(59b) Liver tumours, biliary tract, and pancreas

Question 1

Name a major risk factor for hepatocellular carcinoma

Answer 1

Cirrhosis

Question 2

Who gets hepatocellular carcinoma?

Answer 2

Males more than females

Increasing incidence in west (obesity and alcohol)

Geographical variation, depending on prevalence of viral hepatitis

Question 3

What are late stage clinical features of HCC?

Answer 3

• worsening liver function

- weight loss

Question 4

How are patients with cirrhosis surveilled?

Answer 4

• 6 month USS

- blood test (raised alpha feto-protein in serum in 75% but less than 50% in non-cirrhotic patients and small HCC)

Question 5

How does HCC appear macroscopically?

Answer 5

• expansile soft nodules, often green (bile)
• involvement of portal vein (60%), hepatic vein (20%), bile duct (5%)
• often multifocal in cirrhosis

Question 6

How does HCC appear microscopically?

Answer 6

• cancer cells look like hepatocytes
• may produce bile = diagnostic
• confirm with immunohistochemistry

Question 7

A targeted liver biopsy should be done if diagnosis is unclear. What is the differential diagnosis?

Answer 7

• benign liver vs. well differentiated HCC

- metastatic carcinoma vs. poorly differentiated HCC

Question 8

What is the general prognosis of HCC?

Answer 8

Very poor (less than one year) unless diagnosed early - so surveillance is important!

Question 9

How is HCC treated?

Answer 9

• surgery (if non-cirrhotic or small, peripheral)

- transplant (if 1 tumour 5cm or less, if 3 or less tumours 3cm or less)

Question 10

How is non-resectable HCC treated? (multiple, large, metastasised)

Answer 10

• ablation - radio frequency
• embolisation
• chemotherapy - sorafenib

Question 11

What are the TNM stages for HCC?

Answer 11

• pT1
• pT2
• pT3a
• pT3b
• pT4

Question 12

What is a pT1 HCC?

Answer 12

Solitary tumour without vascular invasion

Question 13

What is a pT2 HCC?

Answer 13

Solitary tumour with vascular invasion or multiple tumours, none more than 5cm in greatest dimension

Question 14

What is a pT3a HCC?

Answer 14

Multiple tumours, any more than 5cm

Question 15

What is a pT3b HCC?

Answer 15

Single or multiple tumours of any size involving a major branch of the portal vein or hepatic vein

Question 16

What is a pT4 HCC?

Answer 16

Tumour(s) with direct invasion of adjacent organs other than the gall bladder or with perforation of visceral peritoneum

Question 17

How common are metastatic tumours of the liver?

Answer 17

Much commoner than primary liver cancer

Question 18

What type of liver metastasis has few large nodules? (suitable for surgical excision)

Answer 18

Large bowel

Question 19

What types of metastatic tumours of the liver are multinodular or infiltrative?

Answer 19

• lung
• pancreas
• breast
• stomach
• melanoma

Question 20

Name the other primary liver cancer, other than hepatocellular carcinoma

Answer 20

Cholangiocarcinoma

Question 21

What is a cholangiocarcinoma?

Answer 21

An adenocarcinoma arising in the bile ducts

Question 22

What are the 2 types of cholangiocarcinoma?

Answer 22

• intrahepatic

- perihilar

Question 23

What are the features of intrahepatic cholangiocarcinoma?

Answer 23

• from small intrahepatic ducts
• peripheral, mass forming, presents late
• risk factor = none, or cirrhosis

Question 24

What are the features of perihilar cholangiocarcinoma?

Answer 24

• from large ducts
• causes obstructive jaundice early
• risk factor = bile duct disease, primary sclerosing cholangitis
• liver flukes

Question 25

Summarise liver cancer

Answer 25

- primary = HCC (in patients with cirrhosis, surveillance), cholangiocarcinoma - metastatic = much more common, most adenocarcinoma (lung, colon, stomach, breast, pancreas, melanoma)

Question 26

How much bile is excreted?

Answer 26

0.5-1l per day is excreted by the liver and concentrated in the gall bladder

Question 27

What does bile contain?

Answer 27

Viscid green liquid that contains bile salts, phospholipids, cholesterol, bilirubin and calcium salts + mucin from peribiliary glands

Question 28

What are the risk factors for gallstones and why?

Answer 28

- female - obesity - diabetes Causes an imbalance of bile constituents causing it to precipitate

Question 29

What are the 2 main types of gallstone?

Answer 29

- cholesterol stones - pigment stones (or mixed = most common)

Question 30

Describe cholesterol stones

Answer 30

- yellow and opalescent | - contain undissolved cholesterol

Question 31

Describe pigment stones

Answer 31

- small and black | - in haemolytic anaemia (bile contains too much bilirubin)

Question 32

10% of gallstones contain what?

Answer 32

Calcium (visible on plain X-ray)

Question 33

What are the complications of gallstones?

Answer 33

- cholecystitis - mucocele - predisposition to carcinoma of gallbladder - obstruction of biliary system - cholangitis and liver abscesses - gallstone illeus - pancreatitis

Question 34

What is cholecystitis?

Answer 34

Inflammation of the gallbladder

Question 35

What is mucocele? (complication of gallstones)

Answer 35

Distention of the gallbladder by an inappropriate accumulation of mucus. Decreased bile flow = predisposing factor

Question 36

Gallstones cause obstruction of biliary system which results in what?

Answer 36

Biliary colic and jaundice

Question 37

What is biliary colic?

Answer 37

Pain related to the gallbladder that occurs when a gallstone transiently obstructs the cystic duct and the gallbladder contracts

Question 38

Why do cholangitis and liver abscesses occur as a complication of gallstones?

Answer 38

Due to infection of static bile

Question 39

Why does gallstone ileus occur as a complication of gallstones?

Answer 39

Due to intestinal obstruction by a gallstone that has entered the gut through a fistulous connection with the gallbladder

Question 40

What are the indications for cholecystectomy?

Answer 40

- pain - gallstones - pancreatitis - gall bladder polyp (rarely)

Question 41

Describe the features of acute cholecystitis

Answer 41

- duct blocked by stone - initially sterile, later infected - large, swollen, congested, ulcerated - complications = empyema, rupture

Question 42

Describe the features of chronic cholecystitis

Answer 42

- usually gallstones - small, fibrotic, stones - fibrosis - Rokitansky Aschoff sinuses

Question 43

What are Rokitansky-Aschoff sinuses?

Answer 43

Pseudodiverticula or pockets in the wall of the gallbladder. Outpouchings of gallbladder mucosa into the gallbladder muscle layer and subserosal tissue as a result of hyperplasia and herniation of epithelial cells through the fibromuscular layer of the gallbladder wall. Associated with cholecystitis.

Question 44

What happens to all gall bladders after cholecystectomy?

Answer 44

They are examined to detect gall bladder cancer

Question 45

What are the associated premalignant lesions before gall bladder cancer?

Answer 45

- polyp | - dysplasia