Hepato-biliary-pancreatic neoplasia Flashcards
How common is hepatocellular cancer?
third most common cause of cancer worldwide
What is the commonest cause of HCC worldwide?
chronic hepatitis B
What is the most common cause of hepatocellular carcinoma in Europe?
chronic hepatitis C
What is the main risk factor for developing hepatocellular carcinoma?
liver cirrhosis, e.g. secondary to hepatitis B and C, alcohol, haemochoromatosis, and primary biliary cirrhosis
What are 12 causes of liver cirrhosis which can predispose to developing HCC?
- Hepatitis B+C
- Alcohol
- Haemochromatosis
- Primary biliary cholangitis
- Alpha-1 antitrypsin deficiency
- Hereditary tyrosinosis
- Glycogen storage disease
- Aflatoxin
- Drug: oral contraceptive pill, anabolic steroids
- Porphyria cutanea tarda
- Male sex
- Diabetes mellitus/ metabolic syndrome
When in the course of hepatocellular carcinoma does the disease tend to present?
late
What are 7 possible clinical features of a patient with hepatocellular carcinoma?
- Jaundice
- Ascites
- Right upper quadrant pain
- Hepatomegaly
- Pruritus
- Splenomegaly
- Could present as decompensation in a patient with chronic liver disease
What tumour marker may be raised in hepatocellular carcinoma?
AFP (alpha feto protein)
How is screening performed for hepatocellular carcinoma?
ultrasound with/without alpha fetoprotein
What are 2 examples of high risk groups who should be considered for screening for hepatocellular carcinoma?
- Patients with liver cirrhosis secondary to hepatitis B & C or haemochromatosis
- Men with liver cirrhosis secondary to alcohol
What are 5 management options for hepatocellular carcinoma?
- Early disease: surgical resection
- Liver transplantation
- Radiofrequency ablation
- Transarterial chemoembolisation
- Sorafenib: multikinase inhibitor
At what point in the disease course is pancreatic cancer often diagnosed and why?
late, tends to present in a non-specific way
What type of tumour is the vast majority of pancreatic cancers?
adenocarcinomas - 80%
Where in the pancreas does the most common type of pancreatic cancer occur?
head of pancreas (adenocarcinomas)
What are 8 things that pancreatic cancer is associated with?
- Increasing age
- Smoking
- Diabetes
- Chronic pancreatitis (alcohol doesn’t appear an independent risk factor though)
- Hereditary non-polyposis colorectal carcinoma
- Multiple endocrine neoplasia
- BRCA2 gene
- KRAS gene mutation
What is the classic presentation of pancreatic cancer?
painless jaundice; pale stools, dark urine, pruritus
cholestatic LFTs
What does Courvoisier’s law state in regards to pancreatic cancer?
in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
What are 6 less common/atypical features of the presentation of pancreatic cancer?
- Anorexia
- Weight loss
- Epigastric pain
- Loss of exocrine function: steatorrhoea
- Loss of endocrine function: diabetes mellitus
- Atypical back pain
What is a sign seen in pancreatic cancer that is more common than with other cancers?
migratory thrombophlebitis - Trousseau’s sign of malignancy
thrombophlebitis that travels/comes back in different part of body, often from one leg to other
What are 2 types of cancers that Trousseau’s sign (migratory thrombophlebitis) is most commonly seen in?
pancreatic and lung
What are 2 key investigations to perform to diagnose pancreatic cancer?
- Ultrasound
- High reslution CT scanning
What is the investigation of choice if a diagnosis of pancreatic cancer is suspected?
high-resolution CT scanning
What may be seen on imaging in pancreatic cancer?
double duct sign: presence of simultaneous dilatation of the common bile duct and pancreatic ducts
What is the 5 year survival rate like of pancreatic cancer?
extremely poor: <5%
What is Courvoisier’s sign in pancreatic cancer?
painless palpable gallbladder with jaundice
What are 3 sites where pancreatic cancer metastasises to?
lung, liver, bowel
(haemoptysis, jaundice, constipation)
What are LFTs likely to show in pancreatic cancer?
raised bilirubin and raised ALP
What are the limitations of using ultrasound to investigate suspected pancreatic cancer?
good at detecting tumours within head of pancreas but poorer for tumours in body or tail and in determining early disease - so normal US doesn’t rule out pancreatic carcinoma
What are 2 types of imaging that can give further information in pancreatic cancer (in addition to US and HRCT)
MRCP: information about biliary ducts but cannot show extension of tumour
Endoscopic USS: invasive test which can detect small lesions and can be used for biopsies
What is the only potentially curative treatment for pancreatic cancer?
resection of tumour
What proportion of patients will present with resectable pancreatic cancer?
only 15-20%