A Preliminary Exploration of TCM Large Compound Formula Treatment of Gallbladder Carcinoma and Bile Duct Carcinoma
I. Overview of Gallbladder Carcinoma and Bile Duct Carcinoma
Biliary tract cancers mainly include two types: gallbladder carcinoma and bile duct carcinoma.
Primary gallbladder carcinoma is one of the most common malignant tumors of the biliary system, accounting for 1%–2% of biliary surgical patients. Among digestive system tumors, the incidence of gallbladder carcinoma ranks about sixth, second only to gastric cancer, colorectal cancer, esophageal cancer, liver cancer, and pancreatic cancer. Early diagnosis of gallbladder carcinoma is difficult; its clinical manifestations resemble those of other diseases such as gallstones, and it is easily misdiagnosed. Most patients with gallbladder carcinoma are already at an advanced stage when they seek care.
It is generally held that chronic cholecystitis, gallstones, gallbladder polypoid lesions, and choledochoenteric internal fistula are risk factors for gallbladder carcinoma; gallbladder adenoma and gallbladder adenomyomatosis are currently recognized as precancerous lesions of gallbladder carcinoma. Domestic data show that the incidence of gallstones concurrent with gallbladder carcinoma is 50%–60%. Clinically, actively treating precancerous lesions and screening high-risk populations has positive significance for preventing gallbladder carcinoma and for early detection and early treatment.
Histologically, gallbladder carcinoma has several types—adenocarcinoma, squamous cell carcinoma, adenosquamous carcinoma, and undifferentiated carcinoma—but the most common is adenocarcinoma, with over 90% being well-differentiated adenocarcinoma. Gallbladder carcinoma occurs more often in the fundus and neck of the gallbladder and less often in the body. The gross pathology of gallbladder carcinoma mainly includes sclerosing, nodular, papillary, and diffuse types, of which the sclerosing type accounts for over 80%.
Primary bile duct carcinoma mainly refers to primary malignant tumors of the left and right hepatic ducts, the common bile duct, the supraduodenal common bile duct, and the distal end of the bile duct.
- Common clinical symptoms of gallbladder carcinoma
- Upper abdominal pain: this is one of the most common symptoms of gallbladder carcinoma. Early gallbladder carcinoma complicated by chronic cholecystitis or gallstones often presents with intermittent abdominal pain; persistent dull pain in the mid-upper abdomen and right upper abdomen that progressively worsens indicates that the tumor has already locally invaded and the disease is at a late stage. The pain may radiate to the right shoulder, right back, or chest. Cancer occurring in the neck of the gallbladder can obstruct the cystic duct, causing gallbladder enlargement, hydrops, and abdominal pain, or even acute abdomen.
- Anorexia and fatigue: anorexia and fatigue are common in advanced gallbladder carcinoma. Invasion of the liver by gallbladder carcinoma or intrahepatic metastasis can cause liver function impairment and poor gastrointestinal motility, leading to symptoms such as poor appetite, anorexia, and fatigue.
- Nausea and vomiting: most patients with advanced gallbladder carcinoma have cachexia and gastrointestinal dysfunction. When the cancer invades the duodenum, gastrointestinal obstruction may occur, presenting with nausea and vomiting—either vomiting as soon as food is eaten, or vomiting food eaten in the morning in the evening.
- Jaundice: intrahepatic metastasis of gallbladder carcinoma destroys intrahepatic tissue and can cause mild or moderate jaundice; if cancer in the gallbladder neck invades the hepatic hilum and bile duct, it can lead to obstructive jaundice.
- Common clinical symptoms of bile duct carcinoma
Progressive obstructive jaundice is the main clinical manifestation of bile duct carcinoma, often accompanied by mild upper abdominal distending pain, aversion to greasy food, fatigue, anorexia, low-grade fever, etc. Bile duct tumors at different sites have different signs.
Carcinoma in the lower segment of the bile duct presents with uniform enlargement of the liver, accompanied by gallbladder enlargement and painless jaundice. Carcinoma in the middle segment of the bile duct often obstructs the cystic duct because the tumor invades it, causing the gallbladder to enlarge and fill with white bile, forming hydrops of the gallbladder. In carcinoma of the upper bile duct, if the tumor invades the common hepatic duct or the confluence of the left and right hepatic ducts, the liver is uniformly enlarged with deep jaundice, but the gallbladder is empty. Carcinoma arising from the left hepatic duct may cause no jaundice as long as it has not yet invaded the hepatic duct confluence or simultaneously invaded the right hepatic duct; the left lobe of the liver is shrunken while the right lobe is compensatorily enlarged, and the gallbladder is usually not enlarged.
- Basic principles of TCM large compound formula treatment of gallbladder carcinoma and bile duct carcinoma
The basic principle of TCM large compound formula treatment of gallbladder carcinoma and bile duct carcinoma is the combination of pattern-based treatment and disease-based treatment, using multiple formulas and groups of herbs in combination to exert multi-target anti-tumor effects, improve the patient's clinical symptoms, and prolong the patient's survival.
Based on pattern differentiation of the clinical symptoms of gallbladder and bile duct carcinoma, we can broadly determine that gallbladder and bile duct carcinoma fall within the TCM category of Shaoyang syndrome. The basic prescription approach should combine Bupleurum-type formulas that soothe the liver and benefit the gallbladder, Artemisia-type formulas, Zhizhu Wan, Xuanfu Daizhe Tang, Dingxiang Shidi San, and Shaoyao Gancao Tang, etc., to improve the patient's symptoms of indigestion, upper abdominal pain, anorexia, and jaundice.
At the same time, the principle of disease-based treatment should be applied, combining formulas with anti-cancer and swelling-resolving actions such as Xihuang Wan, Biejia Jian Wan, and Xiaoluo Wan, etc., to control or slow the progression of the patient's biliary tract tumor and prolong survival.
One should also incorporate the findings of modern medical research, adding to the formula Chinese medicines that dilate the bile ducts, promote bile excretion, and promote digestion, as well as Chinese medicines that have a targeted action on gallbladder and bile duct carcinoma.
- Relevant formulas that may be used
- Chaihu Shugan San (Bupleurum Liver-Out-thrusting Powder): composed of Chenpi (vinegar-fried), Chaihu 6 g, Chuanxiong, Xiangfu, Zhiqiao (bran-fried), and Shaoyao 5 g each, and Gancao (honey-fried) 1.5 g. It mainly treats liver qi stagnation syndrome, presenting with pain in the costal and hypochondriac regions, chest oppression, frequent sighing, emotional depression, irritability, or belching and epigastric and abdominal distension. Chaihu Shugan San has the action of dilating the bile ducts; it has a certain improving effect on abdominal distension and pain caused by biliary tract disease, and can also improve the patient's liver function.
- Zhizhu Wan: composed of Zhishi, Baizhu, Heye, and fried millet; it mainly treats gastric distension and anorexia, and has a certain improving effect on abdominal distension and anorexia caused by digestive tract tumors.
- Xuanfu Daizhe Tang: composed of Xuanfuhua, Daizheshi, Renshen, Banxia, Gancao, Shengjiang, Dazao, etc.; it mainly treats nausea and vomiting.
- Dingxiang Shidi San: composed of Dingxiang, Shidi, Renshen, and Shengjiang; it mainly treats hiccups, nausea, vomiting, and other symptoms.
- Yinchen Wuling San: composed of Yinchen 5 g, Baizhu 9 g, Chifuling 9 g, Zhuling 9 g, Guizhi 6 g, and Zexie 15 g. Yinchen Wuling San mainly treats jaundice; the dosage of Yinchen may be determined according to the patient's degree of jaundice. In addition to Yinchen, Huzhang, Chuipencao, Banzhilian, Banbianlian, Baihua Sheshicao, Yiyiren, and Yumixu, etc., may be added to strengthen the jaundice-resolving action.
- Yinchen Hao Tang: composed of Yinchen, Zhizi, Dahuang, etc.; it mainly treats jaundice accompanied by constipation, and may be used for patients with jaundice and constipation. However, Dahuang is hepatotoxic and should be used with caution.
- Shaoyao Gancao Tang: composed of Baishao and Gancao; it has the action of relieving pain.
- Biejia Jian Wan: composed of Biejia, Taoren, Mudanpi, Baishao, Chishao, Lingxiaohua, Tubiechong, Houpo, Banxia, Shegan, Tinglizi, Qumai, Shiwei, Renshen, Ejiao, Guizhi, Ganjiang, Huangqin, Chaihu, Xiaoshi, Fengfang, and Mangxiao, etc. Its action is to soften hardness and dissipate nodules, fight cancer and resolve swelling; it mainly treats hard lumps below the hypochondrium.
- Xihuang Wan: composed of Shexiang (musk; artificial musk may now be used), Niuhuang (bezoar; artificial bezoar may now be used), Ruxiang, Moyao, etc. Its action is to clear heat and detoxify, fight cancer and resolve swelling; it mainly treats cancerous masses.
- Modified Xiaoluo Wan: composed of Xuanshen, Zhebeimu, Shengmuli, Sanleng, Ezhu, etc.; its action is to resolve phlegm and dissipate nodules, fight cancer and resolve swelling.
The combined use of the above formulas can basically form a large compound formula that both provides targeted relief of the clinical symptoms of biliary tract tumors (gallbladder and bile duct carcinoma) and moderately inhibits the progression of gallbladder and bile duct carcinoma. Modifications based on this formula can achieve the therapeutic goal of multi-target anti-cancer treatment.
- Relevant single herbs that may be used
Banmao (Mylabris): has a definite anti-cancer action, but the raw medicinal material should not be used directly because its toxicity is too great; demethylcantharidin tablets may be considered as a substitute.
Yeshigen (wild persimmon root): has the action of promoting diuresis and resolving jaundice; folk medicine also uses it to treat cancers of the hepatobiliary system. Suitable for use.
Xianhecao (Agrimonia): has the actions of stopping bleeding and dysentery, benefiting the gallbladder and resolving jaundice, supporting the healthy and supplementing deficiency, and fighting cancer and resolving swelling. Suitable for use.
Fengweicao (Pteris): has the actions of clearing heat and resolving swelling, stopping bleeding and pain, and draining dampness and resolving jaundice. Suitable for use.
Qingpi (unripe tangerine peel): has the actions of soothing the liver and benefiting the gallbladder, breaking up accumulations and moving qi, and anti-tumor. Suitable for use.
Foshou (Buddha's hand): has an action similar to Qingpi but slightly weaker. Suitable for use.
Chanchu (toad): has the actions of fighting cancer and resolving swelling, and of using poison to attack poison; but it is toxic, so use it with caution.
Shanqiongchong: has the action of fighting cancer and resolving swelling. Suitable for use.
Xuchangqing (Cynanchum paniculatum): a commonly used painkiller, with a certain degree of relief of cancer pain. Suitable for use.
Yuanhu (Corydalis): a blood-activating painkiller, with a certain degree of relief of cancer pain; the patent medicine Yuanhu Zhitong Tablets are suitable for use.
Chonglou (Paris): a heat-clearing, detoxifying, anti-cancer, and swelling-resolving herb. Suitable for use.
Shijianchuan (Salvia chinensis): a heat-clearing, detoxifying, anti-cancer, and swelling-resolving herb. Suitable for use.
Mihoutaogen (kiwi root): a heat-clearing, detoxifying, anti-cancer, and swelling-resolving herb. Suitable for use.
- Management of common complications
In treating biliary tract tumors, besides considering the pattern-based and disease-based treatment above, one should also consider the management of the most common complications. At the stage when the patient's complications are severe, the complications should be treated first; only after the complications are relieved may the above large compound formula treatment be used.
At present, the common complications of patients with gallbladder and bile duct carcinoma in China are mainly iatrogenic complications, such as chemotherapy-induced myelosuppression, and cancer pain and cancer fever in advanced patients. For myelosuppression, the regimen I previously published for treating post-chemoradiotherapy myelosuppression in cancer patients may be used.
Some patients also have concurrent diseases, such as diabetes, hypertension, and lupus erythematosus; for such patients, a more specific regimen should be formulated according to their physical condition.
The above regimen is a preliminary basic plan; in specific application, it may be moderately adjusted according to the patient's condition on the basis of the above plan.