HPB Flashcards
What is the difference between a gallbladder cancer and a cholangiocarcinoma
GB cancer - arising from gallbladder or cystic duct
CCA - arising from biliary tree ie intrahepatic ducts, hepatic ducts, or CBD
What are the risk factors for a GB carcinoma, and for a CCA
Gall Bladder carcinoma (40%)
Gallstones (>3cm) - largest risk factor, present in 70-90%
Obesity
Chronic typhoid / salmonella
Polyps >1cm
Ulcerative colitis
Cholangiocarcinoma (bile duct) (40%)
Primary sclerosing cholangitis (10% lifetime risk)
Polycystic liver disease
Gallstones
Infection - HPB flukes or hepatolithiasis
Chemical carcinogens: aflatoxin, vinyl chloride, methylene chloride
Cirrhosis & hepatotropic virus - HBV, HCV
What is the management of an early biliary tract carcinoma
Surgery followed by adjuvant capecitabine if complete resection
Approx 80% recurrence if capecitabine not given
If residual disease, given palliative gem/cis instead
What is the management of a locally advanced biliary tract carcinoma
Neo-adjuvant gem/cis, followed by surgery and adjuvant capecitabine
What is the management of an advanced biliary tract carcinoma
Gem/cis/durvalumab
Up to 8 cycles, then maintenance durvalumab until progression or toxicity
What is the genetic referral criteria for pancreatic cancer
Pancreatic cancer age <50
Pancreatic cancer <60 AND
Breast cancer, ovarian cancer or melanoma <60
One first/second degree relative with pancreatic cancer <60 OR
Two first/second degree relatives with any of breast, ovarian or melanoma <60
How is a T3 pancreatic cancer distinguished from T4
T3: clear fat plane between coeliac axis and SMA with patent SMV/portal vein
T4: SMA/coeliac plexus involvement
What determines if a pancreatic cancer is resectable or not
No contact with Coeliac axis, SMA or CHA
No contact with SMV or portal vein (PV)
Clear fat planes around vessels
What is the management of a resectable pancreatic cancer
What proportion are resectable at presentation
What is the benefit of adjuvant folfirinox and based on what trial
Maximal resection following by adjuvant folfirinox if fit, or gem/cape or gem/5FU if less fit
No indication for neoadjuvant chemotherapy
approx 20% are resectable at presentation
Prodigy 24 - DFS 21.6 months vs. 12.8 months
What RT dose is given for pancreatic chemoRT
What are the GTV and CTV/PTV margins
50.4Gy/28# with bd cape on treatment days
GTV - GTVp + GTVn
CTV - GTVpn + 0.5cm (edit GI overlap)
PTV - CTV + 1.5cm sup/inf and 1cm axially
What is the management of a borderline resectable pancreatic cancer
Neoadjuvant folfirinox +/- chemoRT (cape bd), followed by surgery if resectable, and adjuvant chemo
If tumour not resectable, treat as locally advanced
What is the management of a locally advanced pancreatic cancer
Folfirinox followed by assessment for surgery, and either surgery or continuation of medical management
What is the management of metastatic pancreatic cancer
1st line folfirinox, but if not fit, then gem/abraxane (only if metastatic, not just locally advanced - use gem/cape)
If dMMR/MSI-H - pembrolizumab 2nd line
If BRCAmut - main olaparib following first line treatment
If NTRK mut - larotrectinib / entrectanib 2nd line
What is the management of an early HCC
Stage 1 - if <2cm, C-P score A and normal portal pressure - resection or ablation
Stage 1-2, CPA-B - ablation or liver transplant (if one lesion <5cm or up to 3 lesions <3cm, or >5cm but stable over 6mths)
Stage 1-2, CP-A-B, >3cm size / multifocal, and no portal thrombus (HCC have arterial vascularisation)
TACE - doxorubicin, or SIRT (Y-90)
What is the management of an advanced HCC
1st line - atezolizumab & bevacizumab, if unresectable, PS0-1 and CP-A
2nd line - sorafenib/lenvatinib
