Hepatobilliary Neoplasia Flashcards

1
Q

The liver is a common site of metasticies for which cancers?

A

colorectal, pancreatic, breast and lung

note: HCC is the most common type of primary cancer

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2
Q

What are risk factors for HCC?

A

chronic hepatitis infection, esp emigration from endemic country
advanced age, men, lower SES
alcohol, smoking obesity
underlying genetic syndrome

basically any repeated injury to hepatocytes, esp. those that lead to cirrhosis (increase the chances of replicative error)

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3
Q

How does HBV infection modify the risk of HCC?

A

active viral replication is highest risk (HBsAg+, HBeAg+)

treatment and clearance of HBV reduces relative risk only by 60%

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4
Q

What is the best way to screen for HCC?

A

check levels of alpha fetoprotein (can be elevated in chronic liver disease) in tandem with imaging, usually liver ultrasound

only 80% of high risk patients in US get adequate screening

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5
Q

What are the presenting complaints of someone with HCC?

A

usually in the context of preexisting liver disease, often with a change to decompensation or a change in imaging, LFTs or AFP levels.

PE findings include jaundice, ascites, squealer of portal HTN and chronic liver disease, caput medusa, spider angiomata and peripheral wasting

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6
Q

What level of AFP is diagnostic for HCC?

A

> 200ng/mL only other conditions that could exist are testicular cancer or pregnancy

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7
Q

What is the classic imaging finding that accompanies HCC?

A

arterial enhancement with portal venous washout (HCC is nearly 100% arterially supplied) and no tissue sample is required for diagnosis in most cases

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8
Q

How is staging in HCC done?

A

staging is not particularly helpful in HCC, usually local disease is lethal before metastatic spread

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9
Q

What are the tx. options for local HCC?

A

partial hepatectomy can be curative if enough liver function will be preserved to allow the liver to function, although post recurrence rates are high

hepatic transplant can be used for resectable cancers without adequate hepatic reserve, recurrence and mortality is common

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10
Q

Describe the Milan criteria.

A

liver transplant possible in patients with
1 tumor<3cm
no metastatic disease
no vascular invasion or portal venous clot

many may be granted MELD exception in order to get transplant

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11
Q

What are options for tx of localized and advanced HCC?

A

often use temporizing measures pre transplant including
local ablative therapies (percutaneous ethanol infection, radio frequency ablation), trans arterial regional therapies (bland embolizeation “glue”, and chemoembolization); selective internal radiation therapy

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12
Q

What treatments are available for metastatic disease?

A

chemotherapy is relatively ineffective, mostly local therapies are used for symptom relief and tumor debunking

soratenib shows some potential to stop tumor growth by several months (2.8), those not eligible usually go to supportive care only (<3mo OS)

deals largely with management of symptoms of hepatic dysfunction and quality of life

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13
Q

What are some of the inherent difficulties of studying cholangiocarcinomas?

A

difficult to classify and the different types intrahepatic, extra hepatic, ampullary, gallbladder cancer have heterogenous behavior

such few cases also make research difficult, all are very aggressive

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14
Q

What are risk factors for cholangiocarcinoma?

A

PSC
parasitic infections
choledochal cysts
FAP
gallstones: obesity, female gender, high carb intake
anatomic conditions (porcelain gallbladder, gallbladder polyps

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15
Q

Who does cholangiocarcinoma present?

A

unexplained jaundice, abdominal pain, fevers, or often discovered incidentally
elevated LFT’s particularly alkaline phosphatase

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16
Q

T/F Staging for distal bile duct and ampullarf cancer is similar to pancreatic adenoma.

A

T

N1 may still be resectable while T4 tumor is unresectable and behaves like a locally advanced pancreatic cancer

17
Q

What are the tx. recommended for cholangiocarcinoma?

A

gallbladder cancer: radical cholecystectomy

bile duct:
intrahepatic: partial hepatectomy
extra hepatic: pancreaticoduodenectomy with hepaticojejunostmy
hilar: extended R. hemihepatectomy

very small population can undergo neoadjuvant RT and chemo- pre-transplant with long term survival (very few patients meet criteria)

poor survival even when resectable

18
Q

What is the course of action with advanced choliangiocarcinoma?

A

most present with advanced disease

if no surgical resection or transplant is possible, chemotherapy is the primary treatment + gemcitabine chemo may improve QOL and survival

19
Q

What are possible future cellular targets for choleangiocarcinoma?

A

K-ras mutations
p16 mutation and APC activation
p53 overexertion

although it can be hard to study without good pre-clinical models and difficult to get tissue to test (fibrosis)