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3: Surgery Y3 - Cancer Care [1] (check ILOs) > [34] Liver Cancer > Flashcards

[34] Liver Cancer Flashcards

1
Q

What % of liver cancers are metastatic?

A

90%

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2
Q

What % of liver cancers are primary?

A

10%

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3
Q

What is the main primary liver tumour?

A

Hepatocellular carcinoma

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4
Q

How common is hepatocellular carcinoma compared to other cancers?

A

6th most common cancer worldwide

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5
Q

How deadly is hepatocellular carcinoma compared to other cancers?

A

It is the third leading cause of cancer death

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6
Q

How do the incidence rates of hepatocellular cancer differ throughout the world?

A

They vary significantly across the globe, with China having a high incidence and UK having a low incidence

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7
Q

Who do the majority of cases of hepatocellular carcinoma in the UK occur in?

A

Those aged over 70 years

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8
Q

What % of hepatocellular carcinoma in the UK occurs in males?

A

64%

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9
Q

What does hepatocellular carcinoma arise as a result of?

A

Chronic inflammatory processes affecting the liver

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10
Q

What is the most common cause of chronic inflammation leading to HCC worldwide?

A

Viral hepatitis

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11
Q

What are the other common causes of inflammation leading to HCC?

A

Chronic alcoholism
Hereditary haemochromatosis
Primary biliary cirrhosis
Aflatoxin

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12
Q

What is aflatoxin?

A

A toxic fungal metabolite that can be found on cereals and nuts

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13
Q

What are the risk factors for hepatocellular carcinoma?

A 
Viral hepatitis
High alcohol intake
Smoking
Advancing age
Aflatoxin exposure
Family history of liver disease
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14
Q

What are the most common causative organisms of viral hepatitis leading to HCC?

A

Hepatitis B virus

Hepatitis C virus

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15
Q

What % of HCC cases are accounted for by viral hepatitis in developing countries?

A

Around 90%

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16
Q

Which demographic is HCC more commonly found in developing countries?

A

Asian individuals

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17
Q

Why is HCC more common in Asian individuals?

A

Secondary to childhood infections with hepatitis B

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18
Q

Why is the incidence of HCC caused by Hep B decreasing?

A

Due to current vaccination programmes

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19
Q

What % of cases of HCC in the UK are thought to arise secondary to hepatitis?

A

16

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20
Q

What is the relationship between the combined oral contraceptive pill and HCC?

A

While the combined oral contraceptive pill is known to increase the risk of hepatic adenomas, data remains inconclusive regarding its relationship with malignant disease

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21
Q

What are the main symptoms of hepatocellular carcinoma?

A

That of liver cirrhosis, and may include vague, non-specific symptoms such as fatigue, fever, weight loss, and lethargy

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22
Q

Does hepatocellular carcinoma cause a dull ache in the right upper abdomen?

A

It is uncommon, however when present is characteristic of hepatocellular carcinoma, and should raise suspicion in patients with known cirrhosis

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23
Q

How might advanced HCC present?

A

Features of liver failure, such as worsening ascites or jaundice

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24
Q

What will be found on examination in HCC?

A

An irregular, enlarged, craggy and tender liver

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25
Q

What may the differential diagnoses include in a patient presenting with liver failure or non-specific liver signs?

A

Infectious hepatitis
Cardiac failure
Benign hepatocellular adenoma
Other causes of liver cirrhosis

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26
Q

What will suggest a diagnosis of infectious hepatitis rather than HCC?

A

Presence of non-specific serology

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27
Q

What will suggest a diagnosis of cardiac failure rather than HCC?

A

Smooth hepatomegaly

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28
Q

What investigations should be done in HCC?

A

Bloods
Imaging
Staging

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29
Q

What may the bloods show in HCC?

A

Deranged liver function tests (ALP, AST, ALT, bilirubin)

Low platelets or prolonged clotting

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30
Q

How is the AST:ALT ratio important diagnostically in HCC?

A

An AST:ALT ratio >2 suggests likely alcoholic liver disease

An AST:ALT <2 suggests likely viral hepatitis

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31
Q

What tumour marker should be measured in suspected cases of HCC?

A

Alpha fetoprotein

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32
Q

What % of HCC have raised alpha feto-protein?

A

70%

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33
Q

What is the use of alpha feto-protein in HCC?

A

Can be used to monitor treatment response and recurrence

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34
Q

What is the initial imaging modality of choice in HCC?

A

Ultrasound

35
Q

How can ultrasound be diagnostic in HCC?

A

If a mass of >2cm is found, with a raised alpha feto-protein

36
Q

What should be done if a mass is found >2cm on ultrasound with a raised alpha feto-protein?

A

Staging CT scan for further evaluation

37
Q

What should be done if a patient has a raised alpha feto-protein and suggestive ultrasound nodules?

A

MRI liver scanning for further assessment

38
Q

What can be done if the diagnosis is still in doubt following imaging?

A

Biopsy or percutaneous fine-needle aspiration

39
Q

Why is biopsy/fine-needle aspiration a last-resort in the diagnosis of HCC?

A

Due to difficulties commonly associated in this setting of active ascites and/or deranged clotting, and the risks associated with biopsy and tumour-seeding

40
Q

What is a characteristic feature of HCC that can be demonstrated on MRI scanning and contrast CT angiography?

A

Mass with arterial hypervascularisation

41
Q

What is the most accepted staging system for HCC?

A

The Barcelona Clinic Liver Cancer staging system (BCLC)

42
Q

What does the BCLC take into account?

A

Tumour stage
Liver function
Physical status
Cancer related symptoms

43
Q

What is the purpose of the BCLC?

A

To provide guidance on what treatment is most suitable

44
Q

What risk assessment tools are used in HCC?

A

Child-Pugh score

MELD score

45
Q

What is the purpose of the Child-Pugh score and MELD score in HCC?

A

They can be used to assess the risk of mortality from cirrhosis, and to predict potential effectiveness from treatment options

46
Q

What parameters does the Child-Pugh score use?

A 
Serum bilirubin
Albumin
INR
Degree of ascites
Evidence of encephalopathy
47
Q

What is calculated from the Child-Pugh score?

A

The prognosis of patients with liver cirrhosis

48
Q

What is the advantage of recent scores such as the MELD score?

A

Has been shown to be a better predictor of mortality

49
Q

What parameters does the latest MELD score calculator include?

A 
Creatinine
Bilirubin
INR
Sodium
Use of dialysis at least twice a week
50
Q

What additional thinghide can be predicated from the MELD score?

A

The likelihood of a patient tolerating a potential liver transplant

51
Q

How is treatment for hepatocellular carcinoma best organised?

A

Through a MDT, including oncologists, radiologists, hepato-biliary surgeons, and specialist nurses

52
Q

What are the curative options for hepatocellular carcinoma?

A

Surgical resection and transplantation

53
Q

What are the options of surgical resection and transplantation limited by in hepatocellular carcinoma?

A

Tumour size
Liver function
Any co-morbidities present

54
Q

When is surgical resection the treatment of choice in hepatocellular carcinoma?

A

In patients without cirrhosis and a good baseline health status

55
Q

What is the 5 year recurrence rate of HCC post-resection?

A

50-60%

56
Q

When can transplantation be considered in HCC?

A

In patients that fulfil the Milan Criteria

57
Q

What are the Milan Criteria for transplantation in HCC?

A

One lesion that is smaller than 5cm, or 3 lesions that are smaller than 3cm
No extra-hepatic manifestations
No vascular infiltration

58
Q

What are the options for non-surgical management of HCC?

A

Image-guided ablation
Alcohol ablation
Transarterial chemoembolisation

59
Q

Who is image guided ablation indicated for in HCC?

A

Patients with early HCC (BCLC 0 or A)

60
Q

How is image-guided ablation of HCC performed?

A

Ultrasound probes (or microwave probes) are placed in tumour mass to induce necrosis

61
Q

What happens in alcohol ablation in HCC?

A

Alcohol is injected into the tumour, acting to destroy the malignant tissue

62
Q

Where is alcohol ablation of HCC most effective?

A

In those with small tumours, who have well-functioning livers

63
Q

Where is alcohol ablation of HCC the treatment of choice?

A

In those with small, inoperable cancers

64
Q

What is transarterial chemoembolisation used for?

A

Reserved for patients with BCLC stage B (a large multinodular tumour)

65
Q

What happens in transarterial chemoembolisation?

A

High concentrations of chemotherapy drugs are injected directly into the hepatic artery, and an embolising agent is then added to induce ischaemia

66
Q

How is the majority of the liver preserved in transarterial chemoembolisation?

A

Radiological techniques are used to selectively inject and embolise the branches of the hepatic artery supplying the tumour

67
Q

What does the prognosis of hepatocellular carcinoma depend on?

A

The extent of the underlying cirrhosis

68
Q

Why does the prognosis of hepatocellular carcinoma depend on the extent of the underlying cirrhosis?

A

As this plays a large role in determining how aggressively the cancer can be treated

69
Q

What is the median survival time after diagnosis of hepatocellular carcinoma?

A

Around 6 months

70
Q

What is the most common underlying cause of death in patients with cancer?

A

Metastatic liver cancer

71
Q

What are the most common cancers that metastasise to the liver?

A 
Bowel 
Breast 
Pancreas
Stomach
Lung
72
Q

How does cancer spread from bowel to liver?

A

Via portal circulation

73
Q

What are the clinical features of metastatic liver cancer?

A

Similar to that of HCC

74
Q

What proportion of patients with metastatic liver cancer have hepatomegaly and splenomegaly?

A

Roughly half of patients

75
Q

What investigations are done in metatstatic liver cancer?

A

Similar to HCC

76
Q

What may bloods show with metastatic liver cancer?

A

Derangement of LFTs, with ALP being almost invariably raised

77
Q

What is the initial imaging modality of choice in metastatic liver cancer?

A

Often ultrasound scannign

78
Q

What may a CT scan be used for in metastatic liver cancer?

A

To stage the metastasise
Allow imaging of rest of body
Investigate source of metastasis

79
Q

Why is biopsy of metastatic liver cancers not advised if the tumour is operable?

A

As the needle tract may lead to seeding of the tumour

80
Q

Why is surgical a more difficult and less useful option in metastatic liver cancer?

A

For the majority of patients with metastatic liver disease, the primary tumour has metastasised to additional sites

81
Q

Who are often closely involved in the decision making process with metastatic liver disease?

A

Oncological and pallative services

82
Q

When may surgery be indicated in patients with metastatic liver disease?

A

In patients with mets confined to the liver, who have their primary tumour under control

83
Q

What are the non-surgical treatment methods for patients with metastatic liver disease?

A

Transarterial chemoemoblisation

Selective internal radiotherapy

3: Surgery Y3 - Cancer Care [1] (check ILOs) (47 decks)

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