HPB Flashcards
Work up for Colorectal liver Mets
MDT discussion
MRI liver
PET CT (unit or in determent lesions)
MSI staus, KRAS, NRAS and BRAF testing on resected tumour
Treatment options for Liver mets
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
Resectability
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%
Tactics for increasing FLR and/or maximising resectability
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
Prognosis of colorectal liver mets
If resectable 5yr survival similar to stage 3 cancer - 40-60%
Long-term survival in operable patients with 10yr survival is 26%
Options if not resectable after chemo
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
Mutinous cyst neoplasm
Unilocular cyst on EUS
Fluid on FNA is mutinous with high CEA
Presence of ovarian type stroma
Management of MCN
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
Gallbladder cancer
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
HCC on Ct
Showes arterial phase hyper enhancement followed by washout in the portal or delayed phase
How is HCC diagnosed
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
Barcelona Clinic Liver cancer
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
Resection vs Liver transplantation
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
TACE
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)
Advanced HCC
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