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FRCR2 > HPB > Flashcards

HPB Flashcards

1
Q

What is the difference between a gallbladder cancer and a cholangiocarcinoma

A

GB cancer - arising from gallbladder or cystic duct
CCA - arising from biliary tree ie intrahepatic ducts, hepatic ducts, or CBD

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2
Q

What are the risk factors for a GB carcinoma, and for a CCA

A

Gall Bladder carcinoma (40%)
Gallstones (>3cm) - largest risk factor, present in 70-90%
Obesity
Chronic typhoid / salmonella
Polyps >1cm
Ulcerative colitis

Cholangiocarcinoma (bile duct) (40%)
Primary sclerosing cholangitis (10% lifetime risk)
Polycystic liver disease
Gallstones
Infection - HPB flukes or hepatolithiasis
Chemical carcinogens: aflatoxin, vinyl chloride, methylene chloride
Cirrhosis & hepatotropic virus - HBV, HCV

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3
Q

What is the management of an early biliary tract carcinoma

A

Surgery followed by adjuvant capecitabine if complete resection
Approx 80% recurrence if capecitabine not given
If residual disease, given palliative gem/cis instead

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4
Q

What is the management of a locally advanced biliary tract carcinoma

A

Neo-adjuvant gem/cis, followed by surgery and adjuvant capecitabine

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5
Q

What is the management of an advanced biliary tract carcinoma

A

Gem/cis/durvalumab
Up to 8 cycles, then maintenance durvalumab until progression or toxicity

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6
Q

What is the genetic referral criteria for pancreatic cancer

A

Pancreatic cancer age <50

Pancreatic cancer <60 AND
Breast cancer, ovarian cancer or melanoma <60
One first/second degree relative with pancreatic cancer <60 OR
Two first/second degree relatives with any of breast, ovarian or melanoma <60

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7
Q

How is a T3 pancreatic cancer distinguished from T4

A

T3: clear fat plane between coeliac axis and SMA with patent SMV/portal vein
T4: SMA/coeliac plexus involvement

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8
Q

What determines if a pancreatic cancer is resectable or not

A

No contact with Coeliac axis, SMA or CHA
No contact with SMV or portal vein (PV)
Clear fat planes around vessels

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9
Q

What is the management of a resectable pancreatic cancer
What proportion are resectable at presentation

What treatment is given adjuvantly?

A

No indication for neoadjuvant chemotherapy

Maximal resection followed by adjuvant folfirinox if fit, or gem/cape or gem/5FU if less fit

approx 20% are resectable at presentation

Prodigy 24 - DFS 21.6 months vs. 12.8 months

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10
Q

What RT dose is given for pancreatic chemoRT
What are the GTV and CTV/PTV margins

A

50.4Gy/28# with bd cape on treatment days

GTV - GTVp + GTVn
CTV - GTVpn + 0.5cm (edit GI overlap)
PTV - CTV + 1.5cm sup/inf and 1cm axially

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11
Q

What is the management of a borderline resectable pancreatic cancer

A

Neoadjuvant folfirinox +/- chemoRT (cape bd), followed by surgery if resectable, and adjuvant chemo
If tumour not resectable, treat as locally advanced

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12
Q

What is the management of a locally advanced pancreatic cancer

A

Folfirinox followed by assessment for surgery, and either surgery or continuation of medical management

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13
Q

What is the management of metastatic pancreatic cancer

A

1st line folfirinox, but if not fit, then gem/abraxane (only if metastatic, not just locally advanced - use gem/cape)

If dMMR/MSI-H - pembrolizumab 2nd line
If BRCAmut - maint olaparib following first line treatment
If NTRK mut - larotrectinib / entrectanib 2nd line

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14
Q

What is the management of an early HCC

A

Stage 1 - if <2cm, C-P score A and normal portal pressure - resection or ablation

Stage 1-2, CPA-B - ablation or liver transplant (if one lesion <5cm or up to 3 lesions <3cm, or >5cm but stable over 6mths)

Stage 1-2, CP-A-B, >3cm size / multifocal, and no portal thrombus (HCC have arterial vascularisation)
TACE - doxorubicin, or SIRT (Y-90)

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15
Q

What is the management of an advanced HCC

A

1st line - atezolizumab & bevacizumab, if unresectable, PS0-1 and CP-A
2nd line - sorafenib/lenvatinib
3rd line - regorafenib

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16
Q

What are the contraindications for liver transplant for HCC

A

AFP >10,000, extra-hepatic disease, tumour rupture, macroscopic vascular invasion

17
Q

What are the indications for liver transplant in HCC

A

HCC transplant criteria:
- A single tumour ≤5cm diameter
- Up to 5 tumours all ≤3cm
- Single tumour >5cm and ≤7cm diameter where there has been no evidence of tumour progression between interval imaging
+/- known liver disease

18
Q

What syndromes are associated with neuroendocrine tumours

A

MEN 1 - Parathyroid, pituitary, pancreatic NETs, bronchial/gastric NETs

MEN 2 - Hyperparathyroidism, medullary thyroid carcinoma, phaeochromocytoma

Type 1 NF
Neurofibromas, café-au-lait macules, optic glioma, phaeochromocytoma, rarely duodenal somatostatinoma

VHL
RCC, phaeochromocytoma, cerebellar haemangioblastoma, retinal angioma, pancreatic NETs

Tuberous sclerosis

Carney complex
Spotty skin pigmentation, cardiac myxomas, thyroid adenoma, nodular
Adrenocortical disease -> cushing’s syndrome, sertoli cell tumours and ovarian cysts

19
Q

What is the Ki67 of a poorly differentiated NET

What markers tend to be positive

A

G3 - poorly differentiated NEC - Ki-67=>20

Chromogranin A
Synaptophysin
PGP 9.5

urine 5HIAA

20
Q

What is the treatment for a NET

A

surgery 1st line if local, and can also have palliative surgery for symptomatic / obstructing lesions

Symptom control - somatostatin analogues - octreotide

Chemotherapy - cisplatin/carboplatin-etoposide, indicated if grade 3 NET

TKI - sunitinib, indicated for well differentiated G1-2 metastatic NET

Radionuclide tx

Embolisation

21
Q

When is surgery alone adequate for an appendiceal NET

A

If tumour <2cm
If >2cm, deep mesoappendiceal invasion or margin invasion -> hemicolectomy

22
Q

What is given adjuvantly for cholangiocarcinoma

A

Single agent capecitabine

23
Q

What are the surgical criteria for HCC

A

Milan criteria - single lesion <5cm, up to 3 lesions up to 3cm, no extra hepatic disease and no vascular invasion

24
Q

What is the first line treatment for metastatic cholangio

A

Gem/cis + durvalumab

25
Q

What is the treatment for non-resectable locally advanced cholangiocarcinoma

A

CRT - capecitabine / 5FU
50.4/28, 45/15 or 50/5#

26
Q

What are the criteria for liver SABR for a met

A

Confirmed histolgiy
disease free interval 6mths at least
1-3 oligomets in 1-2 organs
Max 5cm
Child Pugh A or better

FRCR2 (38 decks)

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