EXAM #3: HEPATOBILIARY MALIGNANCY

Question 1

How many segments is the liver divided into? How are these segments devised?

Answer 1

8, based on vascular supply

Question 2

List the benign liver lesions.

Answer 2

1) Focal Nodular Hyperplasia
2) Simple Cyst
3) Hemangioma*
4) Adenoma

*Most common

Question 3

What are Liver Adenomas?

Answer 3

Benign glanduar liver tumor

Question 4

What are Liver Adenomas associated with?

Answer 4

Oral contraceptives–regress with contraceptive cessation

Question 5

What is the greatest risk with a Hepatic Adenoma?

Answer 5

Rupture especially during pregnancy

*Also can transform to liver metastasis

Question 6

What are the buzzwords for describing FNH?

Answer 6

Nodular hyperplasia with a “CENTRAL SCAR”

Question 7

What imaging study is best for visualizing FNH?

Answer 7

CT Scan, specifically in the “arterial phase”

Question 8

What is a Hemangioma?

Answer 8

Blood filled space

Question 9

What is a “Giant Hemangioma?”

Answer 9

Hemangioma that is greater than 5cm

Question 10

What are the two primary liver cancers?

Answer 10

1) Hepatocellular carcinoma
2) Cholangiocarcinoma (bile duct cancer)

Note that sometimes HCC is called Hepatoma*

Question 11

Where is HCC common?

Answer 11

Worldwide (non-US and Europe) b/c of endemic viral hepatitis

Question 12

What are the risk factors for HCC?

Answer 12

1) Viral hepatitis (HBV and HCV)
2) Anything causing cirrhosis
- Alcoholism
- Hemochromatosis
- Wilson’s Disease
- Alpha-1 antitrypsin def.
- NAFLD
3) Aflatoxin

Question 13

What are the subtypes of HCC?

Answer 13

• Solitary
• Diffuse
• Fibrolamellar

Question 14

What is unique about Fibrolamellar HCC?

Answer 14

Best prognosis

Commonly seen in women younger than 35

Question 15

What is a Hepatoblastoma?

Answer 15

Childhood primary liver cancer– neoplastic proliferation of fetal liver cells

Question 16

What tumor marker is associated with Hepatoblastoma?

Answer 16

Alpha-fetoprotein

Question 17

How does HCC present?

Answer 17

• Hepatosplenomegaly
• Ascites
• Abdominal pain
• Weight loss

Typically in males over 60 w/ underlying cirrhosis

Question 18

What is the classic diagnostic study for HCC?

Answer 18

Serum alpha-fetoprotein

Question 19

What can you do if you’re unsure that a mass is HCC?

Answer 19

Percutaneous liver biopsy

Question 20

What are the surgical procedures for HCC?

Answer 20

1) Wedge resection
2) Lobectomy
3) Trisegmentectomy
4) Liver transplant

Question 21

What are the challenges of liver surgery?

Answer 21

1) Dual blood supply (hepatic a. and portal vein)
2) Hepatic reserve
3) Coagulopathy

Question 22

What is a Child Pugh Score?

Answer 22

Measure of hepatic reserve

Question 23

What is the scale used for the Child Pugh Score?

Answer 23

Class A, B, or C
A= good risk
B= moderate risk
C= poor risk

B and C normally don’t get resected

Question 24

What makes a good surgical candidate for surgical live resection?

Answer 24

1) Class A Child Pugh Score
2) Solitary tumor
3) No vascular invasion
4) Less than 3 cm tumor size

Question 25

What are the alternative local therapies for patients that are poor surgical candidates?

Answer 25

1) Cryosurgery 2) Microwave ablation 3) Radiofrequency ablation 4) Ethanol injection 5) Acetic acid injection

Question 26

What blood supply feeds most of the tumor tissue? Normal liver?

Answer 26

Hepatic artery= tumor | Portal circulation= normal

Question 27

What are the treatment modalities that will use the hepatic a. to treat un-resectable HCC?

Answer 27

1) Embolization | 2) Radiation therapy

Question 28

What drug is specifically used as a chemotherapy for HCC?

Answer 28

Sorafenib *****Note that this is commonly given via the hepatic a.*****

Question 29

What is the MOA of Sorafenib?

Answer 29

1) Blocks angiogenesis | 2) Targets HCC surface proteins

Question 30

What are the three classifications of Cholangiocarcinoma?

Answer 30

1) Intrahepatic 2) Perihilar* 3) Distal *Perihilar is most common

Question 31

What are the risk factors for Cholangiocarcinoma?

Answer 31

1) PSC i.e. UC 2) Liver flukes 3) Congenital malformations i.e. "Choledochal cyst"

Question 32

What is the only known cure for Cholangiocarcinoma?

Answer 32

Surgery

Question 33

What is the clinical presentation for a Cholangiocarcinoma?

Answer 33

1) Constitutional sx. associated with all cancer 2) Painless jaundice 3) Biliary tract obstruction

Question 34

What is the PE sign associated with a palpable Gallbladder?

Answer 34

Courvoisier's sign

Question 35

What lab studies assist in the diagnosis of Cholangiocarcinoma?

Answer 35

1) Liver fxn tests 2) CEA 3) CA 19-9

Question 36

What imaging studies are used to diagnose Cholangiocarcinoma?

Answer 36

1) ERCP 2) CT/MRI with cholangiography 3) US

Question 37

What surgery is used to treat a perihilar Cholangiocarcinoma?

Answer 37

Roux en Y Hepaticojejunostomy

Question 38

What surgery is used to treat a distal Cholangiocarcinoma?

Answer 38

Whipple Procedure

Question 39

What procedure is used for most cases of Cholangiocarcinoma?

Answer 39

* Most are unresectable b/c of late disease presentation* | - Palliative biliary decompression

Question 40

How does Gallbaldder cancer compare to Cholangiocarcinoma?

Answer 40

Much more aggressive/ poor prognosis

Question 41

What is the typical patient with Gallbladder cancer?

Answer 41

Elderly women without liver disese - Urban areas - Chilean women

Question 42

What is the classic imaging finding associated with Gallbladder cancer?

Answer 42

Porcelain gallbladder i.e. calcification of the gallbladder

Question 43

What stage of GB cancer has the best prognosis?

Answer 43

T1a--incidentally found on lap chole for other pathology