Hepatocellular Carcinoma and Cholangiocarcinoma

Question 1

What are the two main types of Liver cancer?

Incl how common each is

Answer 1

Hepatocellular carcinoma (80%)

Cholangiocarcinoma (20%).

Question 2

List 4 risk factors for hepatocellular carcinoma

Answer 2

Liver cirrhosis due to:

1. Viral hepatitis (B and C)
2. Alcohol
3. NAFLD (diabetes)
4. NASH
5. Haemochromatosis
6. Primary Biliary Cirrhosis

Question 3

How does HCC present?

Answer 3

1. Jaundice
2. Ascites
3. Variceal bleed ( portal vein occlusion by thrombus )
4. Incidental finding​

Non-specific symptoms: Weight loss, abdo pain, anorexia, nausea and vomiting, pruritus

Pain is often not a feature early in disease unless lesion is sub capsular

Question 4

List 4 examination findings of HCC

Answer 4

1. Jaundice
2. Palpable liver + / - bruit
3. Ascites
4. Gynaecomastia
5. Bruising
6. Caput Medusae

Question 5

What scoring system is used to assess the severity of liver disease?

Answer 5

Child-Pugh score - assess prognosis for patients with cirrhosis

(Not specifcally for HCC)

Question 6

What tumour marker is associated with hepatocellular carcinoma?

Answer 6

Alpha-fetoprotein

Question 7

Majority of patients (90%) who have HCC already has pre-exisiting _______ and were predominantly ___(gender)____

Answer 7

cirrhosis, male

Question 8

What is a Fibrolamellar carcinoma?

List 3 specific featurs of this

Answer 8

A rare form of HCC which is:

1. NOT associated with cirrhosis
2. Occurs under age 30
3. Normal AFP

Question 9

List 4 investigations for HCC

Answer 9

1. Blood Tests - FBC / LFTs /U/E / INR
2. AFP
3. HBV/HCV

Imaging

1. Ultrasound to identify tumours
2. CT and MRI for diagnosis and staging
3. Biopsy - only if radiologically it appears inoperable

Question 10

Why is a biopsy is not advised for HCC if the tumour is operable?

Answer 10

The needle tract may lead to seeding of tumour

Question 11

Treatment of HCC

Answer 11

1. Early disease: surgical resection
2. Transplant (Milan Criteria)
3. Radiofrequency ablation
4. Transarterial chemoembolisation (TACE)
5. Sorafenib: multikinase inhibitor

Question 12

What is the Milan Criteria?

Answer 12

Assess suitability of liver transplant in patients with cirrhosis and HCC

• Single lesion ≤5 cm
• Up to 3 lesions ≤3 cm
• No macrovascular invasion

Question 13

What is the main risk factor for Cholangiocarcinoma?

Answer 13

Primary sclerosing cholangitis

Question 14

When does Cholangiocarcinoma tend to present?

Answer 14

In patients > 50 years old unless related to PSC

Question 15

What tumour marker is associated with cholangiocarcinoma?

Answer 15

CA19-9

Question 16

List 4 clinical features of Cholangiocarcinoma

Answer 16

1. Persistent biliary colic symptoms
2. Anorexia, Jaundice and weight loss
3. Palpable mass in the RUQ (Courvoisier sign)
4. Periumbilical lymphadenopathy (Sister Mary Joseph nodes)
5. Left supraclavicular adenopathy (Virchow node) may be seen

Question 17

Investigations for Cholangiocarcinoma

Answer 17

1. Liver to can identify tumour
2. CT and MRI for diagnosis and staging
3. ERCP to take biopsies or brushings to diagnose

Question 18

Compare LFT findings for HCC vs Cholangiocarcinoma

Answer 18

HCC:

Cholangiocarcinoma:

Question 19

Treatment for Cholangiocarcinoma

Answer 19

Early disease → can potentially be cured with surgical resection

Palliative → ERCP stenting to overcome biliary obstruction (relieves jaundice and pruritus)

+ Analgesia

Cholangiocarcinoma is generally resistant to chemo and radiotherapy