Hepatobiliary neoplasia Flashcards
List factors associated with increased risk of HCC
Male Low SES cirrhosis (viral or toxin induced) obesity/ NAFLD aflatoxin
What is the underlying pathophysiology of HCC?f
Chronic inflammation leading to replicative error
There is synergy in patients coinfected with ____ and _____ - the risk of HCC in these patients is greater than the individual risks combined
HCC and HBV
There should be a high degree of suspicion for _______ in patients with chronic liver disease and sudden decompensation
hepatocellular carcinoma
What are the signs of HCC paraneoplastic syndrome?
fevers, hypoglycemia, diarrhea, erythrocytosis, electrolyte disturbance
Why do patients with HCC rarely present with metastatic disease?
Most succumb to the sequelae of local invasion and liver failure prior to the development of disseminated metastases
How is HCC diagnosed
- elevated alpha fetoprotein
- abnormal ultrasound/ MRI
- on MRI with contrast: early arterial enhancement with delayed washout (diagnostic)
HCC is one of few tumors that does not absolutely require a _____ to make a diagnosis
tissue biopsy
If a patient diagnosed with HCC is determined to have a resectable tumor, the next step is to determine:
the volume of functional liver that would be left behind and remaining liver function
Patients diagnosed with HCC with Child-Pugh C cirrhosis should be referred for
transplant evaluation
What therapies are useful in a patient with HCC who is not a candidate for resection or transplant?
- 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
What chemotherapy drug prolongs median survival in HCC?
Sorafenib
still only 11 months survival
What are risk factors for development of biliary tract cancer?
- PSC
- choledochal cysts, associated with liver flukes
- gallstones
Describe the presentation of biliary tract cancers
Jaundice, fatigue, malaise, RUQ pain, palpable gallbladder (Courvoisier’s sign)
A liver mass with elevated _______ is more consistent with biliary tract cancer than hepatocellular carcinoma
CA 19-9
______ is the only truly curative measure for biliary tract cancer
Surgical resection
radical cholecystectomy: removal of gallbladder and all associated lymph nodes, segments IV and V of liver
poor survival even with successful resection
What chemotherapy regimen can be used in biliary tract cancers?
Gemcitabine plus cisplatin
What genetic syndromes increase the risk of HCC?
Alpha 1 antitrypsin deficiency
hereditary hemochromatosis
If a person had chronic hepatitis B which was successfully treated, what should they be told about their risk of HCC?
Significantly reduced risk but not eliminated
Relative risk decreased by 60%
Describe the presentation of HCC
- jaundice, ascites, sequelae of portal HTN- caput medusae, spider angiomata, peripheral wasting
- changes in LFTs, AFP
What is the preferred imaging modality to diagnose HCC?
MRI>CT because tumors tend to involve arterial system, HCC arterially supplied (rather than portal vein supply)
For locally confined HCC, _______ can be curative
partial hepatectomy
Why are post-operative (partial hepatectomy) recurrence rates of HCC so high?
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
Describe the Milan criteria for liver transplant in a patient with HCC
- 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
True or false: liver transplant improves survival in cholangiocarcinoma vs resection alone
True, but results may be misleading based on strict patient selection
