[34] Liver Cancer Flashcards
What % of liver cancers are metastatic?
90%
What % of liver cancers are primary?
10%
What is the main primary liver tumour?
Hepatocellular carcinoma
How common is hepatocellular carcinoma compared to other cancers?
6th most common cancer worldwide
How deadly is hepatocellular carcinoma compared to other cancers?
It is the third leading cause of cancer death
How do the incidence rates of hepatocellular cancer differ throughout the world?
They vary significantly across the globe, with China having a high incidence and UK having a low incidence
Who do the majority of cases of hepatocellular carcinoma in the UK occur in?
Those aged over 70 years
What % of hepatocellular carcinoma in the UK occurs in males?
64%
What does hepatocellular carcinoma arise as a result of?
Chronic inflammatory processes affecting the liver
What is the most common cause of chronic inflammation leading to HCC worldwide?
Viral hepatitis
What are the other common causes of inflammation leading to HCC?
Chronic alcoholism
Hereditary haemochromatosis
Primary biliary cirrhosis
Aflatoxin
What is aflatoxin?
A toxic fungal metabolite that can be found on cereals and nuts
What are the risk factors for hepatocellular carcinoma?
Viral hepatitis High alcohol intake Smoking Advancing age Aflatoxin exposure Family history of liver disease
What are the most common causative organisms of viral hepatitis leading to HCC?
Hepatitis B virus
Hepatitis C virus
What % of HCC cases are accounted for by viral hepatitis in developing countries?
Around 90%
Which demographic is HCC more commonly found in developing countries?
Asian individuals
Why is HCC more common in Asian individuals?
Secondary to childhood infections with hepatitis B
Why is the incidence of HCC caused by Hep B decreasing?
Due to current vaccination programmes
What % of cases of HCC in the UK are thought to arise secondary to hepatitis?
16
What is the relationship between the combined oral contraceptive pill and HCC?
While the combined oral contraceptive pill is known to increase the risk of hepatic adenomas, data remains inconclusive regarding its relationship with malignant disease
What are the main symptoms of hepatocellular carcinoma?
That of liver cirrhosis, and may include vague, non-specific symptoms such as fatigue, fever, weight loss, and lethargy
Does hepatocellular carcinoma cause a dull ache in the right upper abdomen?
It is uncommon, however when present is characteristic of hepatocellular carcinoma, and should raise suspicion in patients with known cirrhosis
How might advanced HCC present?
Features of liver failure, such as worsening ascites or jaundice
What will be found on examination in HCC?
An irregular, enlarged, craggy and tender liver
What may the differential diagnoses include in a patient presenting with liver failure or non-specific liver signs?
Infectious hepatitis
Cardiac failure
Benign hepatocellular adenoma
Other causes of liver cirrhosis
What will suggest a diagnosis of infectious hepatitis rather than HCC?
Presence of non-specific serology
What will suggest a diagnosis of cardiac failure rather than HCC?
Smooth hepatomegaly
What investigations should be done in HCC?
Bloods
Imaging
Staging
What may the bloods show in HCC?
Deranged liver function tests (ALP, AST, ALT, bilirubin)
Low platelets or prolonged clotting
How is the AST:ALT ratio important diagnostically in HCC?
An AST:ALT ratio >2 suggests likely alcoholic liver disease
An AST:ALT <2 suggests likely viral hepatitis
What tumour marker should be measured in suspected cases of HCC?
Alpha fetoprotein
What % of HCC have raised alpha feto-protein?
70%
What is the use of alpha feto-protein in HCC?
Can be used to monitor treatment response and recurrence
What is the initial imaging modality of choice in HCC?
Ultrasound
How can ultrasound be diagnostic in HCC?
If a mass of >2cm is found, with a raised alpha feto-protein
What should be done if a mass is found >2cm on ultrasound with a raised alpha feto-protein?
Staging CT scan for further evaluation
What should be done if a patient has a raised alpha feto-protein and suggestive ultrasound nodules?
MRI liver scanning for further assessment
What can be done if the diagnosis is still in doubt following imaging?
Biopsy or percutaneous fine-needle aspiration
Why is biopsy/fine-needle aspiration a last-resort in the diagnosis of HCC?
Due to difficulties commonly associated in this setting of active ascites and/or deranged clotting, and the risks associated with biopsy and tumour-seeding
What is a characteristic feature of HCC that can be demonstrated on MRI scanning and contrast CT angiography?
Mass with arterial hypervascularisation
What is the most accepted staging system for HCC?
The Barcelona Clinic Liver Cancer staging system (BCLC)
What does the BCLC take into account?
Tumour stage
Liver function
Physical status
Cancer related symptoms
What is the purpose of the BCLC?
To provide guidance on what treatment is most suitable
What risk assessment tools are used in HCC?
Child-Pugh score
MELD score
What is the purpose of the Child-Pugh score and MELD score in HCC?
They can be used to assess the risk of mortality from cirrhosis, and to predict potential effectiveness from treatment options
What parameters does the Child-Pugh score use?
Serum bilirubin Albumin INR Degree of ascites Evidence of encephalopathy
What is calculated from the Child-Pugh score?
The prognosis of patients with liver cirrhosis
What is the advantage of recent scores such as the MELD score?
Has been shown to be a better predictor of mortality
What parameters does the latest MELD score calculator include?
Creatinine Bilirubin INR Sodium Use of dialysis at least twice a week
What additional thinghide can be predicated from the MELD score?
The likelihood of a patient tolerating a potential liver transplant
How is treatment for hepatocellular carcinoma best organised?
Through a MDT, including oncologists, radiologists, hepato-biliary surgeons, and specialist nurses
What are the curative options for hepatocellular carcinoma?
Surgical resection and transplantation
What are the options of surgical resection and transplantation limited by in hepatocellular carcinoma?
Tumour size
Liver function
Any co-morbidities present
When is surgical resection the treatment of choice in hepatocellular carcinoma?
In patients without cirrhosis and a good baseline health status
What is the 5 year recurrence rate of HCC post-resection?
50-60%
When can transplantation be considered in HCC?
In patients that fulfil the Milan Criteria
What are the Milan Criteria for transplantation in HCC?
One lesion that is smaller than 5cm, or 3 lesions that are smaller than 3cm
No extra-hepatic manifestations
No vascular infiltration
What are the options for non-surgical management of HCC?
Image-guided ablation
Alcohol ablation
Transarterial chemoembolisation
Who is image guided ablation indicated for in HCC?
Patients with early HCC (BCLC 0 or A)
How is image-guided ablation of HCC performed?
Ultrasound probes (or microwave probes) are placed in tumour mass to induce necrosis
What happens in alcohol ablation in HCC?
Alcohol is injected into the tumour, acting to destroy the malignant tissue
Where is alcohol ablation of HCC most effective?
In those with small tumours, who have well-functioning livers
Where is alcohol ablation of HCC the treatment of choice?
In those with small, inoperable cancers
What is transarterial chemoembolisation used for?
Reserved for patients with BCLC stage B (a large multinodular tumour)
What happens in transarterial chemoembolisation?
High concentrations of chemotherapy drugs are injected directly into the hepatic artery, and an embolising agent is then added to induce ischaemia
How is the majority of the liver preserved in transarterial chemoembolisation?
Radiological techniques are used to selectively inject and embolise the branches of the hepatic artery supplying the tumour
What does the prognosis of hepatocellular carcinoma depend on?
The extent of the underlying cirrhosis
Why does the prognosis of hepatocellular carcinoma depend on the extent of the underlying cirrhosis?
As this plays a large role in determining how aggressively the cancer can be treated
What is the median survival time after diagnosis of hepatocellular carcinoma?
Around 6 months
What is the most common underlying cause of death in patients with cancer?
Metastatic liver cancer
What are the most common cancers that metastasise to the liver?
Bowel Breast Pancreas Stomach Lung
How does cancer spread from bowel to liver?
Via portal circulation
What are the clinical features of metastatic liver cancer?
Similar to that of HCC
What proportion of patients with metastatic liver cancer have hepatomegaly and splenomegaly?
Roughly half of patients
What investigations are done in metatstatic liver cancer?
Similar to HCC
What may bloods show with metastatic liver cancer?
Derangement of LFTs, with ALP being almost invariably raised
What is the initial imaging modality of choice in metastatic liver cancer?
Often ultrasound scannign
What may a CT scan be used for in metastatic liver cancer?
To stage the metastasise
Allow imaging of rest of body
Investigate source of metastasis
Why is biopsy of metastatic liver cancers not advised if the tumour is operable?
As the needle tract may lead to seeding of the tumour
Why is surgical a more difficult and less useful option in metastatic liver cancer?
For the majority of patients with metastatic liver disease, the primary tumour has metastasised to additional sites
Who are often closely involved in the decision making process with metastatic liver disease?
Oncological and pallative services
When may surgery be indicated in patients with metastatic liver disease?
In patients with mets confined to the liver, who have their primary tumour under control
What are the non-surgical treatment methods for patients with metastatic liver disease?
Transarterial chemoemoblisation
Selective internal radiotherapy
