CCCs), and peripheral (or distal, ~30% of CCCs).

They arise on the basis of cirrhosis, excepting primary biliary cirrhosis.

Aetiology

Although most CCCs have no obvious cause, several predisposing factors have been identified, including primary sclerosing cholangitis, an autoimmune disease (10–20% of PSC patients), and liver fluke in Asians, especially Opisthorchis viverrini and Clonorchis sinensis.

CCC seems also to be associated with any cause of chronic biliary inflammation and injury, with alcoholic liver disease, choledocholithiasis, choledochal cysts (10%), and Caroli’s disease.

Clinical Features:

CCC most typically presents as painless jaundice, often with pruritus or weight loss, and acholic stools.

Investigation:

Diagnosis is made by biopsy, percutaneously for peripheral liver lesions or, more commonly, via endoscopic retrograde cholangiopancreatography (ERCP) under direct vision for central lesions.

The tumors often stain positively for cytokeratins 7, 8, and 19 and negatively for cytokeratin 20.

However, histology alone cannot usually distinguish CCC from metastases from primary tumors of the colon or pancreas.

Serologic tumor markers appear to be nonspecific, but CEA, CA 19-9, and CA-125 are often elevated in CCC patients and are useful for following response to therapy.

Radiologic evaluation typically starts with ultrasound, which is useful in visualizing dilated
bile ducts, and then proceeds with either MRI or magnetic resonance cholangiopancreatography (MRCP) or helical CT scans.

Invasive ERCP is then needed to define the biliary tree and obtain a biopsy or is needed therapeutically to decompress an obstructed biliary tree with internal stent placement.

If that fails, then percutaneous biliary drainage will be needed, with the biliary drainage flowing into an external bag.

Central tumors often invade the porta hepatis, and locoregional lymph node involvement by tumor is frequent.

GALLBLADDER CANCER (GB Ca)

GB Ca has an even worse prognosis than CCC, with typical survival of ~6 months or less. Women are affected much more commonly than men (4:1), unlike in HCC or CCC, and GB Ca is more common than

CCC. Most patients have a history of gallstones, but very few patients with gallstones develop GB Ca (~0.2%). It presents similarly to CCC and is often diagnosed unexpectedly during gallstone or cholecystitis surgery.

Clinical Features:

Presentation is typically that of chronic cholecystitis, Chronic right upper quadrant pain and weight loss.

Investigations:

Useful but nonspecific serum markers include CEA and CA 19-9.

CT scans or MRCP typically reveal a gallbladder mass.

The mainstay of treatment is surgical, either simple or radical cholecystectomy for stages I or II disease, respectively.

CARCINOMA OF THE AMPULLA OF VATER

This tumor arises within 2 cm of the distal end of the common bile duct, and is mainly (90%) an adenocarcinoma. Locoregional lymph nodes are commonly involved (50%), and the liver is the most frequent site for metastases.

Clinical Presentation:

Jaundice, and

many patients also have pruritus,

weight loss, and

epigastric pain.

Investigation:

Initial evaluation is performed with an abdominal ultrasound to assess vascular involvement, biliary dilatation, and liver lesions.

This is followed by a CT scan, or MRI and especially MRCP.

Adjuvant chemotherapy or radiotherapy has not been shown to be useful in enhancing survival. For metastatic tumors, chemotherapy is currently experimental.

Ayurveda can be better option in Cholangiocarcinoma (CCC), Carcinoma of the Ampulla of Vater and Gallbladder Cancer (Gb Ca). Following drugs may be used:

Lashuna, (Allium sativum) Garlic
Nimba, (Azadirachta indica), Neem tree
Sharpunkha, (Tephrosia purpurea)
Kumari, (Aloe barbadensis), Common Indian Aloe
Bhringaraj (Eclipta alba)

Ayurveda is better option as main line therapy or as complimentary therapy in various complications related to Cancer. Herbs mentioned above are just a bucket from the ocean. A good research in the field will help to improve the life of cancer patient without any economic burden.

[20/03 8:29 AM] Vaidya Ramesh Nanal Sir: 

प्रा.ओझा जी,सुप्रभात।आप सतत अध्ययन,चिंतन,मनन करते हैं।आपका हार्दिक अभिनंदन करता हुं।कॅन्सर पर आप लिखते हैं।आधुनिक निदान की परिभाषा सक्षमता से करते हैं।

आयुर्वेद की चिकित्सा बताते समय आप उपयुक्त द्रव्य भी लिखते हैं।आपने ये द्रव्य कैसे सोच लिये,वह "सोच"कैसे बनाई है यह जानना चाहता हुं।इसी सोच के द्वारा संभव है "प्रा ओझा स्कूल ऑफ थॉट्स"का प्रारंभ हो।

द्रव्यनाम के साथ कल्प,मात्रा,काल(सेवन काल-सेवन कालावधी) का भी उपदेश करें तो सोने पे सुहागा होगा।

लशुन, निम्ब, कुमारी,शरपंखा,भृंगराज इ द्रव्य अलग अलग द्रव्यगुण के हैं ।

कौनसा द्रव्य कौनसी अवस्थामे, कौनसे कल्प से,कितनी मात्रा(सामान्य/विशेष)में, कितने काल तक देना होगा-इसपर आप के अनुभव मिले तो वैद्यमित्रों के लिये अधिक लाभकारी होगा।चर्चा भी होगी,शास्त्र भी बढेगा।

मेरा नम्र सुझाव है।

[20/03 9:52 AM] satyendra ojha sir: 

सादर प्रणाम , आचार्य रमेश जी . कैंसर सम्बन्धित आयुर्वेदिक दृष्टिकोण, मेरी समझ से , जल्दी ही आप सभी के समक्ष बिचार विमर्श के लिए प्रस्तुत करुंगा.. आज एक सामाजिक अनुबंध के कारण व्यस्त हूँ. आप सभी को यथोचित प्रणाम एवं आशीष..।

[20/03 1:30 PM] satyendra ojha sir: 

Cholangiocarcinoma ( CCC ) ; Mucin producing Adenocarcinoma of bile duct ( raktavaha srotasa ) , cirrhosis of liver ( rogaartikarshana )  - vaata prakopa ( tantra yantra dharah , kartaa garbhaakritinaam ) - change in cellular character - Adenocarcinoma.- ( vaata kapha sammoorchchhita ) - avarodha - shaakhaashrita kamala..treatment planning as per shaakhaashrita kamala , rakta vaha srotas ..

Even pittaja gulma should be considered ..

[20/03 1:36 PM] sachin chndalia Vd Ay Pth: Thank you Respected Ojha sir..for sharing your thoughts..🏼🏼🏼🏼...

[20/03 1:40 PM] Dr Surendra A. Soni: Great Respected Ojha Sir...

[20/03 1:40 PM] satyendra ojha sir:

 Rason is bile secretagogue ,  it  increases bile secretion ( vriddhya vishandanyaat..) So pitta will increase and will try to clear avarodha.. Rason also works on vaata and kapha directly , so , can clear the obstruction by action on Adenocarcinoma.. Sharapunkha rohitaka will work on yakrita ..

[20/03 1:44 PM] Prof. upendr dixit: 

Yakrit being Moola Sthana of Rakta Vaha Srotas, Pitta is always associated and Rakta, though Panchabhautika, but Agneya. So Rasona can be used?

[20/03 1:45 PM] ‪+91 98941 83853‬: Raktha avarna and rasona?

[20/03 1:46 PM] satyendra ojha sir: For shaakhaa to koshtha gati , rason will work..

[20/03 1:47 PM] satyendra ojha sir: Vriddhi of pitta is accepted till aapittaranjana purisha , thereafter it will be stopped..

[20/03 1:51 PM] satyendra ojha sir: Here avarana is by vaata & kapha (?) , ideally it's sanga pradhaan ( kapha sammoorchchhita vaayu ) , and in turn aashaayapakarsha of pitta are consequences..

[20/03 1:53 PM] satyendra ojha sir: In rason ksheeram , vidradhi is indicated.. Cancer is utsedha pradhaana vyaadhi , so , it can be considered as one of shotha ,or  gulma , or vidradhi ..

[20/03 1:54 PM] satyendra ojha sir: Prof. Upendra ji.

[20/03 1:56 PM] satyendra ojha sir: Biliary tree is shaakhaa of yakrita , so , drugs indicated in yakrittodara , can be planned , here, in CCC..

[20/03 2:06 PM] Ramakant Chulet Sir: 

As for as srotodusti is concerned , in cancer it is alway shira granthi roopa srotodusti causing sang of that srotas ... Srotansi srotansyev praduaayanti pradustah .. Tesham sarceshamev vat pitta salesmanah pradushyitarah bhawanti pradustah

[20/03 5:13 PM] satyendra ojha sir: 

वातोल्बण-त्रिदोषज-शाखाश्रित-कामला

(Cholangiocarcinoma -CCC )

Mucin producing Adenocarcinoma of bile duct - रक्तवहस्रोतोसंग:,

Cirrhosis of liver (वातज-रौक्ष्य-धातुक्षय-काठिन्य-लाघव)
(rogaartikarshana )  - vaata prakopa ( tantra yantra dharah , kartaa garbhaakritinaam ) - change in cellular character -

Adenocarcinoma (वात-कफ-समूर्च्छितः)
अवरोधः शाखाश्रित-कामला

TREATMENT PLANNING
As per-
शाखाश्रित-कामला,
रक्तवहसोतस्,
पित्तज गुल्म:

1. रसोनः is bile secretagogue ,  it  increases bile secretion ( vriddhya vishandanyaat..) So pitta will increase and will try to clear avarodha.. Rason also works on vaata and kapha directly , so , can clear the obstruction by action on Adenocarcinoma..

2. शरपुंखा
3. रोहीतकः
Both work on yakrita . For shaakhaa to koshtha gati , rason will work. Vriddhi of pitta is accepted till aapittaranjana purisha , thereafter it will be stopped..
Here avarana is by vaata & kapha (?) , ideally it's sanga pradhaan ( kapha sammoorchchhita vaayu ) , and in turn aashaayapakarsha of pitta are consequences..
In phalashruti of rason ksheeram , vidradhi is indicated.. Cancer is utsedha pradhaana vyaadhi , so , it can be considered as one of shotha ,or  gulma , or vidradhi .. Biliary tree is shaakhaa of yakrita , so , drugs indicated in yakrittodara , can be planned , here, in CCC..

4. भल्लातकः
गुल्मनाशनः, वात-पित्त-कफ हर:, छेदि, भेदनम्, विबन्धहरः (Antiobstructive)

5. ताम्र:

पित्तनिस्सारकः, लेखनः, यकृत्प्लीहोदरहरः, आयुष्यम्

[20/03 5:14 PM] satyendra ojha sir: Edited by Dr Sunil Vasisth sir.....

[20/03 5:14 PM] satyendra ojha sir: Thanks Dr Vasisth ji , for nice illustration.

[20/03 6:52 PM] Dr Surendra A. Soni: As per my understanding this is the disease that directly affects the जनन कर्म  in the body. It seems that the chennal of affection is as per the exposed Srotas....and involvement of Srotas will depend on the nature of aaharaj vihaararaj manasika pradhanika (exposure to carcinogens) and Paap Karmaja Nidaans.....!

[20/03 6:58 PM] Dr Surendra A. Soni: 

We cannot ignore consideration of  dhatu in pathogenesis as charak describes this ideal pathology "dhatu gatatva" in Jwar...

[20/03 8:06 PM] satyendra ojha sir: 

No , shukra dhaatu consideration in all cancers will not show the specificity in between various Cancers

[20/03 8:08 PM] satyendra ojha sir: 

It's sanga pradhaan vyaadhi , so , eka deshe vriddhi and itar deshe kshaya are present.. Change in cellular structure is due to Vaata involved..

[20/03 8:14 PM] satyendra ojha sir: 

Metastasis is concerned with rakta dhaatu and due to neighborhood ; srotas to srotasa interrelationship..

[20/03 8:15 PM] satyendra ojha sir: 

Dysplasia and metaplasia are major sites to be converted into Cancers..

Change in structure due to imbalance between vaata ( stimulant) and kapha ( inhibitor) ..

Basic pathogenesis should be considered from shotha , and gulma..

[20/03 8:23 PM] Dr Surendra A. Soni: 

May be Sir

But involvement of dhatu cannot be ignored.... we have to justified..... because classification of dhatu is little bit deeper while tridosh concept is definitely a base but little bit superficial....!

[20/03 8:25 PM] satyendra ojha sir: 

Tridosha principle is very deep seated.. See , there may be cancer of srotas initially , then dhatu is involved later..

Acharya have given lots of importance to tridosha and rakta dhatu. These 4 are causes of interconnectivity..

[20/03 8:27 PM] Dr Surendra A. Soni:

 Either shoth or GULM or any other disease.... samprapti viggatanam needs clear picture about dhatu....

No sthanasanshrayavastha could be there without involvement of dhatu Sir...

That's why management has also been described as per dhatugata level...

Rasajanaam vikaaraanaam langhanam..... like wise...!

[20/03 8:28 PM] satyendra ojha sir: 

It's basic , dosha dooshya sammoorchchhana.. It does not mean we have to give importance to dhaatu only , but whole pathogenesis..Even in shotha , doshaanusar and sthaan anusaara classification is mentioned..

[20/03 8:30 PM] satyendra ojha sir: At one place , too many dhaatu may be involved..

[20/03 8:30 PM] Dr Surendra A. Soni: 

Yes Sir...

To Strengthen the involved dhatu is always given importance...

[20/03 8:31 PM] Dr Surendra A. Soni: 

Yes Sir...

It will be as per sequence regarding management...

[20/03 8:31 PM] satyendra ojha sir:

 As per my observation , cancer is heterogeneous with multiple factors involved..

[20/03 8:31 PM] Dr Surendra A. Soni: Ji Sir...

[20/03 8:32 PM] satyendra ojha sir: Bahya , abhyantar,  paapa karma are hetu involved in cancer..

[20/03 8:33 PM] Dr Surendra A. Soni: Mental cause is also there...

[20/03 9:48 PM] Dr. Dinesh Katoch sir: 

Dr Ojha,  your post on CCC at17.13: Clinical concepts about CCC are noteworthy. I have  to say something from technical angle that yakrit & bile duct being the seat of pitta, will it be appropriate to give Rasaun and Bhallatak in such condition though they are potent enough otherwise for their beneficial effects in cancerous conditions elsewhere. I would instead recommend the use of Daruharidra, which is mridu, safe and proven cholegogue, anti-inflammatory, antioxidant, hepatoprotective and anticancer remedy. Simple Triphla as a Rasayan should never be forgotten in this condition with anupan of Ark Makoye or Aja/Avi Ksheer having fibrolytic activity. We need wider discussion on this subject.

[20/03 9:51 PM] ‪+91 97367 63581‬: What if bile duct is completely blocked

[20/03 9:53 PM] Katoch sir: 

Best Tamra Yog for CCC seems to be Loknath Ras or Tamra Parpati and for bile duct blockage Moolak Kshar.

[20/03 9:54 PM] satyendra ojha sir: 

I think , daarvi will not be so potent to work on cancer cells as bhallataka and rasona..

[20/03 9:57 PM] satyendra ojha sir:

 Rason is found to work on cholelithiasis , sanghaata vighatana  , the effect on cancer cells can be presumed..

[20/03 9:59 PM] Katoch sir: 

Daarvi is not for cancer cells but for overall care of the condition of the liver. Tamra yog can take better care of cancer than bhallatak and rasoun being Agnideepak, Lekhan and required in very small dose and comparatively safe.

[20/03 10:00 PM] satyendra ojha sir:

 Rason ksheeram is indicated in visham jvara... So , I don't think it's ushnata is major issue..

[20/03 10:01 PM] satyendra ojha sir:

 Even , hridroga is an other indication of rason ksheeram , so , it will take care of yakrita..

[20/03 10:02 PM] satyendra ojha sir: 

Yes , in combination , daarvi trifala devadaru like drugs should be added..

[20/03 10:02 PM] M gopikrsnan Dr.: Tamra also indicated in hridroga /yakrit vikaara/cancer 

[20/03 10:03 PM] satyendra ojha sir: Yes , Tamra is my choice in CCC..

[20/03 10:04 PM] ‪+91 97367 63581‬: 

I have seen better results with Tamra in case of HCC, CCC,  But limitation seen once Jaundice developed, In CC C ERCP  stanting found very helpful to reduce the  bilirubin level intently then we can carry forward our treatment.this is as per my small experience  Please forgive  me .

[20/03 10:10 PM] Katoch sir: 

Use of Garlic in liver afflictions may be one's own preference but scientific literature does not have much about it in liver disease and cancer except for breast cancer because of allalyl sulphide.

[20/03 10:13 PM] satyendra ojha sir: 

Protective effects from garlic may arise from its antibacterial properties (17) or from its ability to block the formation of cancer-causing substances (18), halt the activation of cancer-causing substances (19), enhance DNA repair (20), reduce cell proliferation, or induce cell death (10). NIH , NCI..

[20/03 10:19 PM] Katoch sir: 

I agree for preventive role of Garlic for many cancers but not curative role specifically in CCC.

[20/03 10:19 PM] satyendra ojha sir: 

Garlic

Garlic belongs to the family of vegetables called Allium, which also includes onions, scallions, leeks and chives. According to AICR's second expert report, Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective, foods belonging to the allium family of vegetables probably protect against stomach cancer. Moreover, the evidence in the report shows that garlic, in particular, probably decreases one’s chances of developing colorectal cancer.

The protective effect of garlic was shown to have a dose response relationship. In other words, highest exposure to the food showed the greatest decrease in risk. For cancer protection, AICR experts suggest including garlic as part of a well-balanced predominantly plant-based diet.

These allium vegetables contain many substances now being studied for their anti-cancer effects, such as quercetin, allixin and a large group of organosulfur compounds that includes allicin, alliin and allyl sulfides. In laboratory studies, components of garlic have shown the ability to slow or stop the growth of tumors in prostate, bladder, colon and stomach tissue.

Laboratory research has also shown that one garlic component, called diallyl disulfide, exerts potent preventive effects against cancers of the skin, colon and lung. Recently, this compound proved able to kill leukemia cells in the laboratory. A compound derived from garlic called ajoene has displayed similar activity.

In animal studies, components in Allium vegetables have slowed the development of cancer in several stages and at various body sites: stomach, breast, esophagus, colon , liver and lung

[20/03 10:21 PM] pawan madan Dr: Katoch sir...🏻

If an arbuda is predominantly of kapha nature or at kaphasthaan predominantly,

..can then we use lahsun and bhallataka for a better action?

[20/03 10:22 PM] Katoch sir: Obviously Dr Pawan.

[20/03 10:22 PM] pawan madan Dr: Jee sir....🏻

[20/03 10:23 PM] satyendra ojha sir: Garlic Rescues Rat Livers

In a 2011 issue of “Indian Journal of Experimental Biology,” researchers fed rats a lead compound for seven days and then gauged the amount of liver injury induced. They then gave the rats a water extract of fresh garlic, which reduced the amount of liver damage. They theorized that this was due to garlic’s antioxidant capabilities. Antioxidants hunt down and disable unstable oxygen molecules that cause cellular damage. In another animal study, scientists used alcohol to induce liver injury in rats and then gave them black garlic extract, which increased antioxidant liver enzymes. It also reduced DNA damage to white immune blood cells called lymphocytes, as reported in a 2011 issue of “Journal of Medicinal Food.” More human studies need to be completed before garlic can be recommended as a therapy for liver disease.
[20/03 10:24 PM] Katoch sir: Concluding line of the above post is self explanatory.
[20/03 10:24 PM] satyendra ojha sir: Garlic & Liver Damage

By Cindy EllOct 08, 2015

Garlic may both prevent and reverse liver damage. The bulb’s strong antioxidant actions are at the root of its therapeutic power. Garlic is a potential adjunct to conventional medical care if you have liver damage. Speak with your physician about which herbal remedies are suitable for you.
[20/03 10:29 PM] satyendra ojha sir: CCC
Only pitta dosh cannot be taken into consideration. Other factors too deserve attention-

अवरोध
रौक्ष्य
कफ दुष्टी

वात दुष्टि

[20/03 10:47 PM] satyendra ojha sir: 

Evaluation of garlic oil as a contact dissolution agent for gallstones: comparison with monooctanoin.

(PMID:11194578)

Citations 

Related Articles 

Nijhawan S , Agarwal V , Sharma D , Rai RR

Department of Gastroenterology, SMS Medical College, Jaipur, India.

Tropical Gastroenterology : Official Journal of the Digestive Diseases Foundation[2000, 21(4):177-179]

Type: Evaluation Studies, Journal Article, Comparative Study

Abstract

Highlight Terms 

 Diseases(2)  Species(1)  Chemicals(1)

To find a better contact solvent to dissolve gallstones we studied invitro use ofgarlic oil and compared it with monooctanoin.In the first stage gall stonesobtained from patients after cholecystectomy were subjected to dissolution in different concentrations of garlic oil. Then the rate of dissolution of gall stonesin garlic oil was compared to that in monooctanoin in stage II. Efficacy of various concentration of garlic oil and monoocatanoin in dissolving gallstonesin artificial gall bladder and common bile duct models were compared in stage III.Garlic oil dissolved the cholesterol gall stones in proportion to the concentration used. The gall stone fragmentation was faster [6 hours V/s 36 hours] and more [88.30% V/s 71.01%] by garlic oil in comparison to monooctanoin in test tubes and even in artificial gallbladder and common bile duct models.Garlic oil is a better contact dissolving agent of gallstones than monooctanoin.

[20/03 10:48 PM] satyendra ojha sir: 

Daruharidra doesn't come near the two great drugs-

- Rasona

- Bhallatak

[20/03 10:54 PM] Katoch sir: 

What for ?. Every drug is great in itself when used judiciously.

[20/03 10:57 PM] Prof gujjarwar ay pith: 

Parnabeeja swarasa , gopitta and kutaki churna in small quantity for blockage / stone of Gall bladder .

Good Pitta rechak and shothaghna.

[20/03 10:58 PM] Prof gujjarwar ay pith: Exlnt Results.

[20/03 10:59 PM] Prof gujjarwar ay pith: Gopitta or gorochan.

[20/03 10:59 PM] Katoch sir:

 Managing a disease condition needs holistic consideration of every aspect of the patient as Acharya Charak says.

[20/03 11:01 PM] satyendra ojha sir: Yes sir , thank you very much for healthy conversations..

[20/03 11:05 PM] satyendra ojha sir: 

Prof. Shriniwas Gujjarwar , parnabeeja patra svarasa is effective in cholelithiasis and nephrolithiasis both..

[20/03 11:16 PM] Prof. K. Nistheswar Sir: 

Ojhaji, Acc. to the opinion of expert pharmacologist Dr. Goodman " À cat or rat can not mimic the human constitution, and final evaluation should be carriedout in human beings". A monograph was first published by British Pharmaceutical works about clinical studies of Anacarcinol (Bhallataka) on 25 cases of hepatic  and oesophageal carcinoma. More than 256 herbs are reported to possess anticancer activity through in vitro studies. Clinical evidence is lacking.

Nishteswar

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Above discussion held on 'Ayurveda Peetha"(Prof. S.N. Ojha initiative) a Whatsapp group of famous Vaidyas from all over the India. 

Compiled & edited by

Dr.Surendra A. Soni

M.D.,PhD (KC)

Associate Professor

Dept. of Kaya-chikitsa

Govt. Ayurveda College

Vadodara Gujarat, India.

EMAIL: surendraasoni@gmail.com

Mobile No. +91 9408441150