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Z - Cancer Care Old > Hepatobiliary Cancer > Flashcards

Hepatobiliary Cancer Flashcards

1
Q

Describe the epidemiology of hepatocellular carcinoma

A

It is one of the most common cancers worldwide, but is less common in the UK

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2
Q

What % of cancer diagnoses in the UK are hepatocellular carcinoma

A

1%

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3
Q

What % of hepatobiliary cancer diagnoses in the UK are hepatocellular carcinoma

A

40%

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4
Q

What does the distribution of hepatocellular carcinoma closely align with?

A

That of chronic HBV infection

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5
Q

Is hepatocellular carcinoma more common in men or women?

A

4-8x more common in men

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6
Q

When are most diagnoses of hepatocellular carcinoma made?

A

In the 5th or 6th decade of life

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7
Q

What does the age of diagnosis of hepatocellular carcinoma correspond with?

A

The time taken for liver cirrhosis to develop

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8
Q

What kind of liver cancer is more common in the UK?

A

Secondary metastasis to the liver, rather than primary tumours

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9
Q

Which cancers in particular metastasise to the liver?

A
  • Colon
  • Pancreas
  • Stomach
  • Breast
  • Lung
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10
Q

What % of hepatobiliary cancer in the UK is cholangiocarcinoma?

A

More than 50%

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11
Q

Where does cholangiocarcinoma affect?

A

The bile ducts inside or outside the liver

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12
Q

What are some rarer types of hepatobiliary cancer?

A
  • Angiosarcoma

- Hepatoblastoma

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13
Q

Who does hepatoblastoma affect?

A

Children under 3 years

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14
Q

What infection is HCC associated with?

A

Chronic hepatitis B or C

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15
Q

What % of HCC cases worldwide are associated with chronic hepatitis B or C infection?

A

More than 70%

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16
Q

What is the lifetime risk of developing HCC in an individual infected with HBV?

A

40%

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17
Q

Is the lifetime risk of developing HCC higher in HBV or HCV infection?

A

Thought to be higher in HCV

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18
Q

Other than chronic hepatitis infection, what are the risk factors for hepatocellular carcinoma?

A
  • Alcoholic cirrhosis
  • Aflatoxin
  • Primary biliary cirrhosis
  • Inherited metabolic disorders
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19
Q

What is aflatoxin?

A

A fungal contaminant of crops in tropical regions

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20
Q

What inherited metabolic disorders are a risk factors for hepatocellular carcinoma?

A
  • Haemochromatosis

- Tyrosinaemia

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21
Q

What is the lifetime risk of developing cholangiocarcinoma for individuals with primary sclerosing cholangitis?

A

10-20%

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22
Q

Other than primary sclerosing cholangitis, what condition is associated with cholangiocarcinoma?

A

Infection with liver flukes

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23
Q

What does infection with liver flukes being implicated in cholangiocarcinoma account for?

A

The higher prevalence of cholangiocarcinoma in Southeast Asia

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24
Q

What are the symptoms of early stage HCC?

A

It is often asymptomatic, or has vague symptoms such as weight loss, nausea, and lethargy.
There may also be pain

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25
Where might the pain be in HCC?
Abdominal pain in RUQ | Right shoulder pain
26
What causes the abdominal pain in the RUQ in HCC?
Stretching of the liver capsule
27
What causes the pain to the right shoulder in HCC?
Referred pain as the enlarging liver irritates the diaphragm
28
When might HCC present with obstructive jaundice?
When the tumour obstructs a bile duct
29
What are the late presenting features of HCC?
Those of liver failure
30
What do the late presenting features of HCC depend on?
The functional reserve of the liver
31
When is the functional reserve of the liver often depleted?
In those with cirrhosis
32
What are acute onset abdominal pain and distention features of in liver failure?
Intraperitoneal haemorrhage
33
What is the significance of intraperitoneal haemorrhage in liver failure?
It can be life threatening
34
What are the early features of cholangiocarcinoma?
- Jaundice - Pruritis - Hepatomegaly
35
What are the later signs and symptoms of cholangiocarcinoma?
- RUQ pain - Weight loss - Palpable gall bladder
36
What should be looked for in the face in hepatobiliary cancer?
- Jaundice | - Fetor hepaticus
37
What should be looked for on the chest in hepatobiliary cancer?
- Gynaecomastia - Breast atrophy - Spider naevi
38
What should be looked for on the hands in hepatobiliary cancer?
- Clubbing - Palmar erythema - Leukonychia - Asterixis (liver flap)
39
What are the systemic presentations of hepatobiliary cancer?
- Weight loss - Fever - Malaise - Signs of liver failure
40
What signs of liver failure may be seen in hepatobiliary cancer?
- Ascites - Jaundice - Itching - Anasarca - Nausea - Watery diarrhoea - Easy bruising - Loss of body hair
41
What is anasarca?
Extreme generalised oedema
42
What may be found on neurological examination in hepatobiliary cancer?
Signs of hepatic encephalopathy
43
What are the signs of hepatic encephalopathy?
- Confusion - Irritability - Coma
44
What may be found on respiratory examination in hepatobiliary cancer?
- Dullness to percussion - Absent breath sounds at right base - Signs of lung mets
45
What should be looked for on skeletal examination in hepatobiliary cancer?
Localised bone pain, indicating bone metastasis
46
What may be found on genital examination in hepatobiliary cancer?
Testicular atrophy
47
What are the paraneoplastic manifestations of hepatobiliary cancer?
- Hypoglycaemia - Hypercalcaemia - Hypercholesterolaemia - Polycythaemia - Dermatomyositis
48
What is the 5 year survival rate of cholangiocarcinoma?
5%
49
What is the 5 year survival rate of gallbladder cancer?
5%
50
What is the 5 year survival rate of hepatocellular carcinoma?
5%
51
What is the 5 year survival rate of periampullary cholangiocarcinoma?
50%
52
What initial investigations should be done in hepatobiliary cancer?
- FBC - Liver and renal function - CXR - Ultrasound assessment of the liver
53
What kind of cancer is a lesion identified in a cirrhotic liver often?
HCC
54
What is alpha fetoprotein (AFP)?
A serum tumour marker
55
What % of cancers of HCC is AFP raised in?
75%
56
What combination of investigation findings is diagnostic for HCC?
Ultrasound lesion >2cm and raised AFP
57
What other tumour markers may be useful in monitoring disease in hepatobiliary cancer?
- CEA | - CA19-9
58
Why may CT be useful in hepatobiliary cancer?
It can determine the extent of spread
59
Why may MRI with contrast and angiography be useful in hepatobiliary cancer?
It provides the detail required to inform the most effective treatment
60
Is liver biopsy used in hepatobiliary cancer?
It may be necessary
61
What is the problem with liver biopsy in hepatobiliary cancer?
It risks seeding tumour cells outside the liver
62
What is often found on LFTs in cholangiocarcinoma?
Raised conjugated bilirubin
63
What tumours markers may be raised in cholangiocarcinoma?
- CEA | - CA19-9
64
Why is ultrasound imaging useful in cholangiocarcinoma?
It will reveal the level of the obstruction
65
Why is MRI cholangiography (MRCP) useful in cholangiocarcinoma?
It provides a clear picture of the biliary tree
66
What is the advantage of surgery in HCC?
It offers the only chance of cure
67
What is the disadvantage of surgery in HCC?
It is only possible in a minority of patients
68
Why is surgery for HCC only available in a minority of patients?
Because success is limited by background cirrhosis
69
How much of the liver can be resected in an otherwise healthy liver and still regenerate?
Up to 80%
70
What is the problem with liver resection in a cirrhotic patient?
Even a small resection can induce liver failure in a cirrhotic patient
71
What is the preferred treatment for HCC in a cirrhotic patient?
Liver transplant
72
What size HCC tumour can be treated with liver transplant in a cirrhotic patient?
<3cm
73
What is the preferred treatment for HCC in a patient with HCV?
Liver transplant
74
Why is liver transplant the preferred treatment for HCC in a patient with HCV?
Because it is likely that HCC will recur in these patients
75
What management options can be considered for HCC when surgical resection is not an option?
- Hepatic artery infusion chemotherapy - Hepatic embolisation - Radiofrequency ablation
76
What happens in hepatic artery infusion chemotherapy for HCC?
Chemotherapy agents are injected into the hepatic artery for local effect
77
What happens in hepatic embolisation for HCC?
An embolising agent is injected to cut off the blood supply to the tumour
78
What is the mechanism of action of radiofrequency ablation in HCC?
It can be used to induce tumour necrosis
79
What is radiofrequency ablation best for in HCC?
More superficial lesions
80
When might chemotherapy be appropriate in HCC?
In advanced disease
81
What agents have been used in chemotherapy for HCC?
- Mitoxantrone - Gemcitabine - Doxorubicin
82
What is the problem with chemotherapy for HCC?
The cancer is relatively resistant to most agents
83
What is sorafenib?
A receptor tyrosine kinase inhibitor
84
What does sorafenib do?
Inhibits tumour cell proliferation and angiogenesis
85
How effective is sorafenib in HCC?
It produces a median overall survival of 9.2 months, and median time to progression of 5.5 months
86
What treatment is required for HCC patients with obstructive jaundice?
Stenting of the biliary tree
87
What management can be used if cholangiocarcinoma is detected in its early stages?
The bile ducts can be resected
88
What is the problem with cholangiocarcinoma?
These tumours tend to present late when symptoms appear
89
What management can be used if cholangiocarcinoma has spread to the liver?
It can be resected, or a Whipple's procedure can be performed
90
What happens in a Whipples procedure?
Part of the stomach, duodenum, pancreas, and gallbladder are removed
91
What management can be used for cholangiocarcinoma if surgery is not possible?
A stent can be inserted to allow bile to flow past the obstruction
92
Are tumours of the biliary tree sensitive to chemotherapy?
Yes, very much so
93
What chemotherapy agents produce benefit in cholangiocarcinoma?
- Gemcitabine | - Cisplatin
94
What is the 5 year survival rate for patients with operable liver cancer, when management involves a partial liver resection
30%
95
What is the 5 year survival rate for patients with liver cancer who receive a liver transplant?
75%
96
What is the median survival for liver cancer patients who are not considered for curative therapy?
6-7 months
97
What is the 5 year survival of liver cancer not considered for curative therapy?
5%
98
What is the 5 year survival of cholangiocarcinoma?
5%
99
What kind of cholangiocarcinoma has the worst prognosis?
Intrahepatic cholangiocarcinoma
100
What is the median survival of intrahepatic cholangiocarcinoma?
12-18 months after diagnosis
101
What is the most important itervention for hepatocellular carcinoma?
The development of an effective vaccination programme against hepatitis B, especially in geographical locations where the virus in endemic

Z - Cancer Care Old (28 decks)

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