30. Hepatocellular carcinoma + cholangiocarcinoma Flashcards
HCC epidemiology ?
HAS A VERY STRONG MALE PREDOMINANCE
other than cirrhosis what else can cause HCC ?
HBV - intergration of its DNA to the human genome then HCC will occur without cirrhosis
while HCV HCC occurs due to the setting of crrhosis
what are the clinical manifestations of hcc ?
ASYMPTOMATIC
weight loss
fever
pain in ruq
ascitis
enlarged, irregular, tender liver
what is the diagnosisi of HCC ?
first ulrasound observation mass nodule lessthan 1 cm repeat after 4 month
more than 1 cm go to :
4 phase multidetector CT scan - most specific
dynamic contrast enhanced MRI
CEUS - contrast inhanced ultrasound
the TYPICAL HALLMARK
HYPERVASCULAR LESION IN ARTERIAL PHASE
WASH OUT IN THE PORTAL VENOUS AND DELAYED PHASES !! -HCC is enhanced less than the rest of the liver because of the less venous supply so washout perisists
IMMUNOSTAINING OF GPC3
HSP70
glutamine synthetase
alpha fetoportein also used
Liver biopsy
what gene expressions are recommened to diffrentiate high grade dysplastic nodules from early HCC
GPC3
HSP70
GLUTAMINE SYNTHetase
LYVE1
survin
what is the staging of HCC
T1 - single small HCC no vascular invasion
1a - less than 2 cm
1b more than 2 cm
T 2 -
2a - less than 5cm with vascular invasion
2b - multifocal tumors less than 5cm
T 3 - multifocal tumors and atleast one more than 5 cm
T4 - single or multifocal of any size involving a major branch of portal vein or hepatic vein
or direct invasion of other organs
what is the HCC staging system invoving liver function
clip score cp a=0 b-1 c=2
tumor
uninodular and less than 50 percent = 0
multinodular and less than 50 percent =1
tumr more than 50 percent = 2
AFP
less than 400ng/ml = 0
moe than 400ng/ml = 1
PV thrombus
no = 0
yes =1
score based on survival 0 = 42 months 1 = 32 months 2 = 16 monh 3=4.5 4=2.5 5 or 6 = 1
what is the performace status test ?
0 = fully active 1 = some symtoms , nearly fully active 2 = less that 50 percent of working hours resting 3= more than 50 percent of waking hours rsting 4= bedridden
how do we treat hcc ?
using barcelona clinic liver cancer classification system
------------ stage 0 solitary tumor less than 2 or equal to it cm child pugh A PS=0 very early stage = 0
potential candiate for liver transplant = no = ablation
potential candiate for liver transplant ?= yes = portal pressure and bilirubin ? —- normal = resection
—-increased = associated diseases ? such as cirrhosis!—-no = transplant
—- yes = ablation
-------------- early stage a equal to 3cm or less child pugh A -b PS =0
solitary ? = yes = portal pressure and bilirubin ? —–normal = resection
increased = associated diseases —- no = tranplant
—– yes = ablation
3 nodules less than or equal to 3 cm
= associated diseases —– no = transplant
—– yes = ablation
-------------- intermediate stage b multinodualar child pugh a-b ps= 0
TACE = transarterial chemoembolisation
-------- advanced stage c portal invasion extrahepatic spread child pugh a-b ps = 1-2
sorafenib tyrosine kinase inhibitor
can do TACE contraindicated if child pugh is c
Selective intracellular radiotherapy (SIRT) = Microspheres loaded with Yttrium-90 ------------ terminal stage d child pugh c ps 3-4
BSC
what are the different hsitological classification of HCC ? and what role do they play in management ?
trabecular acinar solid scirrhous steatoheaptitis - hcc combined hepatocholangiocarcinoma
biopsy does not play a role in managmnet !
what is used for ablation ?
radiofre
or percutaneous ethanol injection
prevention of hcc ?
hep b vacc
and antiviral treatment to hep b and c
what is the classification of cholangiocarcinoma ?
Extrahepatic cholangiocarcinoma is the most common form:
Perihilar (Klatskin tumor): junction of the right and left hepatic ducts
Distal extrahepatic: common bile duct
Intrahepatic cholangiocarcinoma: intrahepatic bile ducts
etiology of cholangiocarcinoma
Primary sclerosing cholangitis
Choledocholithiasis (both with and without hepatic duct involvement)
Chronic viral hepatitis
Liver cirrhosis
signs and symptoms for cholnagiocarcinoma ?
Extrahepatic cholangiocarcinoma
Signs of cholestasis: jaundice,
pale stools,
dark urine,
pruritus
Abdominal pain and weight loss is usually
Courvoisier sign = = presence of a palpably enlarged gallbladder and accompanied with mild jaundice
Intrahepatic cholangiocarcinoma Usually asymptomatic in early stages Nonspecific symptoms -weight loss, fatigue Dull abdominal pain (RUQ or epigastric) Signs of cholestasis rare
