HPB Flashcards

1
Q

Work up for Colorectal liver Mets

A

MDT discussion
MRI liver
PET CT (unit or in determent lesions)

MSI staus, KRAS, NRAS and BRAF testing on resected tumour

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2
Q

Treatment options for Liver mets

A

1)Do nothing
2) Neoadjuvent Chen followed by resection
3) Surgery
4)Ablative therapies (microwave or RFA) with or without Chemo

Mortality of surgery is low (<0.5%) in well selected patients
QoL returns to baseline in around 3 months

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3
Q

Resectability

A

Need to aid for R0 resection
Minium future liver remnant
-20-25% in healthy liver
30% in post chemo liver injury
40% in cirrhotic

Need to have arterial and portal inflow, adequate biliary drainage and hepatic venous outflow

Upfront resectable around 10%
Potentially resectable (with neoadjuvent chemo) 20%
Non resectable 70%

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4
Q

Tactics for increasing FLR and/or maximising resectability

A

1)Chemotheraptuic downsizing
2)Parenchymal sparing (non-anatomical. Anatomic resection thought to have better survival
3)Portal vein embolisation - usually 4-6weeks prior (can promote tumour growth)
4) Two stage hepatectomy - first operation clears FLR and ligates portal vein then second operation resects remaining tumour (can cause tumour growth)
5) Redo/repat hepatectomy
6) ALPPS - Liver partition and port vein ligation for stages hepatectomy (divides collaterals)
7) Resection with ablation
8) Associated visceral/vascular resection

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5
Q

Prognosis of colorectal liver mets

A

If resectable 5yr survival similar to stage 3 cancer - 40-60%

Long-term survival in operable patients with 10yr survival is 26%

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6
Q

Options if not resectable after chemo

A

1) RFA - CCLOCC study (Chemo with/without RFA) No difference between 2 arms but 8yr F/U shows benefit of RFA

2) SIRT - specialist centre only and falling out of favour

3) Second line Chemo

4) TACE - trans arterial chemo embolisation - more used in HCC

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7
Q

Mutinous cyst neoplasm

A

Unilocular cyst on EUS
Fluid on FNA is mutinous with high CEA
Presence of ovarian type stroma

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8
Q

Management of MCN

A

1) Sugary - risk of malignancy - higher risk if >4cm

2) Surveillance - usually <4cm without suspicious features. Usually periodic imaging but no need for FNA. If grows in size, nodules, solid component, jausince, pancreatitis or raised Ca19-9) the EUS,FNA and MDT

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9
Q

Gallbladder cancer

A

Ix - CT with contrast
Diagnostic Lap(esp T3 or poor differentiation)

Mx - T2 tumur - re-resection with at least 2cm addict liver to GB bed - may require Sen 4b and 5 resection and regional lymphadenectomy

35-80% have LN mets T2 or high
Removal all nodes in porta hépatisme, long hepatoduodenal ligament (inc cystic, CBD, HA and PV) - at least 6 nodes needed

Surgery should be within 4-8 weeks of initial Lap chole as provided best survival outcomes

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10
Q

HCC on Ct

A

Showes arterial phase hyper enhancement followed by washout in the portal or delayed phase

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11
Q

How is HCC diagnosed

A

Characteristic findings on CT/MRi and elevated AFP

No need for Biopsy in Cirrhotic patients with lesions >1cm.

In patients without Cirrhotic liver or indeterminate lesions biopsy my be indicated

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12
Q

Barcelona Clinic Liver cancer

A

Integrates tumour stage, liver function and patient performance status

Early stage disease (0orA) - resection, ablation or transplant

Intermediate stage (B) - TACE)

Advanced stage -(C) - vascular invasion or extra hepatic spread - systemic therapies like sorafenib or immune

Terminal stage (D) -supportive care

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13
Q

Resection vs Liver transplantation

A

Resection with single tumour and preserved liver function with portal HTN

Liver transplant best option for patients within Milan criteria (<5cm or up to 3 tumours <3cm each) and have cirrhosis

Patients outside the Milan Criteria may be considered for down staging therapies then become eligible

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14
Q

TACE

A

Contraindicated in patients with poor liver function or main portal vein thrombosis due to risk of hepatic decompression

Indicated in intermediate stage HCC confined to liver but not amenable to curative treatments (resection or FRA)

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15
Q

Advanced HCC

A

Stage C - vascular invasion or extra hepatic spread.

Systemic therapies such as Sorafenib (1st line) or newer agents like Lenvatinib.

Significant side-effects, patient suitability must be carefully evaluated

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16
Q

Surveillance for High risk population for HCC

A

6month US and AFP for high risk groups
-Cirhosis, Chronic Hep C, advanced fibrosis due to NASH or Hep B with family Hx of HCC

17
Q

Work up for Cholangiocarcinoma

A

Hx and Examination
Bloods
Ct C/A/P and/or PET-CT
ERCP with brushing for cytology
Preoperative biliary drainage - bili <50 linked to improved outcomes

18
Q

Types of Cholangiocarcinoma

A

Intrahepatic 7-10% cases - present later with diffuse pain and lower rate of jaudicne

Distal 20-30% of tumours - close to pancreas

Intrahepatic - Klatskin tumours - 40-60% - usually present with obstructive Jaundice

19
Q

Unresectable/Advanced tumours

A

Combination of Gencitabine and cisplatin chemos and symptom control

If unable to tolerate cisplatin a dose reduced regime with oxaliplatin is considered.

Molecular profiling is important for new targeted therapies such as FGFR2 inhibitors or IDH1 inhibitors. (esp in intrahepatic)

If fails first line Tx then FolFox (5-FU, leucovorin and oxaliplatin or targeted therapies).
Some centres exploring TACE or SIR to try and downsize intrahepatic tumours.

Immunotherapy agents like pembrolizumab considered for tumours with high PD-L1 expression

20
Q

Adjuvent Treaetment

A

For patients with positive nodes:

Capecitabine for 6 months - improves survival

Regular follow up with imaging and tumour markers (CA19-9) essential for monitoring for reoccurrence

Radio considered is considers about residual microscopic disease