Hepatobiliary cancers: liver and pancreas

Question 1

What is primary liver cancer?

Answer 1

Primary liver cancer is cancer that originates in the liver.

Question 2

What are the 2 types of primary liver maligant tumours?

Answer 2

1. Hepatocellular carcinoma (HCC) - 80%
2. Cholangiocarcinoma - 20%

Question 3

What are the 2 types of primary liver benign tumours?

Answer 3

1. Haemangioma
2. Hepatic adenoma

Question 4

Define hepatocellular carcinoma.

Answer 4

The most common type of primary liver cancer in adults and is currently the most common cause of death in people with cirrhosis.

Question 5

Give 3 risk factors for HCC.

Answer 5

1. Carriers of HBV and HCV (higher risk)
2. Liver cirrhosis due to Alcohol
3. Liver cirrhosis due to NAFLD
4. Liver cirrhosis due to other chronic liver diseases e.g. haemochromatosis
5. Males (90%)

Question 6

Explain the pathophysiology of HCC.

Answer 6

1. Arises from the liver parenchyma.
2. Tumour is either single or occurs as multiple nodules throughout the liver.
3. Consists of cells resembling hepatocytes.
4. Metastasises via the hepatic or portal veins to the lymph nodes, bones and lungs.

Question 7

Give 4 liver-related symptoms for HCC.

Answer 7

1. Jaundice
2. Ascites
3. HE
4. Pruritus (itching)

Question 8

Give 4 non-specific symptoms for HCC.

Answer 8

1. Weight Loss
2. Fatigue
3. Weakness
4. Nausea + vomiting

Question 9

Investigations for HCC diagnosis.

Answer 9

1. 1st Line: Abdominal Ultrasound
2. CT to confirm (GOLD STANDARD)
3. Serum Alpha-Fetoprotein (AFP) = tumour marker for HCC

Question 10

Management of HCC.

Answer 10

Poor Prognosis
1. Surgical resection of tumour/isoalted lesion
2. Liver Transplant (if isolated to the liver) = only chance for cure

Question 11

Define cholangiocarcinoma.

Answer 11

AKA bile duct cancer - cancer of the biliary tree:
A type of cancer that forms in the bile ducts.

Question 12

Give 4 risk factors for cholangiocarcinoma.

Answer 12

1. Associated with infestation with parasitic worms (flukes) e.g. Clonorchis
   sinensis
2. Biliary cysts
3. Chronic Viral Hep B/C
4. Liver cirrhosis
5. Inflammatory bowel disease e.g. UC and Crohn’s

Question 13

Briefly describe the pathophysiology of cholangiocarcinomas.

Answer 13

Arise from biliary tree – usually adenocarcinomas.
Usually slow-growing.

Question 14

Give 3 signs of clinical presentation for cholangiocarcinoma.

Answer 14

Signs of cholecstasis:
1. Jaundice
2. Pale Stools
3. Dark Urine
4. Pruritus
5. Courvoisier’s Sign

Question 15

Give 3 non-specific symptoms for cholangiocarcinoma.

Answer 15

1. Weight Loss
2. Fatigue
3. Weakness
4. Nausea + vomiting

Question 16

Investigations for cholangiocarcinoma.

Answer 16

1. 1st line – Abdominal Ultrasound and CT
2. ERCP – used to take biopsies - Gold Standard
3. CA19-9 – Tumour marker for Cholangiocarcinoma
4. LFTs – raised bilirubin and ALP

Question 17

Management of cholangiocarcinoma.

Answer 17

1. Surgical resection is rarely possible and patients die within 6 months.
2. Liver transplant is contraindicated.
3. ERCP used to place a stent in the blocked duct = relieves symptoms.

Question 18

What is the most common benign tumour in the liver?

Answer 18

Haemangioma

Question 19

What is the most common liver tumour?

Answer 19

A secondary (metastatic) tumour

Question 20

Define pancreatic cancer.

Answer 20

Pancreatic cancer arises when cells in the pancreas, a glandular organ behind the stomach, begin to multiply out of control and form a mass.

These cancerous cells have the ability to invade other parts of the body.

The most common one is pancreatic adenocarcinomas.

Question 21

Give 3 risk factors for pancreatic cancer.

Answer 21

1. Smoking (associated with a 2-fold risk increase)
2. T2DM
3. Obesity
4. Excess alcohol intake
5. Chronic pancreatitis
6. Genetic mutation predisposing to pancreatic cancer
   
   • Presence of PRSS-1 mutation
7. Fx
8. Old age - 60+

Question 22

Pathophysiology of pancreatic adenocarcinomas.

Answer 22

Adenocarcinoma typically in the head of the pancreas and can compress bile ducts.

Question 23

Give 4 key signs of pancreatic cancer.

Answer 23

1. Obstructive/Painless Jaundice
2. Pale stools
3. Dark urine
4. Generalised itching (pruritus)

Also:
5. Weight loss
6. Worsening of T2DM (or new onset)
7. Can get epigastric pain that radiates to back (body and tail)

Question 24

Which 2 named signs can be observed for pancreatic cancer?

Answer 24

1. Courvoisier’s Sign
   - Palpable gallbladder + jaundice = not due to gallstones
   - The cause is usually cholangiocarcinoma or pancreatic cancer.
2. Trousseau’s sign of malignancy
   - Refers to migratory thrombophlebitis as a sign of malignancy, particularly pancreatic adenocarcinoma
   - Thrombophlebitis is where blood vessels become inflamed with an associated blood clot (thrombus) in that area.
   - Migratory refers to the thrombophlebitis reoccurring in different locations over time.

Question 25

Investigations for pancreatic cancer.

Answer 25

1. Abdominal Ultrasound
2. CT of pancreas / CT TAP
   - Identifies mass and helps with staging of cancer
   - GOLD STANDARD
3. Tumour marker – CA19-9
   - Not diagnostic but helps with monitoring progression

Question 26

Management for pancreatic cancer.

Answer 26

1. Management will be decided at a hepatobiliary (HPB) MDT meeting.
2. Surgery to remove tumour
   - Total pancreatectomy
   - Distal pancreatectomy
   - Pylorus-preserving pancreaticoduodenectomy (PPPD) (modified Whipple procedure)
   - Radical pancreaticoduodenectomy (Whipple procedure)
3. Palliative treatment:
   - Stents inserted to relieve the biliary obstruction
   - Surgery to improve symptoms (e.g., bypassing the biliary obstruction)
   - Palliative chemotherapy (to improve symptoms and extend life)
   - Palliative radiotherapy (to improve symptoms and extend life)
   - End of life care with symptom control