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Z - Cancer Care Old > Hepatobiliary Cancer > Flashcards

Hepatobiliary Cancer Flashcards

1
Q

Describe the epidemiology of hepatocellular carcinoma

A

It is one of the most common cancers worldwide, but is less common in the UK

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2
Q

What % of cancer diagnoses in the UK are hepatocellular carcinoma

A

1%

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3
Q

What % of hepatobiliary cancer diagnoses in the UK are hepatocellular carcinoma

A

40%

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4
Q

What does the distribution of hepatocellular carcinoma closely align with?

A

That of chronic HBV infection

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5
Q

Is hepatocellular carcinoma more common in men or women?

A

4-8x more common in men

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6
Q

When are most diagnoses of hepatocellular carcinoma made?

A

In the 5th or 6th decade of life

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7
Q

What does the age of diagnosis of hepatocellular carcinoma correspond with?

A

The time taken for liver cirrhosis to develop

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8
Q

What kind of liver cancer is more common in the UK?

A

Secondary metastasis to the liver, rather than primary tumours

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9
Q

Which cancers in particular metastasise to the liver?

A
  • Colon
  • Pancreas
  • Stomach
  • Breast
  • Lung
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10
Q

What % of hepatobiliary cancer in the UK is cholangiocarcinoma?

A

More than 50%

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11
Q

Where does cholangiocarcinoma affect?

A

The bile ducts inside or outside the liver

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12
Q

What are some rarer types of hepatobiliary cancer?

A
  • Angiosarcoma

- Hepatoblastoma

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13
Q

Who does hepatoblastoma affect?

A

Children under 3 years

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14
Q

What infection is HCC associated with?

A

Chronic hepatitis B or C

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15
Q

What % of HCC cases worldwide are associated with chronic hepatitis B or C infection?

A

More than 70%

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16
Q

What is the lifetime risk of developing HCC in an individual infected with HBV?

A

40%

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17
Q

Is the lifetime risk of developing HCC higher in HBV or HCV infection?

A

Thought to be higher in HCV

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18
Q

Other than chronic hepatitis infection, what are the risk factors for hepatocellular carcinoma?

A
  • Alcoholic cirrhosis
  • Aflatoxin
  • Primary biliary cirrhosis
  • Inherited metabolic disorders
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19
Q

What is aflatoxin?

A

A fungal contaminant of crops in tropical regions

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20
Q

What inherited metabolic disorders are a risk factors for hepatocellular carcinoma?

A
  • Haemochromatosis

- Tyrosinaemia

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21
Q

What is the lifetime risk of developing cholangiocarcinoma for individuals with primary sclerosing cholangitis?

A

10-20%

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22
Q

Other than primary sclerosing cholangitis, what condition is associated with cholangiocarcinoma?

A

Infection with liver flukes

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23
Q

What does infection with liver flukes being implicated in cholangiocarcinoma account for?

A

The higher prevalence of cholangiocarcinoma in Southeast Asia

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24
Q

What are the symptoms of early stage HCC?

A

It is often asymptomatic, or has vague symptoms such as weight loss, nausea, and lethargy.
There may also be pain

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25
Q

Where might the pain be in HCC?

A

Abdominal pain in RUQ

Right shoulder pain

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26
Q

What causes the abdominal pain in the RUQ in HCC?

A

Stretching of the liver capsule

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27
Q

What causes the pain to the right shoulder in HCC?

A

Referred pain as the enlarging liver irritates the diaphragm

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28
Q

When might HCC present with obstructive jaundice?

A

When the tumour obstructs a bile duct

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29
Q

What are the late presenting features of HCC?

A

Those of liver failure

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30
Q

What do the late presenting features of HCC depend on?

A

The functional reserve of the liver

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31
Q

When is the functional reserve of the liver often depleted?

A

In those with cirrhosis

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32
Q

What are acute onset abdominal pain and distention features of in liver failure?

A

Intraperitoneal haemorrhage

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33
Q

What is the significance of intraperitoneal haemorrhage in liver failure?

A

It can be life threatening

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34
Q

What are the early features of cholangiocarcinoma?

A
  • Jaundice
  • Pruritis
  • Hepatomegaly
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35
Q

What are the later signs and symptoms of cholangiocarcinoma?

A
  • RUQ pain
  • Weight loss
  • Palpable gall bladder
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36
Q

What should be looked for in the face in hepatobiliary cancer?

A
  • Jaundice

- Fetor hepaticus

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37
Q

What should be looked for on the chest in hepatobiliary cancer?

A
  • Gynaecomastia
  • Breast atrophy
  • Spider naevi
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38
Q

What should be looked for on the hands in hepatobiliary cancer?

A
  • Clubbing
  • Palmar erythema
  • Leukonychia
  • Asterixis (liver flap)
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39
Q

What are the systemic presentations of hepatobiliary cancer?

A
  • Weight loss
  • Fever
  • Malaise
  • Signs of liver failure
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40
Q

What signs of liver failure may be seen in hepatobiliary cancer?

A
  • Ascites
  • Jaundice
  • Itching
  • Anasarca
  • Nausea
  • Watery diarrhoea
  • Easy bruising
  • Loss of body hair
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41
Q

What is anasarca?

A

Extreme generalised oedema

42
Q

What may be found on neurological examination in hepatobiliary cancer?

A

Signs of hepatic encephalopathy

43
Q

What are the signs of hepatic encephalopathy?

A
  • Confusion
  • Irritability
  • Coma
44
Q

What may be found on respiratory examination in hepatobiliary cancer?

A
  • Dullness to percussion
  • Absent breath sounds at right base
  • Signs of lung mets
45
Q

What should be looked for on skeletal examination in hepatobiliary cancer?

A

Localised bone pain, indicating bone metastasis

46
Q

What may be found on genital examination in hepatobiliary cancer?

A

Testicular atrophy

47
Q

What are the paraneoplastic manifestations of hepatobiliary cancer?

A
  • Hypoglycaemia
  • Hypercalcaemia
  • Hypercholesterolaemia
  • Polycythaemia
  • Dermatomyositis
48
Q

What is the 5 year survival rate of cholangiocarcinoma?

A

5%

49
Q

What is the 5 year survival rate of gallbladder cancer?

A

5%

50
Q

What is the 5 year survival rate of hepatocellular carcinoma?

A

5%

51
Q

What is the 5 year survival rate of periampullary cholangiocarcinoma?

A

50%

52
Q

What initial investigations should be done in hepatobiliary cancer?

A
  • FBC
  • Liver and renal function
  • CXR
  • Ultrasound assessment of the liver
53
Q

What kind of cancer is a lesion identified in a cirrhotic liver often?

A

HCC

54
Q

What is alpha fetoprotein (AFP)?

A

A serum tumour marker

55
Q

What % of cancers of HCC is AFP raised in?

A

75%

56
Q

What combination of investigation findings is diagnostic for HCC?

A

Ultrasound lesion >2cm and raised AFP

57
Q

What other tumour markers may be useful in monitoring disease in hepatobiliary cancer?

A
  • CEA

- CA19-9

58
Q

Why may CT be useful in hepatobiliary cancer?

A

It can determine the extent of spread

59
Q

Why may MRI with contrast and angiography be useful in hepatobiliary cancer?

A

It provides the detail required to inform the most effective treatment

60
Q

Is liver biopsy used in hepatobiliary cancer?

A

It may be necessary

61
Q

What is the problem with liver biopsy in hepatobiliary cancer?

A

It risks seeding tumour cells outside the liver

62
Q

What is often found on LFTs in cholangiocarcinoma?

A

Raised conjugated bilirubin

63
Q

What tumours markers may be raised in cholangiocarcinoma?

A
  • CEA

- CA19-9

64
Q

Why is ultrasound imaging useful in cholangiocarcinoma?

A

It will reveal the level of the obstruction

65
Q

Why is MRI cholangiography (MRCP) useful in cholangiocarcinoma?

A

It provides a clear picture of the biliary tree

66
Q

What is the advantage of surgery in HCC?

A

It offers the only chance of cure

67
Q

What is the disadvantage of surgery in HCC?

A

It is only possible in a minority of patients

68
Q

Why is surgery for HCC only available in a minority of patients?

A

Because success is limited by background cirrhosis

69
Q

How much of the liver can be resected in an otherwise healthy liver and still regenerate?

A

Up to 80%

70
Q

What is the problem with liver resection in a cirrhotic patient?

A

Even a small resection can induce liver failure in a cirrhotic patient

71
Q

What is the preferred treatment for HCC in a cirrhotic patient?

A

Liver transplant

72
Q

What size HCC tumour can be treated with liver transplant in a cirrhotic patient?

A

<3cm

73
Q

What is the preferred treatment for HCC in a patient with HCV?

A

Liver transplant

74
Q

Why is liver transplant the preferred treatment for HCC in a patient with HCV?

A

Because it is likely that HCC will recur in these patients

75
Q

What management options can be considered for HCC when surgical resection is not an option?

A
  • Hepatic artery infusion chemotherapy
  • Hepatic embolisation
  • Radiofrequency ablation
76
Q

What happens in hepatic artery infusion chemotherapy for HCC?

A

Chemotherapy agents are injected into the hepatic artery for local effect

77
Q

What happens in hepatic embolisation for HCC?

A

An embolising agent is injected to cut off the blood supply to the tumour

78
Q

What is the mechanism of action of radiofrequency ablation in HCC?

A

It can be used to induce tumour necrosis

79
Q

What is radiofrequency ablation best for in HCC?

A

More superficial lesions

80
Q

When might chemotherapy be appropriate in HCC?

A

In advanced disease

81
Q

What agents have been used in chemotherapy for HCC?

A
  • Mitoxantrone
  • Gemcitabine
  • Doxorubicin
82
Q

What is the problem with chemotherapy for HCC?

A

The cancer is relatively resistant to most agents

83
Q

What is sorafenib?

A

A receptor tyrosine kinase inhibitor

84
Q

What does sorafenib do?

A

Inhibits tumour cell proliferation and angiogenesis

85
Q

How effective is sorafenib in HCC?

A

It produces a median overall survival of 9.2 months, and median time to progression of 5.5 months

86
Q

What treatment is required for HCC patients with obstructive jaundice?

A

Stenting of the biliary tree

87
Q

What management can be used if cholangiocarcinoma is detected in its early stages?

A

The bile ducts can be resected

88
Q

What is the problem with cholangiocarcinoma?

A

These tumours tend to present late when symptoms appear

89
Q

What management can be used if cholangiocarcinoma has spread to the liver?

A

It can be resected, or a Whipple’s procedure can be performed

90
Q

What happens in a Whipples procedure?

A

Part of the stomach, duodenum, pancreas, and gallbladder are removed

91
Q

What management can be used for cholangiocarcinoma if surgery is not possible?

A

A stent can be inserted to allow bile to flow past the obstruction

92
Q

Are tumours of the biliary tree sensitive to chemotherapy?

A

Yes, very much so

93
Q

What chemotherapy agents produce benefit in cholangiocarcinoma?

A
  • Gemcitabine

- Cisplatin

94
Q

What is the 5 year survival rate for patients with operable liver cancer, when management involves a partial liver resection

A

30%

95
Q

What is the 5 year survival rate for patients with liver cancer who receive a liver transplant?

A

75%

96
Q

What is the median survival for liver cancer patients who are not considered for curative therapy?

A

6-7 months

97
Q

What is the 5 year survival of liver cancer not considered for curative therapy?

A

5%

98
Q

What is the 5 year survival of cholangiocarcinoma?

A

5%

99
Q

What kind of cholangiocarcinoma has the worst prognosis?

A

Intrahepatic cholangiocarcinoma

100
Q

What is the median survival of intrahepatic cholangiocarcinoma?

A

12-18 months after diagnosis

101
Q

What is the most important itervention for hepatocellular carcinoma?

A

The development of an effective vaccination programme against hepatitis B, especially in geographical locations where the virus in endemic

Z - Cancer Care Old (28 decks)

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