Liver cancers

Question 1

what’s the most common form of cancer in the liver

Answer 1

metastases from another area

Question 2

what are the risk factors for hepatocellular carcinomas?

Answer 2

• viral hepatitis (B and C mainly)
• high alcohol intake
• smoking
• advanced age (> 70)
• aflatoxin - carcinogen produced by moulds
• FHx

Question 3

common causes of hepatocellular carcinomas?

Answer 3

viral hepatitis
chronic alcoholism
hereditary hemochromatosis
primary biliary cirrhosis
aflatoxin

Question 4

clinical features of hepatocellular carcinoma??

Answer 4

• similar symptoms to cirrhosis
• fatigue, fever, weight loss and lethargy

advanced:
- features of liver failure (e.g. ascites/jaundice)

examination:
irregular, enlarged, craggy and tender liver –> highly suggestive of liver malignancy

Question 5

what are the investigations performed in suspected hepatocellular carcinoma??
what are the relevant findings?

Answer 5

lab tests 
LFTs: may be deranged 
low platelets or prolonged clotting - liver failure
alpha fetoprotein (AFP) - should be measured (also to monitor response and recurrence)

imaging
USS - mass >2cm and raised AFP - virtually diagnostic
MRI - for further assessment (alongside CT angiogram shows a mass with hyper vascularisation)
Biopsy/percutanous fine-needle aspiration - last resort

Question 6

how is hepatocellular staged?

Answer 6

the Barcelona clinic liver cancer staging system (BCLC)

Question 7

what is the surgical management of hepatocellular carcinomas?

Answer 7

surgical resection: without cirrhosis and good baseline health status
transplantation - must fulfill Milan criteria :
- one lesion <5cm or three lesions < 3 cm
- there are no extrahepatic manifestations
- no vascular infiltration

Question 8

what is the non-surgical management of hepatocellular carcinoma?

Answer 8

image-guided ablation (USS probes are placed in the tumour mass to induce necrosis) - early HCC

alcohol ablation - injection of alcohol into the tumor
effective on small tumours + well-functioning liver

transarterial chemoembolization (for BCLC stage B)

Question 9

what is transarterial chemoembolization (TACE)?

Answer 9

high concentration of chemotherapy drugs injected into hepatic artery –> embolising agent then added –> induces ischemia

radiology used to inject and embolise branches of hepatic artery supplying tumour –> preserved most of the liver

Question 10

what are the most common cancers that metastasize to the liver

Answer 10

bowel, breast, pancreas, stomach, and lung

*liver metastases are the most common cause of death in patients with cancer

Question 11

what are the clinical features of metastasis to the liver?

Answer 11

asymptomatic –> anorexia and weight loss –> jaundice (late)

Question 12

what are the findings on investigation in metastatic cancers in liver?

Answer 12

similiar to hepatocellular carcinoma
derangement pf LFTs (raised ALP)
USS and CT (look for further metastases)

Question 13

why is biopsy not performed in metastases in the liver?

Answer 13

biopsy risks seeding of the tumour

Question 14

is surgical therapy ever considered in metastatic liver cancer?
what other options are there?

Answer 14

only indicated if metastases are confined to liver + primary tumour under control.
majority simply have palliative care