Neoplasms

Question 1

Neoplasms of the hepatobiliary system

Answer 1

Connective Tissue

1. Hemangioma - b
2. Angiosarcoma - m

Epithelial

• Liver Cell
  1. Liver cell adenoma - b
  2. Hepatocellular carcinoma - m
  3. Hepatoblastoma - m
• Bile duct
  1. Adenoma - b
  2. Cholangiocarcinoma - m
• Gall bladder
  1. Carcinoma

Question 2

Features of liver hemangioma

Answer 2

• most common benign tumour of the liver
• asymptomatic
• mistaken for metastatic tumours
• complications: rupture, intraperitoneal bleeding

Question 3

Features of liver cell adenoma

Answer 3

• involves various mutations - HNF1-α, β-Catenin, gp130
• associated with oral contraceptives (esp high estrogen), anabolic steroids
• abdominal discomfort, intraperitoneal hemorrhage (outgrows blood supply - necrosis - rupture)
• single 2-15cm diameter, well defined, yellowish, well differentiated trabecular of liver cords separated by sinusoids
• risk of malignant transformation

Question 4

Etiological associations of hepatocellular carcinoma (5)

Answer 4

1. Cirrhosis
2. Hepatotropic viruses - chronic infection (HBV, HCV)
3. Aflatoxins - Aspergillus
4. Alcohol
5. Metabolic diseases eg hemochromatosis

Question 5

Precursor lesions of hepatocellular carcinoma (4)

Answer 5

1. Hepatocellular adenoma (β-catenin activating mutations)
2. Small cell change (directly premalignant - high NC ratio)
3. Large cell change (marker of increased risk - hyperchromatic nucleus, pleomorphism)
4. Dysplastic nodules

Question 6

Morphology of hepatocellular carcinoma

Answer 6

G:

• unifocal large mass or widely distributed nodules
• against a background of cirrhosis/diffuse infiltrative cancer
• variegated in cut section, yellowish background, grey necrosis, red hemorrhage, green bile

M:

• tracebulae or hepatocytes separated by sinusoids
• eosinophilic cytoplasm, pleomorphism
• bile production

Question 7

Clinical features of hepatocellular carcinoma

Answer 7

• associated with cirrhosis
• portal vein involvement
• α-fetoprotein - tumour marker - can be taken in the blood, but also indicative of other conditions

Question 8

Prognostic factors of hepatocellular carcinoma

Answer 8

1. Stage
2. Encapsulation (better)
3. Number of tumours
4. Fibrolamellar variant - better prognosis if surrounded by fibrosis
5. Presence of cirrhosis (worse)

Question 9

Features of hepatoblastoma

Answer 9

• almost exclusively in early childhood
• no cirrhosis
• elevated α-fetoprotein
• variants: epithelial type, mixed epithelial and mesenchymal type
• variety of mutations
• usually fatal if untreated, therapy 5y survival 80%

Question 10

Features of cholangiocarcinoma

Answer 10

• primary malignant tumour of biliary tree
• liver flukes infestation (opisthorchis, clonorchis)
• chronic inflammatory disease of large bile ducts
• HBV, HCV, NAFLD
• obstructive jaundice +/- pain, palpable (distended) gallbladder, poor prognosis

Question 11

Morphology of cholangiocarcinoma

Answer 11

• Site - hepatic bile duct (hilar) to ampulla of Vater
• G: small, thickening of wall, papillary growth into the lumen, few mets
• M: adenocarcinoma

Question 12

Features of carcinoma of gall bladder

Answer 12

• G: diffuse (70%), polypoid (30%), cholelithiasis (80-90%)
• simulated chronic cholecystitis
• propensity to invade liver, stomach, duodenum
• mets to liver, lymph node
• poor prognosis