Cancer of the liver, gallbladder, and biliary tree

Question 1

Which cancers are commonest in the liver?

Answer 1

Secondary liver cancer. Most common metastases from breast, bowel, or lung cancer.

Question 2

Describe the prognosis of secondary liver cancer

Answer 2

Most common cause of cancer death (35%)

Only 25% are suitable for curative surgery

Question 3

How does secondary liver cancer present?

Answer 3

Hepatomegaly and ascites (50%)
-Ascites indicates wide dissemination and poor prognosis
Obstructive metastases: Jaundice, malaise, anorexia, weight loss

Question 4

How is secondary liver cancer investigated?

Answer 4

FBC - anaemia and leukocytosis
LFTs - may be abnormal
Bilirubin, ALP, ALT may be raised
Alpha fetoprotein, PVIKA-II, CEA, CA19-9
CXR and Abdominal USS
Biopsy - not advised if tumour is operable

Question 5

What management options exist for secondary liver cancer?

Answer 5

Hepatectomy for stage IV colorectal cancer
Freezing, ethanol, lasers, radio frequency ablation
Transcatheter arterial chemoembolisation
Laparoscopic liver resection for solitary liver met
Selective internal radiation therapy for non-resectable colorectal metastases in the liver

Question 6

What are the types of primary liver cancer?

Answer 6

Hepatocellular carcinoma (90%)
Intrahepatic cholangiocarcinoma
Fibrolamella carcinoma - large vascular mass
Angiosarcoma
Hepatoblastoma - children

Question 7

What is the link between HCC and chronic liver disease?

Answer 7

70-90% of HCC develops in patients with chronic liver disease. Tumours are multifocal in 75% at presentation.

Question 8

Describe the epidemiology of hepatocellular carcinoma

Answer 8

<1% of all new cancers in UK
Prevalence follows HBV and HCV infection
Common in Africa and Asia
M>F 4-8:1

Question 9

Name 5 risk factors for hepatocellular carcinoma

Answer 9

90-95% have underlying cirrhosis

• Chronic HBV: commonest worldwide cause of HCC
• HCV: commonest cause of HCC in Europe
• Alcoholism
• Hereditary haemochromatosis
• Primary biliary cirrhosis
• Aflatoxins, contraceptives, androgens
• Metabolic syndrome, diabetes, smoking

Question 10

How does hepatocellular carcinoma present?

Answer 10

Commonest: rapid deterioration of pre-existing cirrhosis

Symptoms: Pruritus, splenomegaly, bleeding oesophageal varicose, weight loss, jaundice, hepatic encephalopathy, ascites, RUQ pain

Signs: Jaundice, hepatomegaly, ascites, spider naevi, peripheral oedema, anaemia, caput medusa, liver flap/asterixis

Question 11

Where does primary liver cancer metastasise?

Answer 11

Lung
Portal vein
Periportal lymph nodes
Bone
Brain

Question 12

How are primary liver cancers investigated?

Answer 12

Alpha fetoprotein (AFP) >500ng/mL ➔ highly suggestive of HCC
USS: identifies site and cause of obstruction
Needle biopsy to confirm HCC diagnosis

ERCP to diagnose ampullary and bile duct carcinomas
PTC to diagnose intrahepatic biliary tumours
CT to assess local spread, LN, and metastases

Question 13

What surgical treatment is available for primary liver cancer?

Answer 13

Curative:
Partial hepatectomy (HCC)
Liver transplant (HCC associated with chronic hepatitis)

Palliative:
Embolisation. Percutaneous thermal or radio frequency ablation

Question 14

What is the prognosis of HCC?

Answer 14

44% 5yr survival if surgically resectable

20% resectable at diagnosis

Question 15

What types of cholangiocarcinoma exist?

Answer 15

Ductal adenocarcinoma (>90%)
Squamous cell carcinoma

Question 16

Where can cholangiocarcinomas occur?

Answer 16

Perihilar region “Klatskin tumour” (commonest)
Distal: upper border of pancreas to ampulla of Vater
Intrahepatic

Question 17

Describe the epidemiology of cholangiocarcinoma

Answer 17

Rare: 1-2 per 100,000 population per year
Most occur in over 60s
High incidence in SE Asia due to liver flukes parasite

Question 18

Name 2 risk factors for cholangiocarcinoma

Answer 18

Primary sclerosing cholangitis
Liver flukes infection
Industrial chemical exposure
Thorium exposure
Congenital bile duct abnormalities
Caroli's disease - dilatation of intrahepatic biliary tree

Question 19

How is cholangiocarcinoma managed?

Answer 19

Radical excision of bile duct with reconstruction
Pancreaticoduodenectomy (distal cholangiocarcinoma)
Endoscopic/percutaneous stenting (palliative)

Question 20

What is the prognosis of cholangiocarcinoma?

Answer 20

Median survival 9 months