Hepatobiliary Surgery JC064: A Large Liver: Liver Cancer Flashcards
***Hepatomegaly DDx
Malignant:
Primary
1. **HCC (most common)
2. **Cholangiocarcinoma
3. Others (e.g. Lymphoma)
***Secondary
1. GI tract
2. Other primary (Breast, Lung)
***Haematological
1. Lymphoma
2. Leukaemia
3. Myeloproliferative disease
Benign:
Benign tumours
1. **Haemangioma
2. **Adenoma
3. Focal nodular hyperplasia
Cyst
1. Simple cyst
2. ***Polycystic disease
Others
1. **Alcoholic cirrhosis
2. **Liver abscess
History taking of Hepatomegaly
- ***Pain (site, onset, duration)
- ***Tea-colour urine (Jaundice)
- N+V
- Bowel changes
- Systemic review: any symptoms suggestive of other primary malignancy
- Constitutional symptoms: LOW, LOA, malaise
- ***Past history of HBsAg carrier, Hep C, Liver disease
- Social history: ***Alcohol
- Family history of malignancy
Physical examination of Hepatomegaly
General:
1. Pallor
2. **Jaundice
3. **Lymphadenopathy
4. ***Stigmata of chronic liver disease
5. Cachexia
Abdomen:
1. Hepatomegaly
- **size (cm below costal margin)
- tenderness
- **consistency (hard, firm, soft)
- **surface (nodular)
—> Smooth: Fatty liver, alcoholic cirrhosis, primary biliary cholangitis
—> Nodular: Polycystic kidney and liver disease
—> Large nodules: HCC
- edge
- **bruit (suggest vascular tumour e.g. HCC)
—> Vascular tumour (e.g. HCC) —> heard all over
—> Alcoholic hepatitis —> heard all over
—> Compression of aorta —> turn patient to right side and bruit less prominent
- Other organomegaly
- Splenomegaly: **Portal hypertension, **Haematological malignancy - Mass
- ***Ascites
- PR exam
Other systems
***Characteristics of Hepatomegaly
Diffuse smooth firm Hepatomegaly:
- Alcoholic liver disease
- Haematological malignancies (∵ diffuse infiltrative process)
Irregular hard Hepatomegaly (likely to be solid tumours):
- HCC
- Cholangiocarcinoma
- Secondary malignancies
***Investigations of Hepatomegaly
Blood tests
1. CBC
- e.g. **thrombocytopenia: ∵ hypersplenism in cirrhosis
- **abnormal WBC: haematological malignancies
- Coagulation profile
- e.g. ***prolonged INR in cirrhosis - LFT
- clue to chronic hepatitis / cirrhosis - Viral hepatitis serology
- **HBsAg
- **Anti-HCV Ab - Tumour markers
- **AFP: HCC, Embryonal carcinoma, Yolk sac tumour
- **CEA: Cholangiocarcinoma, CRC
- **CA 19.9: Cholangiocarcinoma, GI malignancies (e.g. **Pancreatic CA)
—> Help but NOT diagnostic
—> NOT all patients have ↑ tumour markers, mildly ↑ tumour markers can occur in benign conditions
Imaging
1. CXR (primary lung cancer, cannon ball lesions)
- USG (**1st line)
- whether a mass
- confirm whether hepatomegaly
- cirrhosis
- **splenomegaly
- tumours in pancreas - CT (***Contrast)
- MRI
- more phases, accuracies generally higher than CT - PET-CT
- confirm primary tumour + detect metastasis in other organs
Endoscopy (for suspected primary GI malignancy)
1. Upper endoscopy
2. Colonoscopy
Biopsy
1. USG-guided percutaneous **FNAC
2. **Trucut core biopsy
- 1-2% bleeding risk
- 1-2% chance percutaneous needle tract seeding
—> **NOT advocate biopsy for all patients if well-established cancer + resectable (will do surgical resection + pathology instead)
—> only useful in patients with **advanced malignancy beyond surgery (chemotherapy + histopathology to establish nature)
Management of Hepatomegaly
Depends on underlying pathology
- Surgical / Non-surgical
Hepatocellular Carcinoma (HCC)
Causes:
1. ***HBV (80% of HCC)
2. HCV (common in japan, western)
3. Cirrhosis (Alcoholic and other types)
4. Alflatoxin (fungal derivatives, ↑ chance of HCC esp. in HBV carrier, in peanuts not probably stored, contaminated by mould)
3 pathological / macroscopic types:
1. Massive (i.e. big mass)
2. Diffuse (i.e. infiltrative)
3. Nodular (i.e. multiple small nodules)
4. Fibrolamellar HCC (very rare histological variant, in young females, in western mainly, good prognosis)
Pathology:
- **Rapid tumour growth (double size in 3-4 months)
- **Venous invasion tendency (portal vein / hepatic vein)
- **Intrahepatic metastasis to rest of liver (via **portal venous circulation)
- **Lung metastasis (via hepatic vein dissemination)
- **Peritoneal metastasis
- frequency association with cirrhosis (80% in HK)
Incidence:
- 1800 new cases per year
- commonest primary liver cancer
- 2rd commonest cancer deaths
- 5th commonest cancer incidence
- ***M:F = 4:1
- mostly >50 yo (but can occur in young patient)
***Clinical features of HCC
- Subclinical
- liver relatively insensitive organ, large tumour can be asymptomatic, usually in HBV carrier who perform regular imaging surveillance —> incidental findings
- screening with **AFP, **USG in HBsAg carrier / cirrhotic patients - RUQ / Epigastric pain
- can be mistaken as peptic disease - Hepatomegaly
- abnormal mass felt in upper abdomen - LOA, LOW, malaise
- ***Decompensation of cirrhosis
- Child-Pugh A suddenly develop ascites, variceal bleeding, hepatic encephalopathy
- NB: HCC may also occur in patients without cirrhosis! - ***Tumour rupture
- rare, intraperitoneal haemorrhage, acute abdominal pain, shock - Paraneoplastic features
- rare, e.g. **polycythaemia, refractory diarrhoea, **fever of unknown origin, **hypercalcaemia, **hypoglycaemia
***Diagnosis of HCC
One of cancers that no need histological diagnosis
1. ↑ AFP ***>400 ng/mL (quite specific)
- AFP normal (<20) in 30% HCC
- can be ↑ in chronic hepatitis / cirrhosis esp. with active viral replications (high HBV DNA in blood)
- Imaging
- USG
-
CT scan (typical appearance)
—> Non-contrast phase: hypodense
—> Arterial phase / Contrast phase (1st 30 seconds, contrast still in arterial system): **hyperdense (tumour takes up blood mainly from hepatic artery instead of portal vein, on CT scan: compare with aorta (hyperdense aorta —> arterial phase))
—> Portal venous phase: **hypodense (washout) (compared to parenchyma ∵ surrounding liver has more blood supply from portal vein)
(NB: other cancers e.g. Cholangiocarcinoma / Secondary malignancy: arterial phase: ***hypodense instead (exact reverse)) - Post-Lipiodol CT (lipiodol injected via arteriography, repeat CT in 2 weeks for uptake by tumour, for uncertain cases after CT + Hepatic arteriography)
- MRI (alternative to CT, may also be useful in uncertain cases after CT)
- Hepatic arteriography (past, typical neovascularisation, for uncertain cases after CT)
- **PET scan (2 phases: **FDG + ***C-11 acetate) (FDG alone can miss HCC up to 50%)
- Biopsy (only for inoperable cases / very uncertain imaging results)
- FNAC
- Trucut biopsy - Indocyanine (ICG) clearance test
- a special dye excreted solely by liver
- best test for ***liver function reserve if planning for surgical resection
- ICG retention at 15 mins of <14% —> Adequate liver function
***Surgical treatment of HCC
- Hepatic resection
- 20% HCC resectable
—> **Unilobar
—> **Absence of main portal vein invasion
—> **Absence of distant metastasis
—> **Adequate liver function (ICG retention at 15 mins of <14%)
- 5 year survival rate >50%
- operative mortality rate 1-5%
- recurrence **50% (mainly in liver remnant due to **intrahepatic metastasis via portal vein / multicentric tumours, need regular 3-monthly surveillance with AFP, CT, early detection of recurrence —> re-resection / TOCE / ethanol injection) - Liver transplantation (one of few solid tumours that can be treated by transplantation)
- HCC **<5-6.5cm (i.e. **Early HCC) (5cm: Milan criteria, 6.5cm: UCSF criteria)
- **no macroscopic venous invasion / distant metastasis
- **Child B/C cirrhosis (∵ may not be good candidate for surgery due to poor LFT)
- 5-year survival rate 70-80%
- immunosuppressants may ↑ recurrence chance, ∴ not for advanced cancers
***Locoregional treatment of HCC
Embolisation
1. Transarterial oily chemoembolisation (TACE / TOCE) / Radioembolisation
- Local Chemotherapy + Embolisation
—> **Lipiodol (selectively taken up by HCC, unknown reasons)
+
—> **Cisplatin / Doxorubicin
+
—> **Gelfoam (block arterial supply of tumour —> slow down growth)
- bilobar / unilobar **unresectable tumours, reasonable liver function (bilirubin **<50), absence of main **portal vein thrombosis / distant metastasis
- **1st choice if **ruptured HCC (if still uncontrolled bleeding —> laparotomy)
- response rate: 30-40%
- continue once every 2-3 months
Ablation treatment (chemical / energy)
2. Percutaneous ethanol injection
- USG-guided for **<=3 tumours of **<=3-5 cm
- Cryotherapy
- Microwave / Radiofrequency thermoablation (**RFA)
- for tumours **<5 cm, ***<4 nodules
- outcome ~ surgical resection
Non-surgical Palliative treatment
- for Metastasis to other organs
- Overall response rate: only 15-25%
- Chemotherapy (e.g. doxorubicin), Tamoxifen, IFN
- not proven to be effective (∵ HCC is a ***chemo-resistant cancer + poor LFT cannot tolerate chemo well) - External radiotherapy
- stereotactic body radiation therapy (SBRT)
- benefit limited for large tumours - Targeted therapy (***Sorafenib, Lenvatinib)
- prolong survival by 3-4 months - ***Anti-PD1 immunotherapy (Nivolumab)
- modulate immune cells to kill cancer cells
- response ~20%
Distribution of treatment in HCC
100 HCC patient:
- 20 Surgery
- 15 RFA
- <5 Liver transplantation (∵ only suitable for ***early HCC + scarce supply of organs)
- 20 TACE
- 35 Systemic treatment
Long-term survival rate of HCC
5-year survival rate
- **Partial hepatectomy: 60%
- **Transplantation: 75%
- ***RFA: 50%
- TACE: 15%
- Systemic therapy: <5%
Advanced HCC with supportive treatment: 2-4 months
Cholangiocarcinoma
- 5-20% of primary liver cancer
- ***Adenocarcinoma of bile duct
- > 50 yo
Causes:
- no exact known cause
- associated with
—> **HBV carrier
—> **RPC (common in chinese)
—> ***PSC
—> Ulcerative colitis (rare in chinese)
2 types:
- Intrahepatic Cholangiocarcinoma (~ HCC, present as a mass)
- Extrahepatic Cholangiocarcinoma (present as strictures —> **Jaundice)
—> **different presentation
Clinical features of Cholangiocarcinoma
- RUQ pain
- ***Hepatomegaly
- ***Jaundice (depend on location, e.g. near liver hilum)
- LOA, LOW, fever
Diagnosis of Cholangiocarcinoma
Tumour markers (may be ↑):
1. CEA (carcinoembryonic antigen)
2. CA 19.9
Imaging:
1. USG
2. CT
- hypodense in arterial phase (can be difficult to differentiate from secondary metastasis, must also do other imaging e.g. PET)
3. MRI
4. FDG-PET (no need dual tracer)
5. ***ERCP (can do stenting)
Biopsy (only for unresectable cases):
1. FNAC
2. Trucut