HPB Flashcards
What is the difference between a gallbladder cancer and a cholangiocarcinoma
GB cancer - arising from gallbladder or cystic duct
CCA - arising from biliary tree ie intrahepatic ducts, hepatic ducts, or CBD
What are the risk factors for a GB carcinoma, and for a CCA
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
What is the management of an early biliary tract carcinoma
Surgery followed by adjuvant capecitabine if complete resection
Approx 80% recurrence if capecitabine not given
If residual disease, given palliative gem/cis instead
What is the management of a locally advanced biliary tract carcinoma
Neo-adjuvant gem/cis, followed by surgery and adjuvant capecitabine
What is the management of an advanced biliary tract carcinoma
Gem/cis/durvalumab
Up to 8 cycles, then maintenance durvalumab until progression or toxicity
What is the genetic referral criteria for pancreatic cancer
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
How is a T3 pancreatic cancer distinguished from T4
T3: clear fat plane between coeliac axis and SMA with patent SMV/portal vein
T4: SMA/coeliac plexus involvement
What determines if a pancreatic cancer is resectable or not
No contact with Coeliac axis, SMA or CHA
No contact with SMV or portal vein (PV)
Clear fat planes around vessels
What is the management of a resectable pancreatic cancer
What proportion are resectable at presentation
What treatment is given adjuvantly?
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
What RT dose is given for pancreatic chemoRT
What are the GTV and CTV/PTV margins
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
What is the management of a borderline resectable pancreatic cancer
Neoadjuvant folfirinox +/- chemoRT (cape bd), followed by surgery if resectable, and adjuvant chemo
If tumour not resectable, treat as locally advanced
What is the management of a locally advanced pancreatic cancer
Folfirinox followed by assessment for surgery, and either surgery or continuation of medical management
What is the management of metastatic pancreatic cancer
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
What is the management of an early HCC
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)
What is the management of an advanced HCC
1st line - atezolizumab & bevacizumab, if unresectable, PS0-1 and CP-A
2nd line - sorafenib/lenvatinib
3rd line - regorafenib
What are the contraindications for liver transplant for HCC
AFP >10,000, extra-hepatic disease, tumour rupture, macroscopic vascular invasion
What are the indications for liver transplant in HCC
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
What syndromes are associated with neuroendocrine tumours
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
What is the Ki67 of a poorly differentiated NET
What markers tend to be positive
G3 - poorly differentiated NEC - Ki-67=>20
Chromogranin A
Synaptophysin
PGP 9.5
urine 5HIAA
What is the treatment for a NET
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
When is surgery alone adequate for an appendiceal NET
If tumour <2cm
If >2cm, deep mesoappendiceal invasion or margin invasion -> hemicolectomy
What is given adjuvantly for cholangiocarcinoma
Single agent capecitabine
What are the surgical criteria for HCC
Milan criteria - single lesion <5cm, up to 3 lesions up to 3cm, no extra hepatic disease and no vascular invasion
What is the first line treatment for metastatic cholangio
Gem/cis + durvalumab
What is the treatment for non-resectable locally advanced cholangiocarcinoma
CRT - capecitabine / 5FU
50.4/28, 45/15 or 50/5#
What are the criteria for liver SABR for a met
Confirmed histolgiy
disease free interval 6mths at least
1-3 oligomets in 1-2 organs
Max 5cm
Child Pugh A or better
