Cancer of the Liver and Hepatobiliary Tract Flashcards
Liver
What structure divides the liver into left and right lobes?
falciform ligament
Liver
What segments are in the left lobe of the liver?
the lateral segments (II and III) the medial segment (IV) caudate lobe (segment I) *** I - medial superior area II - lateral segment/lateral superior area III - lateral inferior area/left anterior lateral segment IV - medial segment/medial inferior area
Liver
What segments are in the right lobe of the liver?
the posterior segments (VI and VII)
the anterior segments (V and VIII)
***
V - anterior medial segment/anterior inferior area
VI - right anterior lateral segment/Posterior inferior area
VII - posterior lateral segment/posterior superior area
VIII - posterior medial segment/anterior superior area
Liver
What anatomic landmark separates the medial and lateral segments of the liver?
falciform ligament (drawn between gallbladder and IVC)
Liver
What anatomic landmark separates the anterior from the posterior segments of the liver?
right hepatic vein
Liver
What anatomic landmark separates the left medial segment from the anterior segment of the liver?
middle hepatic vein
Liver Cancer
The recent rise of HCC in the developed regions is attributed to the higher prevalence of what related infection?
HCV infection
Liver Cancer
Antiviral therapy has also been shown to reduce recurrence and improve survival for HBV-related HCC.
TRUE or FALSE?
True
Liver Cancer
There is a reduction in mortality for hepatitis B patients who had undergone surveillance.
TRUE or FALSE?
True.
***
A randomized study demonstrated a 37% reduction in mortality for hepatitis B patients who had undergone surveillance.
Liver Cancer
Fungi associated with aflatoxins that are considered risk factors for developing HCC.
Aspergilus (flavus and parasiticus)
Liver Cancer
The risk of HCC is even higher in patients who are HBcAg positive compared
with those who are HBcAg negative.
TRUE or FALSE?
False.
It’s “e” envelope, not “c” core
Liver Cancer
Chronic alcohol use of >__ g/day for more than 10
years increases the risk for HCC by approximately fivefold.
80
Liver Cancer
Hereditary liver diseases associated with a higher risk of developing HCC.
hemochromatosis
Wilson disease
hereditary tyrosinemia
type I glycogen storage disease
Liver Cancer
NCCN recommends screening for which group of patients?
HBsAg carriers without cirrhosis
and
cirrhosis from all causes
Liver Cancer
NCCN recommends screening procedure for high-risk patients?
serum AFP
ultrasound
Liver Cancer
Fifteenminute
retention rate of _______ before treatment is very useful
for determining resectability and/or the feasibility of radiation
indocyanine green (ICG)
Liver Cancer
What are the noninvasive criteria for diagnosing HCC in a cirrhotic liver as suggested by the AASLD in 2005?
AFP > 200 ng/mL
or
typical enhancement pattern (arterial enhancement and delayed portal vein washout) on dynamic imaging of hepatic mass >2 cm in a cirrhotic liver.
Liver Cancer
Ultrasound examination of the liver is commonly used as a screening tool.
Which of the following is/are TRUE?
I. Small tumors are often hyperechoic.
II. As the tumor grows, the echo pattern tends to become isoechoic or hypoechoic, and HCC can be difficult to distinguish from the surrounding liver.
III. Nodules <2 cm should be followed with ultrasonography again at intervals of 3 months.
IV. Nodules over 2 cm in a cirrhotic liver should be investigated further with four-phase dynamic CT scan.
None.
I. hypo
II. to hyper
III. <1
IV. >1
Liver Cancer
Identify the BCLC stage:
Child-Pugh C
ECOG 3-4
D
Liver Cancer
Identify the BCLC stage:
Portal Invasion N1 M1 Child-Pugh A–B ECOG 1–2
C
Liver Cancer
Identify the BCLC stage:
Multinodular
Child-Pugh A–B
ECOG 0
B
Liver Cancer
Identify the BCLC stage:
Single nodule <2 cm
Child-Pugh A
ECOG 0
0
Liver Cancer
Identify the BCLC stage:
Single nodule or 3 nodules <3 cm
Child-Pugh A–B
ECOG 0
A
Liver Cancer
The fibrolamellar variant of HCC has a relatively better prognosis.
It occurs more frequently in the elderly and has a more indolent clinical course than conventional HCC.
TRUE or FALSE?
False.
***
adolescents/young adults
Liver Cancer
Hepatoblastoma occurs most commonly in young children (median age,
13 to 16 months) and usually presents as an incidental finding with an early-stage and favorable course.
TRUE or FALSE?
False.
***
advanced stage
Liver Cancer
Child Pugh score 1
bil <2 (low)
albumin >3.5 (high)
protime <4 (short)
no hepatic enceph and ascites
Liver Cancer
Child Pugh score 2
bil 2–3 albumin 3.5 to 2.8 4–6 grade 1–2 enceph mild detectable ascites
Liver Cancer
Child Pugh score 3
bil >3 (high) albumin <2.8 (low) protime >6 (prolonged) grade 3–4 enceph severe tense ascites
Liver Cancer
Child Pugh Class A
score 5 to 6
Liver Cancer
Child Pugh Class B
7-9
Liver Cancer
Child Pugh Class C
> 9
Liver Cancer
What is Milan’s size and number criteria for eligibility for liver transplantation?
solitary tumor 5 cm
up to 3 tumors (smaller than 3 cm)
Liver Cancer
Which is/are true regarding liver transplantation?
I. Many patients are not candidates for definitive surgery because of underlying
liver dysfunction. The increasing availability of liver transplantation has made
this procedure a viable alternative to tumor resection for selected patients
II. excellent overall 3- to 4-year actuarial
(75% to 85%) and recurrence-free survival rates (83% to 92%) can be
achieved
III. Risk factors of recurrence after transplantation include tumor
size, number of tumors, vascular invasion, and persistence of HBV
infection
IV. Local treatment such as TACE or RFA could downstage HCC for
transplantation purposes.
Downstaging could increase the opportunity for
transplantation and improve survival. Besides, local treatment could also be a
bridging therapy for patients on the waiting list to keep them away from
progression of disease diminishing the chance of transplantation
All are true
Liver Cancer
For patients with early-stage HCC who are not suitable for resection or
transplantation, percutaneous ablation could be a treatment option.
Percutaneous ________ is highly effective for small HCC. It achieves
necrosis rate of 90% to 100% of the HCC <2 cm in size, but the necrosis rate is
reduced to 50% if HCC is >3 cm
ethanol injection
Liver Cancer
RFA involves the local application of radiofrequency thermal energy to the
lesion. RFA is a reasonable option for patients who do not meet resectability
criteria for HCC and yet are candidates for a liver-directed procedure based on
the presence of liver-only disease. The best outcomes are in patients with a
single tumor _______(range) cm in diameter. Randomized control trials comparing
RFA and ethanol injection have shown that RFA provides superior local disease
control that could result in an improved survival.
> 2 and <4
Liver Cancer
HCC is a radiosensitive tumor.
TRUE or FALSE?
True
Liver Cancer
Indications for RT
larger unresectable HCC
relieving portal vein tumor–induced thrombosis
obstructive jaundice
failure of prior TACE
and as component of combined modality with TACE and percutaneous ablation.
Liver Cancer
A patient with Child-Pugh Class ≥B or score ≥8 is usually not treated with SBRT due to the risk of RILD, unless…
the patient is already on the list for liver transplantation soon enough.
Liver Cancer
Treatment for large unresectable tumors?
TACE + RT
Liver
(from in-service bank)
18. Hepatocellular carcinoma is quite unique in that it gets it arterial blood supply differently from the blood supply of the rest of the liver. The tumor is supplied by the \_\_\_\_\_\_\_\_. A. Portal vein B. Hepatic artery C. Portal vein and hepatic artery D. Superior mesenteric artery
B
Liver
(from in-service bank)
- Malignant tumors of the liver are uniformly characterized by the following images on triphasic CT scan.
A. early enhancement in the arterial phase compared to the rest of the surrounding liver tissue and washout or hypodense image in the porto-venous phase
B. hypodense image in the arterial phase compared to the rest of the surrounding liver tissue and enhancement in the porto-venous phase
C. no difference in contrast enhancement between tumor and surrounding liver tissue in arterial phase
D. no difference in contrast enhancement between tumor and surrounding liver tissue in the porto-venous phase
A
Liver
(from in-service bank)
- To rule out other conditions, a tissue biopsy must always be performed to make a diagnosis of hepatocellular carcinoma.
A. True
B. False
B
Liver
(from in-service bank)
- The Barcelona Clinic Liver Cancer (BCLC) Staging System is widely used as guide in the treatment decision for Hepatocellular Carcinoma. What is/are the first line of treatment recommendation for stage 0 (Very Early) and Stage A (Early)?
A. Resection
B. Liver transplantation
C. Percutaneous Ethanol Injection (PEI)/Radiofrequency ablation (RF)
D. All of the above
D
Liver
(from in-service bank)
- For stage 0 and A, according to the Barcelona Clinic Liver Cancer System, radiation may be used in the following circumstance/s.
A. Definitive RT is patient is not suitable for resection, transplant or RT
B. RT as bridge to transplant (while waiting for transplant donor)
C. Both A & B are correct
D. No role for RT in this situation
C
Liver
(from in-service bank)
23. There are five clinical and laboratory parameters that are important in the pretreatment evaluation of a patient with Hepatocellular Carcinoma. They are: Ascites, Bilirubin, Albumin, Prothrombin and \_\_\_\_\_\_\_\_. A. Platelet count B. Alkaline phosphatase C. Encephalopathy D. LVMH
C
Liver
(from in-service bank)
- The following statement is true for the use of RT in Hepatocellular Carcinoma.
A. HCC is a radiosensitive tumor. The surrounding normal liver tissue has poor tolerance to radiation.
B. SBRT is the radiation technique of choice because of the large fraction size resulting in a higher BED.
C. Image guidance (IGRT) allows better target localization.
D. There is very minimal respiratory organ motion and intrafraction motion is not a problem.
D (parang mali yung question. Dapat except)
Biliary Tract Cancer
What is the most common cancer of the biliary tract and accounts for two-thirds of these cancers?
gallbladder
Biliary Tract Cancer
What is the term used to describe cancers arising from the epithelial cells of the bile ducts?
cholangiocarcinoma
Biliary Tract Cancer
Surgical excision of all resectable biliary tract cancers is associated with a good
long-term survival, whereas for unresectable tumors, the treatment is usually
palliative aiming to relieve obstructive jaundice with drainage of bile and
management of biliary tract infection, pain, and ascites.
TRUE or FALSE?
True
Biliary Tract Cancer
What is the major risk factor in developing ICC in Western countries, which is closely associated with chronic inflammatory bowel disease, particularly ulcerative colitis?
primary sclerosing cholangitis
Biliary Tract Cancer
What flukes are associated with developing cholangiocarcinoma?
Clonorchis sinensis
Opistorchis viverrini
Biliary Tract Cancer
Patients with extrahepatic tumor usually present with jaundice, acholic stools, and tea-colored urine.
Patients with intrahepatic tumors are less likely to be jaundiced and more likely to present with abdominal symptoms and more advanced disease.
Which is TRUE?
Both
Biliary Tract Cancer
A serum CA 19-9 value >___ U/mL has a sensitivity of approximately 75% and a specificity of approximately 80%.
100
Biliary Tract Cancer
Aside from CCa, what condition also presents with significantly increased biliary CEA levels?
intrahepatic cholelithiasis
***
Biliary CEA levels
increase significantly in patients with cholangiocarcinoma and also in patients
with intrahepatic cholelithiasis (average, 50.2 to 57.4 ng/mL) compared with
patients with benign strictures (average, 10.1 ng/mL) and patients with
sclerosing cholangitis and choledochal cysts (average, 20.0 to 21.6 ng/mL).
Biliary Tract Cancer
Mixed HCC and cholangiocarcinoma can be detected by the elevation of this tumor marker.
serum AFP
Biliary Tract Cancer
There are two main histologic subtypes of cholangiocarcinoma: bile ductular type (mixed), arising from large intrahepatic bile ducts, and bile duct type (mucinous), arising from small intrahepatic and extrahepatic bile ducts.
TRUE or FALSE?
False.
ductular (mixed) - small
bile duct (mucinous) - large
Biliary Tract Cancer
What is the main histology of cholangiocarcinoma?
adenocarcinoma
Biliary Tract Cancer
What are the three types of cholangiocarcinoma, adenocarcinoma.
Which is most common?
Which has the best prognosis?
sclerosing - most common
nodular
papillary - presents with obstructive symptoms hence early diagnosis and favorable prognosis
Biliary Tract Cancer
Cholangiocarcinomas rarely invade lymphatic,
perineural, and periductal spaces, and portal tracts.
TRUE or FALSE?
False.
Frequently
Biliary Tract Cancer
Mutations in p53 tumor suppressor gene and KRAS proto-oncogene have been identified in cholangiocarcinoma.
p53 overexpression and K-RAS mutations are associated with a _____ survival.
shortened
Biliary Tract Cancer
IDH mutations block normal cellular differentiation and
promote tumorigenesis via the abnormal production of what oncometabolite?
D-2-hydroxyglutarate (2-HG)
Biliary Tract Cancer
The incidence of lymph node metastasis in ICC ranges from 50% to 60%.
ICCs, irrespective of their intrahepatic location, mainly spread to which nodes?
hepatoduodenal ligament
then to paraaortic, retropancreatic, or common hepatic artery node group.
Biliary Tract Cancer
Which type of cholangiocarcinoma tends to spread along the left gastric nodes through the lesser curvature?
The left peripheral type or hilar type
Biliary Tract Cancer
Main nodes involved in perihilar cholangiocarcinoma
pericholedocal 43%
perioportal 31%
common hepatic nodes 27%
posterior pancreaticoduodenal 15%
The celiac and superior mesenteric nodes are rarely
involved
Biliary Tract Cancer
Main nodes involved in distal cholangiocarcinoma
posterior pancreaticoduodenal 35%
hepatoduodenal 35%
common hepatic artery 30%
Biliary Tract Cancer
In distal CC, paraaortic lymph node involvement occurred in 25% of patients and was
significantly associated with ________.
(Yoshida et al).
Pancreatic parenchymal invasion.
Biliary Tract Cancer
TNM staging
Identify the T-stage for intrahepatic bile duct tumors:
Tumor perforating the visceral peritoneum
T3
Biliary Tract Cancer
TNM staging
Identify the T-stage for intrahepatic bile duct tumors:
Tumor involving local extrahepatic structures by direct invasion
T4
Biliary Tract Cancer
TNM staging
Identify the T-stage for intrahepatic bile duct tumors:
Solitary tumor with intrahepatic vascular invasion or multiple tumors without vascular invasion
T2
Biliary Tract Cancer
TNM staging
Identify the T-stage for intrahepatic bile duct tumors:
Solitary tumor ≤5 cm without vascular invasion
T1a
T1b if >5 cm
Biliary Tract Cancer
What is N1 in intrahepatic bile duct tumors?
What is the likely minimal stage?
+Regional nodal metastasis
Stage IIIB
Biliary Tract Cancer
TNM staging
Identify the T-stage for perihilar bile duct tumors:
Tumor confined to the bile duct, with extension up to the muscle layer or fibrous tissue
T1
Biliary Tract Cancer
TNM staging
Identify the T-stage for perihilar bile duct tumors:
Tumor invades unilateral branches of the PV or HA
T3
Biliary Tract Cancer
TNM staging
Identify the T-stage for perihilar bile duct tumors:
Tumor invades beyond the wall of the bile duct to surrounding adipose tissue
T2a
Biliary Tract Cancer
TNM staging
Identify the T-stage for perihilar bile duct tumors:
Tumor invades beyond the wall of the bile duct to adjacent hepatic parenchyma
T2b
Biliary Tract Cancer
TNM staging
Identify the T-stage for perihilar bile duct tumors:
Tumor invades the main portal vein or its branches bilaterally or the CHA,
or unilateral second-order biliary radicals bilaterally with contralateral portal vein or hepatic artery involvement
T4
Biliary Tract Cancer
What is N1 in perihilar bile duct tumors?
What is the likely minimal stage?
1-3 positive nodes (Typically involving the hilar, cystic duct, common bile duct, hepatic artery, posterior pancreaticoduodenal, and portal vein lymph nodes)
Stage IIIC
N2 is 4 or more (IVA)
Biliary Tract Cancer
TNM staging
Stratify the distal bile duct tumors into T1-3 based on depth of invasion to the bile duct wall.
T1: <5 mm;
T2: 5–12 mm;
T3: >12 mm;
Tis: in situ/high-grade dysplasia;
T4: celiac axis, SMA, and/or CHA
Biliary Tract Cancer
What is N1 in distal bile duct tumors?
N1 is 1-3 + nodes
N2 is 4 or more
Biliary Tract Cancer
What is the most common location of BTCs?
A. Intrahepatic (ICC)
B. Perihilar
C. Distal
B
Biliary Tract Cancer
Perihilar Cholangiocarcinoma
What is the Bismuth classification?
multicentric tumors
type IV
Biliary Tract Cancer
Perihilar Cholangiocarcinoma
What is the Bismuth classification?
involve the confluence and both right and left hepatic ducts
type IV
Biliary Tract Cancer
Perihilar Cholangiocarcinoma
What is the Bismuth classification?
tumors below the confluence of the right and left hepatic ducts
type I
Biliary Tract Cancer
Perihilar Cholangiocarcinoma
What is the Bismuth classification?
tumors reaching the confluence
type II
Biliary Tract Cancer
Perihilar Cholangiocarcinoma
What is the Bismuth classification?
tumors involving the CHD and the right or left hepatic ducts
types IIIA and IIIB
Biliary Tract Cancer
Perihilar Cholangiocarcinoma
I. The role of postoperative radiotherapy with or without chemotherapy in patients with completely resected cholangiocarcinoma remains unproven. A retrospective analysis suggests that postoperative adjuvant radiation therapy does not improve survival.
II. Postoperative radiotherapy or chemoradiotherapy reduces the rate of local recurrence in patients with incomplete resection.
Which is TRUE?
Both
Biliary Tract Cancer
Perihilar Cholangiocarcinoma
Patients with perihilar duct carcinomas have the highest rate of curative resection as compared to distal duct carcinomas.
TRUE or FALSE?
False.
Distal have the highest rate of curative resection
Biliary Tract Cancer
Distal Cholangiocarcinoma
What is the chemotherapy of choice of advanced unresectable or metastatic cholangiocarcinoma?
gemcitabine +/- cisplatin
Biliary Tract Cancer
GTV
any visible tumor by CT and/or MRI
Biliary Tract Cancer
CTV
GTV + 1.5 cm (which includes nodes along the porta hepatis, pancreaticoduodenal system, and celiac axis)
Biliary Tract Cancer
RT dose using coventional external beam RT
45 to 50 / 1.8 to 2 / 25 to 28 fx
Biliary Tract Cancer
Gallbladder CA
Which of the following is/are not factors for developing gallbladder ca?
cholelithiasis
anomalous junction of pancreaticobiliary ducts
porcelain gallbladder
cigarette smoking
alcohol consumption
obesity
polyps >10 mm
chronic gallbladder bacterial infection
none of the above
Biliary Tract Cancer
Gallbladder CA
What chronic bacterial infections are associated with the development of gallbladder cancer?
Salmonella typhi
Helicobacter bilis
Biliary Tract Cancer
Gallbladder CA
Patients with T1a disease often are cured after simple cholecystectomy and require no further adjuvant treatment.
TRUE or FALSE?
True
Biliary Tract Cancer
Gallbladder CA
What are the factors predictive for recurrence?
positive surgical margins,
lymph node metastasis,
and perineural invasion.
Biliary Tract Cancer
(from in-service bank)
25. The primary lymphatic drainage of the biliary tract is to the lymphatic nodes in the following EXCEPT: A. Greater curvature B. Hepatoduodenal ligament C. Pancreaticoduodenal region D. Periportal region
A
Biliary Tract Cancer
(from in-service bank)
- Choose the best answer regarding the management of cholangiocarcinoma.
A. For unresectable intrahepatic cholangiocarcinoma (ICC), radiation can be given as EBRT, brachytherapy & SBRT.
B. Targeted therapy is proven to increase overall survival of patients.
C. The role of postoperative radiotherapy is proven to increase overall survival of patients.
D. Total hepatectomy with liver transplantation is not an option for ICC.
A
Biliary Tract Cancer
(from in-service bank)
27. A 60 year old man presents with significant weight loss and persistent RUQ pain. UTZ reveals a 0.6 cm stone and a 1.2 cm polyp. He undergoes a laparoscopic cholecystectomy. Histopath reveals a well differentiated gallbladder adenoCA invading up to the perimuscular connective tissue. Margins of resection are negative for tumor. Which of the following steps may NOT be considered. A. Adjuvant chemotherapy B. Adjuvant RT C. Adjuvant chemoRT D. Observe
D
