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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
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
26
What will suggest a diagnosis of infectious hepatitis rather than HCC?
Presence of non-specific serology
27
What will suggest a diagnosis of cardiac failure rather than HCC?
Smooth hepatomegaly
28
What investigations should be done in HCC?
Bloods Imaging Staging
29
What may the bloods show in HCC?
Deranged liver function tests (ALP, AST, ALT, bilirubin) | Low platelets or prolonged clotting
30
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
31
What tumour marker should be measured in suspected cases of HCC?
Alpha fetoprotein
32
What % of HCC have raised alpha feto-protein?
70%
33
What is the use of alpha feto-protein in HCC?
Can be used to monitor treatment response and recurrence
34
What is the initial imaging modality of choice in HCC?
Ultrasound
35
How can ultrasound be diagnostic in HCC?
If a mass of >2cm is found, with a raised alpha feto-protein
36
What should be done if a mass is found >2cm on ultrasound with a raised alpha feto-protein?
Staging CT scan for further evaluation
37
What should be done if a patient has a raised alpha feto-protein and suggestive ultrasound nodules?
MRI liver scanning for further assessment
38
What can be done if the diagnosis is still in doubt following imaging?
Biopsy or percutaneous fine-needle aspiration
39
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
40
What is a characteristic feature of HCC that can be demonstrated on MRI scanning and contrast CT angiography?
Mass with arterial hypervascularisation
41
What is the most accepted staging system for HCC?
The Barcelona Clinic Liver Cancer staging system (BCLC)
42
What does the BCLC take into account?
Tumour stage Liver function Physical status Cancer related symptoms
43
What is the purpose of the BCLC?
To provide guidance on what treatment is most suitable
44
What risk assessment tools are used in HCC?
Child-Pugh score | MELD score
45
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
46
What parameters does the Child-Pugh score use?
``` Serum bilirubin Albumin INR Degree of ascites Evidence of encephalopathy ```
47
What is calculated from the Child-Pugh score?
The prognosis of patients with liver cirrhosis
48
What is the advantage of recent scores such as the MELD score?
Has been shown to be a better predictor of mortality
49
What parameters does the latest MELD score calculator include?
``` Creatinine Bilirubin INR Sodium Use of dialysis at least twice a week ```
50
What additional thinghide can be predicated from the MELD score?
The likelihood of a patient tolerating a potential liver transplant
51
How is treatment for hepatocellular carcinoma best organised?
Through a MDT, including oncologists, radiologists, hepato-biliary surgeons, and specialist nurses
52
What are the curative options for hepatocellular carcinoma?
Surgical resection and transplantation
53
What are the options of surgical resection and transplantation limited by in hepatocellular carcinoma?
Tumour size Liver function Any co-morbidities present
54
When is surgical resection the treatment of choice in hepatocellular carcinoma?
In patients without cirrhosis and a good baseline health status
55
What is the 5 year recurrence rate of HCC post-resection?
50-60%
56
When can transplantation be considered in HCC?
In patients that fulfil the Milan Criteria
57
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
58
What are the options for non-surgical management of HCC?
Image-guided ablation Alcohol ablation Transarterial chemoembolisation
59
Who is image guided ablation indicated for in HCC?
Patients with early HCC (BCLC 0 or A)
60
How is image-guided ablation of HCC performed?
Ultrasound probes (or microwave probes) are placed in tumour mass to induce necrosis
61
What happens in alcohol ablation in HCC?
Alcohol is injected into the tumour, acting to destroy the malignant tissue
62
Where is alcohol ablation of HCC most effective?
In those with small tumours, who have well-functioning livers
63
Where is alcohol ablation of HCC the treatment of choice?
In those with small, inoperable cancers
64
What is transarterial chemoembolisation used for?
Reserved for patients with BCLC stage B (a large multinodular tumour)
65
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
66
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
67
What does the prognosis of hepatocellular carcinoma depend on?
The extent of the underlying cirrhosis
68
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
69
What is the median survival time after diagnosis of hepatocellular carcinoma?
Around 6 months
70
What is the most common underlying cause of death in patients with cancer?
Metastatic liver cancer
71
What are the most common cancers that metastasise to the liver?
``` Bowel Breast Pancreas Stomach Lung ```
72
How does cancer spread from bowel to liver?
Via portal circulation
73
What are the clinical features of metastatic liver cancer?
Similar to that of HCC
74
What proportion of patients with metastatic liver cancer have hepatomegaly and splenomegaly?
Roughly half of patients
75
What investigations are done in metatstatic liver cancer?
Similar to HCC
76
What may bloods show with metastatic liver cancer?
Derangement of LFTs, with ALP being almost invariably raised
77
What is the initial imaging modality of choice in metastatic liver cancer?
Often ultrasound scannign
78
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
79
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
80
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
81
Who are often closely involved in the decision making process with metastatic liver disease?
Oncological and pallative services
82
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
83
What are the non-surgical treatment methods for patients with metastatic liver disease?
Transarterial chemoemoblisation | Selective internal radiotherapy

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

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