Hepato-biliary: Liver Cancer Flashcards
What liver disease is liver cancer assocaited with
- Cirrhosis
- Secondary to chronic HBV and HCV
- Alcoholic liver disease
- Metabolic
- Haemachromatosis
- Alpha-1-antitrypsin deficiency
- Autoimmune liver disease
- Autoimmune hepatitis
- PBC
What tymour makrer is associated with liver cancer
AFP
What proportion of liver tumours are metastases?
90%
What are common sites for liver mets to spread from?
- Stomach
- Colon
- Pancreas
- Bone - leukaemia/lymphoma
- Carcinoid tumours
- Breast
- Bronchus
What are symptoms of liver tumours?
- Fever
- Malaise
- Anorexia
- Decreased weight
- RUQ pain
- Jaundice - late unless cholangiocarcinoma
What are signs that someone may have a luiver tumour?
- Hepatomegaly
- Signs of chronic liver disease +/- evidence of decompensation
- Abdominal masses
- Liver bruit
- Cachexia
What are causes of hepatocellular carcinoma?
- HBV
- HCV
- Cirrhosis - alcohol, haemochromatosis, PBC
- NAFLD
- Anabolic steroids
- Aflatoxin
What sex does HCC occur most commonly in?
Males
What investigations would you consider doing if you suspected liver cancer?
- Bloods - FBC, U+E’s, Clotting, LFTs, hepatitis serology, alpha-fetoprotein
- Imaging - US/CT, MRI, ERCP (if chlangiocarcinoma suspected),
- Other - biopsy
If secondary mets found, perform CXR/Mammography/colonoscopy/CT/MRI/marrow biopsy when looking for primary
What specific type of imaging would you use in suspected HCC?
3-phase CT - delayed wash-out in a suspected mass
What might you find on FBC in someone with HCC?
- Microcytic anaemia - due to bleeding in e.g. alcoholic liver cirrhosis
- Thrombocytopenia - indicative of portal hypertension due to cirrhosis
What might you see on U+E’s in someone with HCC?
- Hyponatraemia - volume overload/diuretic use
- Increased Urea - secondary to prerenal azotaemia, AKI, cCKD, or hepatorenal syndrome.
What might you see on LFTs in someone with liver cancer?
- ALT/AST increased
- ALP increased
- Bilirubin increased
- Low albumin
What might you find on hepatitis screening in someone with suspected HCC?
Hepatitis B/C
What are used as screening for high risk groups?
AFP and US
(Pateints with liver cirrhosis secondary to HBV, HCV, haemachromatosis)
(Men with cirrhosis secondary to alcohol)
What tumour marker is used in the detection of HCC?
Alpha-fetoprotein
What imaging would you use first in someone who you suspected had liver cancer?
US of liver - poorly defined margins, and course, irregular internal echoes
Hwo would you manage HCC?
Early disease
- Consider resection - if < 3cm
- Consider Liver transplantation +/- TACE +/- RFA
Intermediate disease
- Transcatheter arterial chemoembolization (TACE)
- Percutaneous ablation
Advanced
- Chemotherapy
What chemotherapy/radiotherpay is sued in liver cancer?
- Chemotherapy:
- Tyrosine kinase inhibitors
- Trans-arterial chemoembolization
- Systemic chemotherapy
- Radiotherapy
- Radiofreqeuncy ablation
What are types of malignant primary liver cancers?
- HCC
- Cholangiocarcinoma
- Angiosarcoma
- Hepatoblastoma
- GIST
- Fibrosarcoma
Where in the biliary tree can cholangiocarcinoma occur?
Intra (6%)
Extrahepatic
- Hilor (67%)
- Distal (29%)
What are causes of cholangiocarcinoma?
- Liver Flukes
- Alcoholic liver disease
- PSC and hence IBD
- Choledocal cyst
- CAroli’s disease
- HBV/HCV
- Diabetes
- Toxins
What are clinical features of cholangiocarcinoma?
- Fever
- Abdo Pain
-
Progressive obstructive malignant jaundice – no pain
- Conjugated hperbilirubinaemia
- Pruritis
- Weight loss
- Persistant biliary colic symptoms
What sign is positive in cholangiocarcinoma?
Courvoisier sign
How are extrahepatic cholangiocarcinomas divided in terms of location?
- Perihilar
- Distal
What is the most common type of cholangiocarcinoma; intra- or extra-hepatic?
Extra-hepatic
What investigations would you consider doing in someone who you suspected might have cholangiocarcinoma?
- Bloods - LFTs, PT, serum CA 19-9/CA-125
- Abdo ultrasound - GOLD STANDARD
- Consider CT/MRI abdo/MRCP/ERCP
- Consider PET scan
- Biopsy and cytology
How would you manage someone with cholangiocarcinoma?
- Surgical resection - only curative option
- Palliative interventions
What palliative procedures can be done to paliate someone with chlangiocarcinoma?
- Surgical bypass
- Stenting (Percutaneous vs Endoscopic)
- Palliative radiotherapy
- Chemotherapy
- PDT
- Liver transplant (not standard)
What are examples of benign liver cancers?
- Haemangiomas
- Adenomas
- Cysts
- Fibroma
- Benign GIST
- Focal nodular hyperplasia
Prognosis of liver cancer
6-12months
