Hepatobilliary Neoplasia Flashcards
The liver is a common site of metasticies for which cancers?
colorectal, pancreatic, breast and lung
note: HCC is the most common type of primary cancer
What are risk factors for HCC?
chronic hepatitis infection, esp emigration from endemic country
advanced age, men, lower SES
alcohol, smoking obesity
underlying genetic syndrome
basically any repeated injury to hepatocytes, esp. those that lead to cirrhosis (increase the chances of replicative error)
How does HBV infection modify the risk of HCC?
active viral replication is highest risk (HBsAg+, HBeAg+)
treatment and clearance of HBV reduces relative risk only by 60%
What is the best way to screen for HCC?
check levels of alpha fetoprotein (can be elevated in chronic liver disease) in tandem with imaging, usually liver ultrasound
only 80% of high risk patients in US get adequate screening
What are the presenting complaints of someone with HCC?
usually in the context of preexisting liver disease, often with a change to decompensation or a change in imaging, LFTs or AFP levels.
PE findings include jaundice, ascites, squealer of portal HTN and chronic liver disease, caput medusa, spider angiomata and peripheral wasting
What level of AFP is diagnostic for HCC?
> 200ng/mL only other conditions that could exist are testicular cancer or pregnancy
What is the classic imaging finding that accompanies HCC?
arterial enhancement with portal venous washout (HCC is nearly 100% arterially supplied) and no tissue sample is required for diagnosis in most cases
How is staging in HCC done?
staging is not particularly helpful in HCC, usually local disease is lethal before metastatic spread
What are the tx. options for local HCC?
partial hepatectomy can be curative if enough liver function will be preserved to allow the liver to function, although post recurrence rates are high
hepatic transplant can be used for resectable cancers without adequate hepatic reserve, recurrence and mortality is common
Describe the Milan criteria.
liver transplant possible in patients with
1 tumor<3cm
no metastatic disease
no vascular invasion or portal venous clot
many may be granted MELD exception in order to get transplant
What are options for tx of localized and advanced HCC?
often use temporizing measures pre transplant including
local ablative therapies (percutaneous ethanol infection, radio frequency ablation), trans arterial regional therapies (bland embolizeation “glue”, and chemoembolization); selective internal radiation therapy
What treatments are available for metastatic disease?
chemotherapy is relatively ineffective, mostly local therapies are used for symptom relief and tumor debunking
soratenib shows some potential to stop tumor growth by several months (2.8), those not eligible usually go to supportive care only (<3mo OS)
deals largely with management of symptoms of hepatic dysfunction and quality of life
What are some of the inherent difficulties of studying cholangiocarcinomas?
difficult to classify and the different types intrahepatic, extra hepatic, ampullary, gallbladder cancer have heterogenous behavior
such few cases also make research difficult, all are very aggressive
What are risk factors for cholangiocarcinoma?
PSC
parasitic infections
choledochal cysts
FAP
gallstones: obesity, female gender, high carb intake
anatomic conditions (porcelain gallbladder, gallbladder polyps
Who does cholangiocarcinoma present?
unexplained jaundice, abdominal pain, fevers, or often discovered incidentally
elevated LFT’s particularly alkaline phosphatase
