Liver Cancer

Question 1

Is liver cancer usually primary or secondary?

Answer 1

Metastic/Secondary (90%)

Primary (10%)

Question 2

Main primary liver tumour

Answer 2

Hepatocellular carcinoma HCC

Question 3

Epidemilogy HCC

Answer 3

Sixth most common cancer world wide

Third leading in cause of cancer death

Incidence rates vary significantly across the globe

Common in china but uncommon in the UK

Question 4

Aetiology

Answer 4

Due to chronic inflammatory process

Viral hepatitis is the leading cause

Can also be from…

Chronic alcoholism

Hereditary haemochromatosis

PBC

Aflatoxin from toxic fungal metabolite in cereals and nuts

Question 5

Risk factors

Answer 5

Hep B and Hep C

High alcohol intake

Smoking

Advanced age >70

Aflatoxin exposure

FH of liver disease

Question 6

Lobes and ligaments of the liver

Answer 6

Question 7

Clinical features

Answer 7

Liver cirrhosis with vague nonspecific symptoms like fatigue, fever, weight loss and lethargy

Dull ache in RUQ is uncommon but can happen.
That should raise suspicion in patients with known cirrhosis

Worsening ascites or jaundice can also happen

Question 8

Examination findings

Answer 8

Irregular enlarged and tender liver

Question 9

Dx

Answer 9

Infectious hepatitis

Cardiac failure

Benign hepatocellular adenoma

Other causes of liver cirrhosis

Question 10

Lab tests to be done

Answer 10

LFTs

Routine bloods and platelets + clotting

Alpha fetoprotein should be done as well

Question 11

Lab test findings

Answer 11

ALP, ALT, AST and bilirubin might be deranged.
AST:ALT ratio >2 is likely due to alcoholic liver disease
AST:ALT around 1 is likely viral hepatitis

Low platelets and prolonged clotting might be seen

Alpha fetoprotein should be monitored as it is raised in 70% of cases.

Should also be monitored for treatment response and recurrence

Question 12

Imaging

Answer 12

Ultrasound is the initial imaging of choice

CT scan can be done for further evaluation

Patients with rising AFP and US nodules can have MRI liver scan for further assessment

Question 13

USS findings

Answer 13

Mass >2cm + raised AFP is diagnostic

Question 14

MRI liver scanning findings

Answer 14

Mass with arterial hypervascularisation which is characteristic of HCC

Question 15

If diagnosis is still in doubt after MRI scanning, what can be done?

Answer 15

Biopsy or percutaneous fine-needle aspiration

This is last-resort due to difficulty with active ascites, risk of bleeds and risks of tumour seeding

Question 16

Staging tool

Answer 16

Barcelona Clinic Liver Cancer system BCLC

Question 17

Explain BCLC

Answer 17

Tumour stage

Liver function

Physical status

Cancer releated symptoms

This provides guidance on what treatment is most suitable

Question 18

What risk assessment tools might be used?

Answer 18

Child-Pugh score

MELD score

This is to assess risk of mortality from cirrhosis and predict potential effectiveness from potential treatment options.

Question 19

Explain Child-Pugh score

Answer 19

Serum bilirubin

Albumin

INR

Degree of ascites

Evidence of encephalopathy

Question 20

Explain MELD score

Answer 20

Creatinine

Bilirubin

INR

Sodium

Use of dialysis

This can predict the likelihood of a patient tolerating a potential liver transplant.

Question 21

General management

Answer 21

MDT with oncologist, radiologist, hepato-biliary surgeons and speciliast nurses

Question 22

Only curative options for HCC

Answer 22

Surgical resection

Transplantation

Question 23

When is surgical resection done?

Answer 23

In aptients without cirrhosis and with a good baseline health status

5 year recurrence is 50-60%

Question 24

When is transplantation done?

Answer 24

In patients fulfilling Milan criteria:

One lesion is small than 5 cm or three lesions smaller than 3 cm

No extrahepatic manifestations

No vascular infiltration

Question 25

Non-surgical interventions

Answer 25

Image-Guided ablation Transarterial Chemoembolisation

Question 26

Indications of image-guided ablation

Answer 26

Early HCC where BCLC is 0 or A Ultrasound probes are placed in the tumour mass to induce necrosis

Question 27

What is alcohol ablation?

Answer 27

Injection of alcohol into the tumour This destroys the malignant tissue and is most effective on small tumours in well-functioning livers.

Question 28

Indications of transarterial chemoembolisation TACE

Answer 28

BCLC stage B (large multinodular tumour) High concentrations of chemotherapy drugs are injected directly into the hepatic artery + embolising agent is added to induce ischaemia

Question 29

Prognosis

Answer 29

Depends on extent of underlying cirrhosis Median survival time from diagnosis is around 6 months

Question 30

Metastasis to liver from other cancer (Secondary liver cancer)

Answer 30

Bowel via portal circulation Breast Pancreas Stomach Lung

Question 31

Clinical features of secondary liver cancer

Answer 31

Similar to HCC Hepatomegaly and ascites in 50% of patients Jaundice and upper abdo pain can be present as well.

Question 32

Lab tests of secondary liver malignancy

Answer 32

Deranged LFTs ALP almost always raised as a sign of biliary obstruction

Question 33

Initial imaging modality of choice in secondary liver malignancy

Answer 33

USS CT scan can also be used to stage the metastases and allow imaging for the rest of the body.

Question 34

Should biopsy be done in secondary liver malignancy?

Answer 34

Not if the tumour is operable. This is because of potential tumour seeding

Question 35

Management of secondary liver cancer

Answer 35

Primary tumour has metastasised to additional sites as well usually This means that surgery is more difficult and less useful. Oncological and palliative services are more likely to be used. Surgery could be done in metastases confined to the liver. TACE or selective internal radiotherapy might be trialled.