(59b) Liver tumours, biliary tract, and pancreas Flashcards
Name a major risk factor for hepatocellular carcinoma
Cirrhosis
Who gets hepatocellular carcinoma?
Males more than females
Increasing incidence in west (obesity and alcohol)
Geographical variation, depending on prevalence of viral hepatitis
What are late stage clinical features of HCC?
- worsening liver function
- weight loss
How are patients with cirrhosis surveilled?
- 6 month USS
- blood test (raised alpha feto-protein in serum in 75% but less than 50% in non-cirrhotic patients and small HCC)
How does HCC appear macroscopically?
- expansile soft nodules, often green (bile)
- involvement of portal vein (60%), hepatic vein (20%), bile duct (5%)
- often multifocal in cirrhosis
How does HCC appear microscopically?
- cancer cells look like hepatocytes
- may produce bile = diagnostic
- confirm with immunohistochemistry
A targeted liver biopsy should be done if diagnosis is unclear. What is the differential diagnosis?
- benign liver vs. well differentiated HCC
- metastatic carcinoma vs. poorly differentiated HCC
What is the general prognosis of HCC?
Very poor (less than one year) unless diagnosed early - so surveillance is important!
How is HCC treated?
- surgery (if non-cirrhotic or small, peripheral)
- transplant (if 1 tumour 5cm or less, if 3 or less tumours 3cm or less)
How is non-resectable HCC treated? (multiple, large, metastasised)
- ablation - radio frequency
- embolisation
- chemotherapy - sorafenib
What are the TNM stages for HCC?
- pT1
- pT2
- pT3a
- pT3b
- pT4
What is a pT1 HCC?
Solitary tumour without vascular invasion
What is a pT2 HCC?
Solitary tumour with vascular invasion or multiple tumours, none more than 5cm in greatest dimension
What is a pT3a HCC?
Multiple tumours, any more than 5cm
What is a pT3b HCC?
Single or multiple tumours of any size involving a major branch of the portal vein or hepatic vein
What is a pT4 HCC?
Tumour(s) with direct invasion of adjacent organs other than the gall bladder or with perforation of visceral peritoneum
How common are metastatic tumours of the liver?
Much commoner than primary liver cancer
What type of liver metastasis has few large nodules? (suitable for surgical excision)
Large bowel
What types of metastatic tumours of the liver are multinodular or infiltrative?
- lung
- pancreas
- breast
- stomach
- melanoma
Name the other primary liver cancer, other than hepatocellular carcinoma
Cholangiocarcinoma
What is a cholangiocarcinoma?
An adenocarcinoma arising in the bile ducts
What are the 2 types of cholangiocarcinoma?
- intrahepatic
- perihilar
What are the features of intrahepatic cholangiocarcinoma?
- from small intrahepatic ducts
- peripheral, mass forming, presents late
- risk factor = none, or cirrhosis
What are the features of perihilar cholangiocarcinoma?
- from large ducts
- causes obstructive jaundice early
- risk factor = bile duct disease, primary sclerosing cholangitis
- liver flukes
Summarise liver cancer
- primary = HCC (in patients with cirrhosis, surveillance), cholangiocarcinoma
- metastatic = much more common, most adenocarcinoma (lung, colon, stomach, breast, pancreas, melanoma)
How much bile is excreted?
0.5-1l per day is excreted by the liver and concentrated in the gall bladder
What does bile contain?
Viscid green liquid that contains bile salts, phospholipids, cholesterol, bilirubin and calcium salts + mucin from peribiliary glands
What are the risk factors for gallstones and why?
- female
- obesity
- diabetes
Causes an imbalance of bile constituents causing it to precipitate
What are the 2 main types of gallstone?
- cholesterol stones
- pigment stones
(or mixed = most common)
Describe cholesterol stones
- yellow and opalescent
- contain undissolved cholesterol
Describe pigment stones
- small and black
- in haemolytic anaemia (bile contains too much bilirubin)
10% of gallstones contain what?
Calcium (visible on plain X-ray)
What are the complications of gallstones?
- cholecystitis
- mucocele
- predisposition to carcinoma of gallbladder
- obstruction of biliary system
- cholangitis and liver abscesses
- gallstone illeus
- pancreatitis
What is cholecystitis?
Inflammation of the gallbladder
What is mucocele? (complication of gallstones)
Distention of the gallbladder by an inappropriate accumulation of mucus. Decreased bile flow = predisposing factor
Gallstones cause obstruction of biliary system which results in what?
Biliary colic and jaundice
What is biliary colic?
Pain related to the gallbladder that occurs when a gallstone transiently obstructs the cystic duct and the gallbladder contracts
Why do cholangitis and liver abscesses occur as a complication of gallstones?
Due to infection of static bile
Why does gallstone ileus occur as a complication of gallstones?
Due to intestinal obstruction by a gallstone that has entered the gut through a fistulous connection with the gallbladder
What are the indications for cholecystectomy?
- pain
- gallstones
- pancreatitis
- gall bladder polyp (rarely)
Describe the features of acute cholecystitis
- duct blocked by stone
- initially sterile, later infected
- large, swollen, congested, ulcerated
- complications = empyema, rupture
Describe the features of chronic cholecystitis
- usually gallstones
- small, fibrotic, stones
- fibrosis
- Rokitansky Aschoff sinuses
What are Rokitansky-Aschoff sinuses?
Pseudodiverticula or pockets in the wall of the gallbladder.
Outpouchings of gallbladder mucosa into the gallbladder muscle layer and subserosal tissue as a result of hyperplasia and herniation of epithelial cells through the fibromuscular layer of the gallbladder wall.
Associated with cholecystitis.
What happens to all gall bladders after cholecystectomy?
They are examined to detect gall bladder cancer
What are the associated premalignant lesions before gall bladder cancer?
- polyp
- dysplasia
