Chapter 13: Primary Liver Cancer

Question 1

primary liver cancer

Answer 1

hepatocellular carcinoma

Question 2

leading cause of HCC

Answer 2

Hepatitis B Virus in places where hep B is endemic, and hepatitis C virus in North America.

Question 3

surveillance using ____ and _____ shows an improvement in overall mortality from HCC

Answer 3

Alpha fetal protein Ultrasound

Question 4

high risk populations in which HCC surveillance is cost-effective

Answer 4

1. cirrhosis (regardless of the ethology) 2. certain HBV carriers - asian males >40 Asian females >50 Africans >30 - those with a family history of HCC

Question 5

when is follow up after surveillance required?

Answer 5

if nodules are found on the surveillance US

Question 6

T/F: you need a biopsy to diagnose HCC

Answer 6

false. HCC can be diagnosed with multi-detection computerized tomography (MDCT) or contrast MRI or CEUS. Also need AFP level. The higher the AFP, the poorer the prognosis. you require a biopsy only if these studies are negative.

Question 7

Contrast enhanced studies take advantage of the ____ blood supply of the liver and that as nodules progress from a low-grade dysplastic nodule (L-DN) → high-grade dysplastic nodule (H-DN) → well differentiated HCC (WD-HCC) → moderately differentiated HCC (MD-HCC) they have ____ of their blood supply from neoplastic arteries with ____ blood supplied from the portal venous system (from GI)

Answer 7

Contrast enhanced studies take advantage of the dual blood supply of the liver and that as nodules progress from a low-grade dysplastic nodule (L-DN) → high-grade dysplastic nodule (H-DN) → well differentiated HCC (WD-HCC) → moderately differentiated HCC (MD-HCC) they have more of their blood supply from neoplastic arteries with less blood supplied from the portal venous system

Question 8

Explain the portal venous washout effect

Answer 8

the contrast from the bowel usually travels to the liver through the portal vein (80% of the blood supply of the normal liver), but as the HCC has little of its blood supply from the portal vein and the arterial contrast has now left the lesion, it appears darker than the surrounding liver.

Question 9

difference in portal space as the progression of HCC progresses

Answer 9

there’s less portal space and more neoplastic artery.

Question 10

what factors does the barcelona clinic liver cancer staging system use to classify tumor stage

Answer 10

• tumor burden
• eastern cooperative oncology group performance satus
• liver function via Child Pugh class.

Question 11

aspects of child pugh classification

Answer 11

BCLC 0 & A (Very Early & Early Stage)
 5 year survival of 70% can be seen in patients carefully selected for curative options
of resection, radiofrequency ablation (RFA) or liver transplant (LT)
o BCLC B (Intermediate Stage)
 TACE increases median survival from 16 to 20 months
 TACE with drug eluting beads (DEB-TACE) can achieve median survival of 4 years

BCLC C (Advanced Stage)
 Sorafenib increases survival from 8 to 11 months o BCLC D (End Stage)
 Survival is < 3 months
 Patients with Child Pugh class C cirrhosis are end-stage unless LT candidates

Question 12

curative and palliative treatment options

Answer 12

curative: sugical resection, RFablation, Percutaneous ethanol injection, liver transplantation in patients scoring 0 and A BCLC

Palliative treatment options: TACE, Sorafenib, levatinib, regorafenib, cabozatinib (chemotherapeutics).

In BCLC B, TACE increases median survival from 16 to 20 months. IN BCLC C, sorafenib increases survival from 8-11 months. In BCLC D, endstage, survival is less than three months unless they’re LT candidates.

Question 13

rare liver cancer whose incident rate is increasing

Answer 13

intrahepatic cholangiocarcinoma

Question 14

risk factors

Answer 14

Risk factors
o Cirrhosis
o Chronic viral hepatitis
o Primary sclerosing cholangitis
o Alcohol abuse
o Diabetes
o Obesity

Question 15

surveillance of iCCA

Answer 15

it’s controversial, but carbohydrate antigen CA19-19 and US surveillance should be done in cirrhotics

Question 16

diagnosing iCCA

Answer 16

MRI or CT shows liver mass with arterial phase enhancement. CEUS can show early and rapid washout. PET may be able to demonstrate lymph node involvement or metastases.

Question 17

In pts with resectable iccA (stage I and II), what’s the survival?

Answer 17

With curative resection, 5 year survival of 40% can be achieved but this falls to only 20% if
metastatic lymph nodes or vascular invasion are found at surgery

Question 18

in two thirds of patients (III and IV), iCCA is unresectable. what are some options?

Answer 18

if intra-heaptic disease, TACE can be offered but outcomes are worse than with HCC. Median survival is 15 months.

if extra-hepatic disease, chemotherapy with gemcitabine and cisplatin can be offered by median survival is typically <1 year.