Liver Flashcards
epidemiology
18th most common in UK, 6th most common in the world
38% increase by 2035
8th most common death
1/58 males diagnosed
1/122 females diagnosed
aetiology
liver cirrhosis
obesity
smoking
long term infections: Hep B/C
liver flukes: parasites in contaminated food/water
what is the most common pathology
hepatic cell carcinoma (85%)
what are the other pathology types
cholangiosarcoma of bile duct
angiosarcoma - vascular cancer
hepatoblastoma
liver mets from other primary sites
diagnosis
active surveillance: high risk patients with hep B/C
CT/MRI
US
blood tests: raised LFT may indicate something other than liver cancer
biopsy
what are the spread types
local/primary and lymphatics
what is the primary spread
mets in other lobes
multiple in the liver
lung/live from blood
gall bladder
what is the ;lymphatic spread
hepatic
coeliac
para-aortic
what staging is used
BCLC = Barcelona Clinic Liver Cancer
what does the BCLC look at
performance status: fitness level, child Pugh score (liver function), and number and size of the tumours
what does the staging system determine
the treatment most suitable/ advised treatment route
RFA
Radio-frequency ablation, high RF waves are used
PEI
Percutaneous Ethanol Injection
when is surgery the treatment
early stages
are high doses required
yes, they are necessary for killing the tumour
presentation
jaundice: yellow pigmented skin, white spots in the eyes due to excess bilirubicin in the blood
abdominal pain
vomiting
weight-loss is RARE
physical lump
uncontrolled fever (jaundice or functional issue)
ascites: build up of fluid in the peritoneum, could be confused with bloating
shoulder pain, due to the nerves being trapped
what is the dose for RT for single centres
66Gy in 33
what is SIRT
selective internal radiotherapy
injects radioactive beads into the tumour
what types of RT can be given
TACE + RT
SABR/SBRT [most common, takes 45 minutes], VMAT is RARE
what is the predominant dose for RT
54Gy in 30
what is the survival rate
63-76%
what does TACE stand for
Trans Arterial Chemo Emobilisation
what is TACE
high dose of chemo (doxorubicin/cisplatin) are injected into the tumour injected, the contrast which is used to highlight the vessels is injected into the femoral artery, making it less systemic. This reduces the blood supply to the tumour, causing it to be starved of O2 and nutrients required for growth.
why is TACE normally before RT
RT can shrink the vessels making it more difficult for TACE to work
Inclusion criteria for TACE
1-3 mets
unsuitable for surgery
curative intent (LE>6months)
max size of met is <6cm
class A CPS
exclusion criteria for TACE
hepatitis or liver failure
previous RT to liver
what is SABR
Stereo Ablative RT
short dose regimes with high doses in less fractions, for patients unsuitable for treatment via surgery, early stages with no distant mets
types of doses for SABR
40-60Gy in 3 (alternate days)
50-60Gy in 5 fractions (alternate or daily)
30-60Gy in 10 fractions (TV doesn’t meet SABR eligibility)
what is the palliative RT
20Gy in 5 or 30Gy in 10
ant and post field
where are mets found
colorectal
lung
stomach
breast
prostate
pancreas
skin
oesophagus
breathing immobilisation techniques
SGRT
Exhale hold
Metronome - control breathing in and out
Compression belt, abdominal bridge, thermoplastic
what is the issue with irradiating the liver
you might irradiate the skin or duodenum
what happens during tumour lysis
the body goes into overdrive, risk of sepsis
uncontrolled fever and immune response
what does bigger mets lead to
bigger cell death and bigger issues
what does velindre do
wing board
free breathing
full inhale and exhale = ITV
CBCT- 10 min later, CBCT again to check no inter fraction motion of day 0
0 tol
what do other centres do
breath-hold/ exhale
Vacfix on wing board
4DCT on CBCT software
FFF for high dose rate
what are the RT side effects and complications
skin
nausea
diarrhoea
loss of appetite
fatigue
radiation induced liver damage: low Childs Pugh score
SABR daily toxicity scoring
what’s the survival if mets are treated with SABR
70-100%
what happens with late presentation
poor prognosis
what does active surveillance allow for?
early detection of liver mets
