CT 2.3 Hepato-pancreato-biliary cancer Flashcards
how are cancers of the hepatobiliary system classified
tumours occurring in the liver are called hepatocellular carcinoma
tumours that occur in the ductal system above the merging of the cystic duct and common hepatic duct are coined as intrahepatic cholangiocarcinomas and hilar cholangiocarcinomas
tumours below this merge up until the ampulla of vater are called extrahepatic cholangiocarcinomas
cancers can occur within the pancreas, gallbladder and duodenum which are also managed by the HPB team
what are the clinical presentations of HPB cancer
jaundice
weight loss
abdominal/back pain
N+V
signs of metastatic disease
new onset diabetes
asymptomatic
Change in BH
what are some background facts about pancreatic cancer
mostly in reference to exocrine pancreas with adenocarcinoma of the ductal and acinar cells (95%)
5% are endocrine (insulinomas, gastrinomas etc)
more common in those >60 yrs
what are the risk factors for pancreatic cancer
smoking
chronic pancreatitis
obesity
DM
FHx
BRCA2 + HNPCC
where do most pancreatic cancers occur
2/3 confined to head of pancreas
1/3 = tail
what genes are implicated in pancreatic cancer
KRAS oncogene in 90% of cases
TP53
SMAD4
what are presentations of pancreatic cancer
- painless jaundice
- weight loss
- pale stools
- dark urine
- pruritus
- enlarged gallbladder without pain
what sign describes an enlarged gallbladder
Courvoiser’s sign
what would happen to each of the following in haemolytic/pre-hepatic jaundice:
- unconjugated bilirubin
- conjugated bilirubin
- urine urobilinogen
- ALT/AST
- ALP/GGT
1) Increase
2) normal
3) increase
4) normal
5) normal
what would happen to each of the following in hepatic jaundice:
- unconjugated bilirubin
- conjugated bilirubin
- urine urobilinogen
- ALT/AST
- ALP/GGT
1) increase
2) increase
3) increase
4) increase
5) normal or mild elevation
what would happen to each of the following in cholestatic/post-hepatic jaundice:
- unconjugated bilirubin
- conjugated bilirubin
- urine urobilinogen
- ALT/AST
- ALP/GGT
1) normal
2) increase
3) decrease
4) normal or mild elevation
5) increase
what are pre-hepatic causes of jaundice (increase in unconjugated bilirubin)
haemolytic anaemia (autoimmune or drug induced)
sickle cell disease
thalassemia
G6PD deficiency
pernicious anaemia
causes of hepatic jaundice (a mix of both conjugated and unconjugated bilirubin)
hepatocellular:
- viral hepatitis (A, B, C, D, E)
- alcoholic hepatitis
- NASH
- cirrhosis
metabolic disorders:
- Gilbert’s syndrome ( AR hereditary condition in which body lacks enzyme that conjugates bilirubin leading to increased levels of UC bilirubin)
- Crigler najjar syndrome (congenital AR condition in which body lacks enzyme responsible for glucuronidation of bilirubin
Drug induced liver injury
liver tumours or mets
autoimmune hepatitis
causes of post-hepatic jaundice
- gallstones
- biliary strictures
- cholangiocarcinomas
- pancreatic cancer
- primary sclerosing cholangitis
- parasitic infections such liver flukes
what is the pathway for heme metabolism
old RBCs are engulfed by kuppfer cells
- through lysosomal action heme is broken down into biliverdin and then bilirubin.
- bilirubin is released from maropahes into circulation where it binds to albumin for transport into liver
- processed by liver to undergo conjugation reactions (glucoronic acid)
- after conjugation becomes water soluble so is excreted via bile into bowel and as faeces( stercobilogens( and urine (urobilogens)
what imaging is used for investigating pancreatic cancer
<40 jaundice = USS
> 40 jaundice painless = CT r/o malignancy
> jaundice painful = USS
adjunct imaging:
for stones: MRCP + ERCP
cancer staging = CT, ERCP etc
fibroscan
pancreatic cancer tumour marker
CA 19.9
what is the 5 year prognosis for those with pancreatic cancer
stage 1 - 14%
stage 5 <1%
what is the purpose of the cancer MDT
Specialists for different tumour types
Patients provided with information and support
Communication between diagnostic, primary, secondary & tertiary care
Improve outcomes and compliance with guidelines
Enter patients into high quality research projects
Holistic approach to patients and their cancer
