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Y4 Gastrointestinal > Liver cancer (read) > Flashcards

Liver cancer (read) Flashcards

1
Q

What are solid liver lesions in older patients most likely to be ?

A

Malignant, with metastases more common than primary liver cancer in the absence of liver disease.

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2
Q

Solid liver lesions in chronic liver disease patients (cirrhosis or active Hepatitis B) are most likely to be what ?

A

Primary liver cancer rather than metastases or benign tumours.

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3
Q

In non-cirrhotic patients what is the most likely cause of a solid liver lesion?

A

Haemangioma

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4
Q

What are the main types of malignant liver tumours ?

A
  1. Primary liver cancers either a hepatocellular carcinoma or a cholangiocarcinoma
  2. Metastases
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5
Q

What are the 4 main types of benign solid liver lesions ?

A
  1. Haemangioma
  2. Focal nodular hyperplasia
  3. Adenoma
  4. Liver cysts
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6
Q

If a benign liver lesions is symptomatic what may it cause ?

A

RUQ pain or fullness or mass

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7
Q

What is an haemangioma and its clinical features ?

A
  • The most common benign liver lesion, it consists of blood vessels and originates from Mesenchyme.
  • It is thought to be congenital and may increase under the influence of oral contraceptives
  • They are usually asymptomatic and appear as single small well demarcated capsules (have a fibrous capsule)
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8
Q

What is the appearance of a liver haemangioma on CT, MRI and US?

A
  • US: hyperechoic spot, well demarcated
  • CT: venous enhancement from periphery to center
  • MRI: high intensity area
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9
Q

What is the treatment of a liver haemangioma ?

A

None

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10
Q

What is a focal nodular hyperplasia (FNH) lesion of the liver and its clinical features?

A
  • Benign nodule formation of normal liver tissue which may be associated with Osler-Weber-Rendu and liver haemangiomas
  • Appears as a central scar containing a large artery, radiating branches to the periphery
  • More common in young and middle age women
  • No relation with sex hormones
  • Usually asymptomatic, may cause minimal pain
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11
Q

What are the results on US, CT, MRI or FNA which suggest FNH as the diagnosis ?

A
  • US: Nodule with varying echogenicity
  • CT: Hypervascular mass with central scar
  • MRI: Iso or hypo intense
  • FNA: Normal hepatocytes and Kupffer cells with central core
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12
Q

What is the treatment of FNH ?

A

No treatment necessary

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13
Q

What is a hepatic adenoma and its clinical features ?

A
  • It is a benign neoplasm composed of normal hepatocytes no portal tract, central veins or bile ducts
  • Occurs most commonly in women of child bearing age (females 10:1 males)
  • Development linked with contraceptive hormones and anabolic steroids
  • Usually seen as solitary well demarcated fat containing lesions (do not have a fibrous capsule)
  • Usually asymptomatic but may have RUQ pain or haemorrhage
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14
Q

Can hepatic adenomas become malignant ?

A

Yes - more commonly in males

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15
Q

What is the appearance of hepatic adenomas on US, CT, MRI and FNA?

A
  • US: Filling defect, mixed echoity and heterogeneous texture.
  • CT: Diffuse arterial enhancement
  • MRI: Hypo or hyper intense lesion
  • FNA: May be needed
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16
Q

What is the treatment of heaptic adenomas ?

A

Stop hormones, weight loss

Males (irrespective of size) : surgical excision

Females : imaging after 6months:

  • <5cm or reducing in size - annual MRI
  • >5cm or increase in size - for surgical excision
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17
Q

Go over this

A
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18
Q

What are the clinical features of a simple liver cyst and what is it?

A
  • It is a liquid collection lined by an epithelium.
  • It has no biliar tree communication and is solitary and uniloculated

Most of the time asymptomatic but can present with:

  • Intracystic haemorrhage
  • Infection
  • Compression
  • Rupture (rare)
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19
Q

What is the management of a simple liver cyst ?

A
  • No follow up necessary
  • If doubt, imaging in 3-6 mths
  • If symptomatic or uncertain diagnosis (complex cystic lesion), then consider surgical intervention
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20
Q

What causes a hydatid cyst ?

A

Echinococcus infection

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21
Q

Where are hydatid cysts most common ?

A

Eastern Europe Central America and South America, Middle East and North Africa

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22
Q

What is the typical appearance of a hydatid cyst ?

A
  • Typically an intense fibrotic reaction occurs around sites of infection
  • The cyst has no epithelial lining
  • Cysts are commonly unilocular and may grow to 20cm in size. The cyst wall is thick and has an external laminated hilar membrane and an internal enucleated germinal layer
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23
Q

What are the clinical features suggestive of a hydatid cyst ?

A
  • Typically presents with malaise and right upper quadrant pain. Secondary bacterial infection occurs in 10%.
  • Liver function tests are usually abnormal and eosinophilia is present in 33% cases
24
Q

What is the appearance of a hydatid cyst on US ?

A

Septa and hyatid sand or daughter cysts.

25
Q

How are hydatid cysts diagnosed ?

A

Treatment is by sterilisation of the cyst with albendazole and surgical resection.

26
Q

What is the treatment of a hydatid cyst ?

A
27
Q

What is polycystic liver disease ?

A

Embryonic ductal plate malformation of the intrahepatic biliary tree resulting in numerous cysts throughout liver parenchyma

28
Q

What does PCLD usually occur in association with ?

A

ADPKD

29
Q

What genetic mutations cause PCLD and ADPKD ?

A
  • PCLD gene – PRKCSH and SEC63
  • ADPKD genes – PKD1 and PKD2
30
Q

What are the clinical features of PCLD ?

A
  • Liver symptoms = Abdo pain/distension
  • Renal symptoms due to associated ADPKD = haematuria, renal calculi, Increased BP, progressive renal failure
31
Q

What is the treatment of PCLD?

A

Conservative treatment is recommended to halt cyst growth to allow abdominal decompression and ameliorate symptoms

In selected patients with advanced PCLD, ADPKD or liver failure:

  • Defenestration/aspiration
  • Liver transplantation

Pharmacological therapy by somatostatin analogues e.g. octreotide = better outcomes

32
Q

What are the clinical features suggestive of a liver abscess ?

A
  • High fever
  • Leukocytosis
  • Abdominal Pain - RUQ
  • History of Abdominal/biliary infection or a Dental procedure
33
Q

What is the appearance of a liver abscess on US ?

A

Ultrasound will usually show a fluid filled cavity +/- hyperechoic walls

34
Q

What is the management of a liver abscess ?

A
  • Initial empiric broad spectrum antibiotics (IV GAM)
  • Aspiration/drainage percutaneously
  • Echocardiogram

Operation if no clinical improvement:

  • Open drainage
  • Resection

4 weeks antibiotic therapy with repeat imaging

35
Q

Ameobic abscess covered in another set of cards

A
36
Q

What is the most common primary liver tumour ?

A

A hepatocellular carcinoma (HCC)

37
Q

Who do HCC’s most commonly present in ?

A

People with pre-existing liver cirrhosis

38
Q

What are the main causes of HCC?

A
  • Hep B&C
  • Autoimmune hepatitis
  • Alcohol
  • PBC
  • HH
  • NAFLD
  • Aflatoxin

Basically anything that causes liver cirrhosis

39
Q

What are the clinical features suggestive of HCC ?

A
  • Wt loss and RUQ pain (most common)
  • Worsening of pre-existing chronic liver disease
  • Acute liver failure

O/E:

  • Signs of cirrhosis
  • Hard enlarged RUQ mass
  • Liver bruit (rare)
40
Q

What on blood test is usually elevated in patients with HCC’s?

A

Alpha-fetoprotein (>100)

41
Q

How are HCC’s usually initially picked up ?

A

Someone with existing cirrhosis with a mass found on screening U/S

42
Q

How are HCC’s diagnosed ?

A
  • 1st = do US & AFP
  • 2nd = diagnose with triphasic CT & MRI + biopsy
43
Q

How are HCC’s staged ?

A

MRI and chest, abdomen and pelvic CT scan.

44
Q

Where do HCC’s metastasise to ?

A
  • Rest of the liver
  • Portal vein
  • Lymph nodes
  • Lung
  • Bone
  • Brain
45
Q

When is liver transplant viable for someone with HCC?

A
  • Only if single tumour less than 5cm or less than 3 tumours less than 3cm each
  • This is the best available treatment
46
Q

When is resection used in the treatment of HCC’s?

A

For single small tumours <2cm with preserved liver function
(no jaundice or portal HTN) and no associated diseases

47
Q

When is local ablation (ethanol or radifequency) used for treatment of HCC?

A

For small or 3 tumours ≤ 3cm with associated diseases e.g. with advanced liver cirrhosis

48
Q

For intermediate stage HCC’s what treatment is used ?

A
  • TransArterial ChemoEmbolization - TACE
  • Only done in patients with early cirrhosis
49
Q

What systemic therapy is used for advanced HCC’s?

A

Sorafenib

50
Q

What is a cholangiocarcinoma ?

A

This is the second most common type of primary liver malignancy. As its name suggests these tumours arise in the bile ducts. (mainly the extra-hepatic biliary tree)

51
Q

What are the main risk factors for cholangiocarcinoma development ?

A
  • Primary sclerosing cholangitis is the main risk factor.
  • In deprived countries typhoid and liver flukes are also major risk factors.
52
Q

What are the clinical features of a cholangiocarcinoma ?

A
  • Most patients present with obstructive jaundice and by this stage the majority will have disease that is not resectable.
  • May also have fever, abdo pain (+/- ascites), malaise or constitutional symptoms of (weight loss, anorexia)
53
Q

How is a cholangiocarcinoma diagnosed ?

A
  • CA 19-9, CEA and CA 125 are often elevated
  • CT/ MRI and MRCP are the imaging methods of choice.
54
Q

What is the treatment of a cholangiocarcinoma ?

A
  • Majority are not suitable for surgery but if they are then hepatectomy + extrahepatic bile duct excision + caudate lobe resection
  • If not then stenting may help palliate
55
Q

List the common cancers which metastasise to the liver ?

A
  • Colon
  • Breast
  • Lung
  • Stomach
  • Pancreas
  • Melanoma

Y4 Gastrointestinal (28 decks)

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