Hepatobiliary neoplasia

Question 1

List factors associated with increased risk of HCC

Answer 1

Male
Low SES
cirrhosis (viral or toxin induced)
obesity/ NAFLD
aflatoxin

Question 2

What is the underlying pathophysiology of HCC?f

Answer 2

Chronic inflammation leading to replicative error

Question 3

There is synergy in patients coinfected with ____ and _____ - the risk of HCC in these patients is greater than the individual risks combined

Answer 3

HCC and HBV

Question 4

There should be a high degree of suspicion for _______ in patients with chronic liver disease and sudden decompensation

Answer 4

hepatocellular carcinoma

Question 5

What are the signs of HCC paraneoplastic syndrome?

Answer 5

fevers, hypoglycemia, diarrhea, erythrocytosis, electrolyte disturbance

Question 6

Why do patients with HCC rarely present with metastatic disease?

Answer 6

Most succumb to the sequelae of local invasion and liver failure prior to the development of disseminated metastases

Question 7

How is HCC diagnosed

Answer 7

• elevated alpha fetoprotein
• abnormal ultrasound/ MRI
• on MRI with contrast: early arterial enhancement with delayed washout (diagnostic)

Question 8

HCC is one of few tumors that does not absolutely require a _____ to make a diagnosis

Answer 8

tissue biopsy

Question 9

If a patient diagnosed with HCC is determined to have a resectable tumor, the next step is to determine:

Answer 9

the volume of functional liver that would be left behind and remaining liver function

Question 10

Patients diagnosed with HCC with Child-Pugh C cirrhosis should be referred for

Answer 10

transplant evaluation

Question 11

What therapies are useful in a patient with HCC who is not a candidate for resection or transplant?

Answer 11

• chemoembolization: accessing hepatic arterial supply to inject chemotherapy or radiation, or a bland fat embolus to limit the arterial supply to the tumor
• ablation: delivery of thermal injury to the tumor (tumor must be away from major vessels)
• sorafenib, only marginally effective
• best supportive care

Question 12

What chemotherapy drug prolongs median survival in HCC?

Answer 12

Sorafenib

still only 11 months survival

Question 13

What are risk factors for development of biliary tract cancer?

Answer 13

• PSC
• choledochal cysts, associated with liver flukes
• gallstones

Question 14

Describe the presentation of biliary tract cancers

Answer 14

Jaundice, fatigue, malaise, RUQ pain, palpable gallbladder (Courvoisier’s sign)

Question 15

A liver mass with elevated _______ is more consistent with biliary tract cancer than hepatocellular carcinoma

Answer 15

CA 19-9

Question 16

______ is the only truly curative measure for biliary tract cancer

Answer 16

Surgical resection
radical cholecystectomy: removal of gallbladder and all associated lymph nodes, segments IV and V of liver
poor survival even with successful resection

Question 17

What chemotherapy regimen can be used in biliary tract cancers?

Answer 17

Gemcitabine plus cisplatin

Question 18

What genetic syndromes increase the risk of HCC?

Answer 18

Alpha 1 antitrypsin deficiency

hereditary hemochromatosis

Question 19

If a person had chronic hepatitis B which was successfully treated, what should they be told about their risk of HCC?

Answer 19

Significantly reduced risk but not eliminated

Relative risk decreased by 60%

Question 20

Describe the presentation of HCC

Answer 20

• jaundice, ascites, sequelae of portal HTN- caput medusae, spider angiomata, peripheral wasting
• changes in LFTs, AFP

Question 21

What is the preferred imaging modality to diagnose HCC?

Answer 21

MRI>CT because tumors tend to involve arterial system, HCC arterially supplied (rather than portal vein supply)

Question 22

For locally confined HCC, _______ can be curative

Answer 22

partial hepatectomy

Question 23

Why are post-operative (partial hepatectomy) recurrence rates of HCC so high?

Answer 23

Risk factors are still present- the entire liver was subject to toxins, damage not just the resected part
recurrence likely represents new primary tumor, not metastasis

Question 24

Describe the Milan criteria for liver transplant in a patient with HCC

Answer 24

• 1 tumor less than 5 cm
• 3 tumors all less than 3 cm
• no metastatic disease
• no vascular invasion
• patients can move to the top of the line for bad MELD score

Question 25

True or false: liver transplant improves survival in cholangiocarcinoma vs resection alone

Answer 25

True, but results may be misleading based on strict patient selection