Hepato-biliary: Liver Cancer

Question 1

What liver disease is liver cancer assocaited with

Answer 1

• Cirrhosis
  
  • Secondary to chronic HBV and HCV
  • Alcoholic liver disease
  • Metabolic
    
    • Haemachromatosis
    • Alpha-1-antitrypsin deficiency
  • Autoimmune liver disease
    
    • Autoimmune hepatitis
    • PBC

Question 2

What tymour makrer is associated with liver cancer

Answer 2

AFP

Question 3

What proportion of liver tumours are metastases?

Answer 3

90%

Question 4

What are common sites for liver mets to spread from?

Answer 4

• Stomach
• Colon
• Pancreas
• Bone - leukaemia/lymphoma
• Carcinoid tumours
• Breast
• Bronchus

Question 5

What are symptoms of liver tumours?

Answer 5

• Fever
• Malaise
• Anorexia
• Decreased weight
• RUQ pain
• Jaundice - late unless cholangiocarcinoma

Question 6

What are signs that someone may have a luiver tumour?

Answer 6

• Hepatomegaly
• Signs of chronic liver disease +/- evidence of decompensation
• Abdominal masses
• Liver bruit
• Cachexia

Question 7

What are causes of hepatocellular carcinoma?

Answer 7

• HBV
• HCV
• Cirrhosis - alcohol, haemochromatosis, PBC
• NAFLD
• Anabolic steroids
• Aflatoxin

Question 8

What sex does HCC occur most commonly in?

Answer 8

Males

Question 9

What investigations would you consider doing if you suspected liver cancer?

Answer 9

• 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

Question 10

What specific type of imaging would you use in suspected HCC?

Answer 10

3-phase CT - delayed wash-out in a suspected mass

Question 11

What might you find on FBC in someone with HCC?

Answer 11

• Microcytic anaemia - due to bleeding in e.g. alcoholic liver cirrhosis
• Thrombocytopenia - indicative of portal hypertension due to cirrhosis

Question 12

What might you see on U+E’s in someone with HCC?

Answer 12

• Hyponatraemia - volume overload/diuretic use
• Increased Urea - secondary to prerenal azotaemia, AKI, cCKD, or hepatorenal syndrome.

Question 13

What might you see on LFTs in someone with liver cancer?

Answer 13

• ALT/AST increased
• ALP increased
• Bilirubin increased
• Low albumin

Question 14

What might you find on hepatitis screening in someone with suspected HCC?

Answer 14

Hepatitis B/C

Question 15

What are used as screening for high risk groups?

Answer 15

AFP and US

(Pateints with liver cirrhosis secondary to HBV, HCV, haemachromatosis)

(Men with cirrhosis secondary to alcohol)

Question 16

What tumour marker is used in the detection of HCC?

Answer 16

Alpha-fetoprotein

Question 17

What imaging would you use first in someone who you suspected had liver cancer?

Answer 17

US of liver - poorly defined margins, and course, irregular internal echoes

Question 18

Hwo would you manage HCC?

Answer 18

Early disease

• Consider resection - if < 3cm
• Consider Liver transplantation +/- TACE +/- RFA

Intermediate disease

• Transcatheter arterial chemoembolization (TACE)
• Percutaneous ablation

Advanced

• Chemotherapy

Question 19

What chemotherapy/radiotherpay is sued in liver cancer?

Answer 19

• Chemotherapy:
  
  • Tyrosine kinase inhibitors
  • Trans-arterial chemoembolization
  • Systemic chemotherapy
• Radiotherapy
  
  • Radiofreqeuncy ablation

Question 20

What are types of malignant primary liver cancers?

Answer 20

• HCC
• Cholangiocarcinoma
• Angiosarcoma
• Hepatoblastoma
• GIST
• Fibrosarcoma

Question 21

Where in the biliary tree can cholangiocarcinoma occur?

Answer 21

Intra (6%)

Extrahepatic

• Hilor (67%)
• Distal (29%)

Question 22

What are causes of cholangiocarcinoma?

Answer 22

• Liver Flukes
• Alcoholic liver disease
• PSC and hence IBD
• Choledocal cyst
• CAroli’s disease
• HBV/HCV
• Diabetes
• Toxins

Question 23

What are clinical features of cholangiocarcinoma?

Answer 23

• Fever
• Abdo Pain
• Progressive obstructive malignant jaundice – no pain
  
  • Conjugated hperbilirubinaemia
• Pruritis
• Weight loss
• Persistant biliary colic symptoms

Question 24

What sign is positive in cholangiocarcinoma?

Answer 24

Courvoisier sign

Question 25

How are extrahepatic cholangiocarcinomas divided in terms of location?

Answer 25

• Perihilar
• Distal

Question 26

What is the most common type of cholangiocarcinoma; intra- or extra-hepatic?

Answer 26

Extra-hepatic

Question 27

What investigations would you consider doing in someone who you suspected might have cholangiocarcinoma?

Answer 27

• 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

Question 28

How would you manage someone with cholangiocarcinoma?

Answer 28

• Surgical resection - only curative option
• Palliative interventions

Question 29

What palliative procedures can be done to paliate someone with chlangiocarcinoma?

Answer 29

• Surgical bypass
• Stenting (Percutaneous vs Endoscopic)
• Palliative radiotherapy
• Chemotherapy
• PDT
• Liver transplant (not standard)

Question 30

What are examples of benign liver cancers?

Answer 30

• Haemangiomas
• Adenomas
• Cysts
• Fibroma
• Benign GIST
• Focal nodular hyperplasia

Question 31

Prognosis of liver cancer

Answer 31

6-12months