Liver Cancer Flashcards
Is liver cancer usually primary or secondary?
Metastic/Secondary (90%)
Primary (10%)
Main primary liver tumour
Hepatocellular carcinoma HCC
Epidemilogy HCC
Sixth most common cancer world wide
Third leading in cause of cancer death
Incidence rates vary significantly across the globe
Common in china but uncommon in the UK
Aetiology
Due to chronic inflammatory process
Viral hepatitis is the leading cause
Can also be from…
Chronic alcoholism
Hereditary haemochromatosis
PBC
Aflatoxin from toxic fungal metabolite in cereals and nuts
Risk factors
Hep B and Hep C
High alcohol intake
Smoking
Advanced age >70
Aflatoxin exposure
FH of liver disease
Lobes and ligaments of the liver
Clinical features
Liver cirrhosis with vague nonspecific symptoms like fatigue, fever, weight loss and lethargy
Dull ache in RUQ is uncommon but can happen.
That should raise suspicion in patients with known cirrhosis
Worsening ascites or jaundice can also happen
Examination findings
Irregular enlarged and tender liver
Dx
Infectious hepatitis
Cardiac failure
Benign hepatocellular adenoma
Other causes of liver cirrhosis
Lab tests to be done
LFTs
Routine bloods and platelets + clotting
Alpha fetoprotein should be done as well
Lab test findings
ALP, ALT, AST and bilirubin might be deranged.
AST:ALT ratio >2 is likely due to alcoholic liver disease
AST:ALT around 1 is likely viral hepatitis
Low platelets and prolonged clotting might be seen
Alpha fetoprotein should be monitored as it is raised in 70% of cases.
Should also be monitored for treatment response and recurrence
Imaging
Ultrasound is the initial imaging of choice
CT scan can be done for further evaluation
Patients with rising AFP and US nodules can have MRI liver scan for further assessment
USS findings
Mass >2cm + raised AFP is diagnostic
MRI liver scanning findings
Mass with arterial hypervascularisation which is characteristic of HCC
If diagnosis is still in doubt after MRI scanning, what can be done?
Biopsy or percutaneous fine-needle aspiration
This is last-resort due to difficulty with active ascites, risk of bleeds and risks of tumour seeding
Staging tool
Barcelona Clinic Liver Cancer system BCLC
Explain BCLC
Tumour stage
Liver function
Physical status
Cancer releated symptoms
This provides guidance on what treatment is most suitable
What risk assessment tools might be used?
Child-Pugh score
MELD score
This is to assess risk of mortality from cirrhosis and predict potential effectiveness from potential treatment options.
Explain Child-Pugh score
Serum bilirubin
Albumin
INR
Degree of ascites
Evidence of encephalopathy
Explain MELD score
Creatinine
Bilirubin
INR
Sodium
Use of dialysis
This can predict the likelihood of a patient tolerating a potential liver transplant.
General management
MDT with oncologist, radiologist, hepato-biliary surgeons and speciliast nurses
Only curative options for HCC
Surgical resection
Transplantation
When is surgical resection done?
In aptients without cirrhosis and with a good baseline health status
5 year recurrence is 50-60%
When is transplantation done?
In patients fulfilling Milan criteria:
One lesion is small than 5 cm or three lesions smaller than 3 cm
No extrahepatic manifestations
No vascular infiltration
Non-surgical interventions
Image-Guided ablation
Transarterial Chemoembolisation
Indications of image-guided ablation
Early HCC where BCLC is 0 or A
Ultrasound probes are placed in the tumour mass to induce necrosis
What is alcohol ablation?
Injection of alcohol into the tumour
This destroys the malignant tissue and is most effective on small tumours in well-functioning livers.
Indications of transarterial chemoembolisation TACE
BCLC stage B (large multinodular tumour)
High concentrations of chemotherapy drugs are injected directly into the hepatic artery + embolising agent is added to induce ischaemia
Prognosis
Depends on extent of underlying cirrhosis
Median survival time from diagnosis is around 6 months
Metastasis to liver from other cancer (Secondary liver cancer)
Bowel via portal circulation
Breast
Pancreas
Stomach
Lung
Clinical features of secondary liver cancer
Similar to HCC
Hepatomegaly and ascites in 50% of patients
Jaundice and upper abdo pain can be present as well.
Lab tests of secondary liver malignancy
Deranged LFTs
ALP almost always raised as a sign of biliary obstruction
Initial imaging modality of choice in secondary liver malignancy
USS
CT scan can also be used to stage the metastases and allow imaging for the rest of the body.
Should biopsy be done in secondary liver malignancy?
Not if the tumour is operable.
This is because of potential tumour seeding
Management of secondary liver cancer
Primary tumour has metastasised to additional sites as well usually
This means that surgery is more difficult and less useful.
Oncological and palliative services are more likely to be used.
Surgery could be done in metastases confined to the liver.
TACE or selective internal radiotherapy might be trialled.
