Workup/Staging Flashcards
What initial labs should be sent if suspecting CC or GB cancer?
Bilirubin, alk phos, aspartate aminotransferase (AST), and alanine transaminase (ALT) (can often be normal); γ-glutamyl transpeptidase, CEA, and CA 19-9 are particularly helpful in CC or GB cancer.
In what pts is CA 19-9 less reliable?
Pts without Lewis blood group antigen (10% of population) do not have CA 19-9. Hyperbilirubinemia can decrease specificity and accuracy of CA 19-9.
What initial imaging is used for suspected CC and GB cancer?
RUQ US, contrast CT (preferably multiphase), and MRCP are typically performed for suspected CC or GB cancer.
On contrast-enhanced CT, how can hepatocellular carcinoma (HCC) and IHCC be distinguished?
On contrast-enhanced CT of the liver, HCC usually enhances during the arterial phase, while IHCC may show delayed enhancement.
What is the imaging study of choice for EHCC?
MRCP is the imaging study of choice for EHCC, as it has improved the ability to define tumor extent and LN involvement.
What invasive imaging strategies are available?
ERCP and percutaneous transhepatic cholangiography (PTC) can help image obstruction, but MRCP/CT is preferred.
How is a pathologic Dx obtained for CC?
For resectable pts without obstruction, pathology can be obtained at Sg. For unresectable pts or pts with obstruction requiring stenting, duct brushings can be obtained at ERCP, or Bx can be done at time of PTC or EUS.
How is a pathologic Dx obtained for GB cancer?
Definitive resection is the diagnostic approach if GB cancer is suspected. Bile cytology (low yield) or percutaneous Bx can be performed in unresectable pts.
When is ERCP- or PTC-based stenting indicated prior to Sg?
If bilirubin is elevated (i.e., >10–15), ERCP- or PTC-guided stents are placed to decompress obstruction and allow liver recovery prior to Sg.
In addition to locoregional imaging, what staging imaging is recommended for GB cancer and CC?
In addition to locoregional imaging, staging for GB cancer and CC should include CT chest.
What staging procedure is recommended at the beginning of Sg for GB cancer or CC?
Staging laparoscopy is generally recommended at the beginning of Sg for GB cancer or CC to r/o peritoneal dissemination.
How should tumors arising from mid common bile duct (CBD) be staged?
These EHCCs are exceedingly rare, but they are staged as distal CCs.
What is the AJCC 8th edition (2017) T staging for IHCC (changes from 7th edition are in bold for all staging questions)?
Tis: carcinoma in situ
T1a: solitary tumor ≤5 cm without vascular invasion
T1b: solitary tumor >5 cm without vascular invasion
T2: solitary tumor with intrahepatic vascular invasion OR multiple tumors with or without vascular invasion
T3: tumor perforating visceral peritoneum
T4: tumor involving local extrahepatic structures by direct invasion
What is the AJCC 8th edition (2017) T staging for perihilar CC?
Tis: carcinoma in situ/high-grade dysplasia
T1: tumor confined to bile duct, with extension up to muscle layer or fibrous tissue
T2a: tumor invades beyond bile duct wall to surrounding fat
T2b: tumor invades hepatic parenchyma
T3: tumor invades unilat branches of portal vein (right or left) or hepatic artery (right or left)
T4: tumor invades any of the following: main portal vein or bilat branches, common hepatic artery, or unilat 2nd-order biliary radicals with contralat portal vein or hepatic artery involvement
What is the AJCC 8th edition (2017) T staging for distal bile duct CC?
Tis: carcinoma in situ/high-grade dysplasia
T1: tumor invades the bile duct wall to a depth <5 mm
T2: tumor invades the bile duct wall to a depth 5–12 mm
T3: tumor invades the bile duct wall to a depth >12 mm
T4: tumor invades celiac axis, SMA, and/or common hepatic artery
