Tumours of the liver, gallbladder and pancreas

Question 1

What are the key features of a benign tumour?

Answer 1

Locak displacement
No metastases

Pathology by:
Pushing borders
Slow growth
Resembles normal tissue

Question 2

What are the key features of malignant tumours?

Answer 2

Local invasion
Distant metastases

Pathology:
Infiltrative
Rapid growth
Highly abnormal cells

Question 3

What are the three cell types found within the liver?

Answer 3

Hepatocyte
Endothelial cell
Cholangiocyte

Question 4

What are the key benign tumours found in the liver?

Answer 4

Hepatocyte adenoma
Intraductal papillary neoplasm (from cholangiocytes)
Haemangioma (from endothelial cells)

Question 5

What are the different types of malignant tumours found in the liver?

Answer 5

Hepatocellular carcinoma
Cholangiocarcinoma (cholangiocytes)
Angiosarcoma (endo)

Question 6

What are the risk factors for hepatocellular adenoma?

Answer 6

Oral contraceptive pill
Anabolic steroids
Pregnancy
Obesity
Conditions - glycogen storage disease, hemochromatosis, beta-thallassaemia

Question 7

What is the typical clinical presentation of hepatocellular adenoma?

Answer 7

Mostly incidental
Female
Larger adenoma with risk of haemorrhage or bleeding -> large enough to cause pain
Lower risk of abdominal pain

Question 8

What is the typical prognosis of hepatocellular adenoma?

Answer 8

Minor risk of malignant transformation

Question 9

What is the key pathology grossly of hepatocellular adenoma?

Answer 9

Soft, well-circumscribed, tan coloured tumour
Is a solid tumour of malignant hepatocytic cells

Question 10

What is the key histology of hepatocellular adenoma?

Answer 10

Sheets of bland hepatocytic cells without normal portal triads/tracts

Question 11

What are the key clinical differentials for hepatocellular adenoma?

Answer 11

Malignancy
FNH - focal nodular hyperplasia - non neoplastic

Question 12

What are the new concepts in the classification of hepatocellular adenoma?

Answer 12

Historically = pathomolecular characteristics
2023 - 4 subtypes based on pathology
Exon 3 beta-catening activating mutation associated with higher risk of malignancy

Question 13

What is the relevant epidemiology of hepatocellular carcinoma?

Answer 13

Makes up 90% of primary malignant liver tumours
6th most common cancer
More common in Asia and Africa

Question 14

What are the key causes/risk factors for hepatocellular carcinoma?

Answer 14

90% occur in cirrhotic liver
Hepatitis B, Hepatitis C,
Alcohol
FLD
Hereditary haemochromatosis
Aflatoxin (fungal toxin)

Question 15

What is the typical presentation of hepatocellular carcinoma?

Answer 15

Asymptomatic - excpet CLD - usually found by surveillance of these at risk individuals
Upper abdo pain, palpable mass, weight loss

Question 16

What is the key gross pathology of hepatocellular carcinoma?

Answer 16

Round, soft, bulging, tan, green (due to bile production) and haemorrhagic
Often multiple tumours

Question 17

What is the key histology of hepatocellular carcinoma?

Answer 17

Abnormal hepatocytic cells in mostly trabceular arrangements
With intervening endothelial lined spaces, bile production

Question 18

What are the future changes expected in hepatocellular carcinoma?

Answer 18

Increasing incidence - due to FLD in western world
Molecular classicaition -> allow personalised treatment
Improved outcomes - due to locoregional and systemic therapies.

Question 19

What is cholangiocarcinoma?

Answer 19

Adenocarcinoma (malignant) of the billiary tree
Glands produce mucin

Question 20

What are the different groups of cholangiocarcinoma based on anatomy?

Answer 20

Intrahepatic - iCCA
Perihilar - left, right or common hepatic duct - pCCA
Distal - common bile duct onwards - dCCA

Question 21

What is the key epidemiology of cholangiocarcinoma?

Answer 21

Rare than hepatocellular carcinoma
Poor prognosis with 5yrs survival 7-20%

Question 22

What are the key causes/risk factors for cholangiocarcinoma?

Answer 22

Inflammation of the bile duct epithelium and bile stasis
Cirrhosis, Hepatitis B+C
Alcohol + smoking
Liver flukes (parasites)
Malformations of bile ducts
Common bile duct strictures and stones

Question 23

What is the key presentation of cholangiosarcoma?

Answer 23

Intrahepatic - vague, insidious, late presentation
Perihilar and distal - jaundice, itch, abdominal pain, weight loss, fever

Question 24

What are the gross pathology of cholangiocarcinomas?

Answer 24

Intrahepatic - expansile, firm, white tumours with scalloped margin
Perihilar and distal - infiltrating, ill-defined, fibrous tumour

Question 25

What is the key histology of a cholangiocarcinoma?

Answer 25

Abnormal glands/tubules with mucin prodcution assocaited with stroma

Question 26

What are the classifications within intrahepatic cholangiocarcinoma?

Answer 26

Small duct: nodular growth with small glands with no or minimal mucin - tends be be FGFR2 and IDH alterations Large duct: periductal infiltrating or intraductal - similar to pCCA and dCCA - tends to be TP53, KRAS mutations

Question 27

What are the key features of liver secondary tumours?

Answer 27

More common than primary Due to dual blood supply and fenestrated endothelium Typically from intrabdominal organs via portal venous drainage Large bowel, breast, lung carcinoma are the most common primary.

Question 28

What is the key epidmiology of gallbadder carcinoma?

Answer 28

Rare, more common in females Typically related to gallstones and chronic cholecystitis

Question 29

What is the key clinical presentation of gallbladder carcinoma?

Answer 29

Incidental Late stage = abdo pain, N/V, jaundice, weight loss -> poor outcome

Question 30

What is the key pathology of a gallbladder carcinoma?

Answer 30

Thickened wall Gallstones >3cm

Question 31

What is the key histology of gallbladder carcinoma?

Answer 31

90% are adenocarcinomas - gland forming with mucin production Irregular glands in fibrous stroma

Question 32

What are the different primary cell types in the pancreas that can become cancerous?

Answer 32

Acinar cell - exocrine Ductal cells Endocrine cells

Question 33

What is the most commont type of pancreatic cancer?

Answer 33

Pancreatic ductal adenocarcinoma Gland forming mucin production tumour

Question 34

What is the key epidemiology for pancreatic ductal adenocarcinoma?

Answer 34

12 most common but 7th leading cause of death

Question 35

What are the key risk factors for pancreatic cancer?

Answer 35

Most = smoking Type 2 diabetes mellitus Chronic pancreatitis including hereditary Family history

Question 36

What are the key symptoms of pancreatic ductal adenocarcinoma?

Answer 36

Late symptoms - 85% inoperable at presentation Abdominal or back pain, jaundice, weight loss Diabetes mellitus, N/V, poor appetite, thromboses, Trousseaus sign

Question 37

What is the key gross pathology of pancreatic cancer?

Answer 37

Ill-defined Infiltrative Firm and fibrous tumour Commonest in head of pancreas

Question 38

What is the key histology of the pancreas?

Answer 38

Abnormal glands associated with prominent stroma (fibrous tissue)

Question 39

What is the key prognosis of pancreatic ductal adenocarcinoma?

Answer 39

Poor with 5yrs survival of 6-8% Surgery is the only curative option No systemic treatments No personalised treatment protocols but clinical trials for immunotherapy and stroma modifying drugs

Question 40

What is the key pathology of pancreatic neuroendocrine neoplasms?

Answer 40

Rare tumors from endocrine cells Mostly well differentiated, potentially malignant, slow progression = NETs Poorly differentiated are rare and highly aggressive = NECs = neuroendocrine carcinomas

Question 41

What are the key causes of pancreatic neuroendocrine tumours?

Answer 41

Mostly sporadic FH -> cancer Elevated BMI Diabetes Cigarrete smoking Elevated alcohol consumption MEN1

Question 42

What is the key clinical presentation of pancreatic neuroendocrine tumours?

Answer 42

Non-function - incidental, abdo pain or mets Functional - insulin production presents with hypoglycaemia -> insulinoma

Question 43

What is the key gross pathology of pancreatic neuroendocrine tumours?

Answer 43

Well cricmscribed Solid Pale or tan Occuasionaly cystic

Question 44

What is the key histology of pancreatic neuroendocrine tumours?

Answer 44

Organois architectural patterns Commonly nested or trabecular.