Flashcards in Cancer of the liver, gallbladder, and biliary tree Deck (20)
Which cancers are commonest in the liver?
Secondary liver cancer. Most common metastases from breast, bowel, or lung cancer.
Describe the prognosis of secondary liver cancer
Most common cause of cancer death (35%)
Only 25% are suitable for curative surgery
How does secondary liver cancer present?
Hepatomegaly and ascites (50%)
-Ascites indicates wide dissemination and poor prognosis
Obstructive metastases: Jaundice, malaise, anorexia, weight loss
How is secondary liver cancer investigated?
FBC - anaemia and leukocytosis
LFTs - may be abnormal
Bilirubin, ALP, ALT may be raised
Alpha fetoprotein, PVIKA-II, CEA, CA19-9
CXR and Abdominal USS
Biopsy - not advised if tumour is operable
What management options exist for secondary liver cancer?
Hepatectomy for stage IV colorectal cancer
Freezing, ethanol, lasers, radio frequency ablation
Transcatheter arterial chemoembolisation
Laparoscopic liver resection for solitary liver met
Selective internal radiation therapy for non-resectable colorectal metastases in the liver
What are the types of primary liver cancer?
Hepatocellular carcinoma (90%)
Fibrolamella carcinoma - large vascular mass
Hepatoblastoma - children
What is the link between HCC and chronic liver disease?
70-90% of HCC develops in patients with chronic liver disease. Tumours are multifocal in 75% at presentation.
Describe the epidemiology of hepatocellular carcinoma
<1% of all new cancers in UK
Prevalence follows HBV and HCV infection
Common in Africa and Asia
Name 5 risk factors for hepatocellular carcinoma
90-95% have underlying cirrhosis
-Chronic HBV: commonest worldwide cause of HCC
-HCV: commonest cause of HCC in Europe
-Primary biliary cirrhosis
-Aflatoxins, contraceptives, androgens
-Metabolic syndrome, diabetes, smoking
How does hepatocellular carcinoma present?
Commonest: rapid deterioration of pre-existing cirrhosis
Symptoms: Pruritus, splenomegaly, bleeding oesophageal varicose, weight loss, jaundice, hepatic encephalopathy, ascites, RUQ pain
Signs: Jaundice, hepatomegaly, ascites, spider naevi, peripheral oedema, anaemia, caput medusa, liver flap/asterixis
Where does primary liver cancer metastasise?
Periportal lymph nodes
How are primary liver cancers investigated?
Alpha fetoprotein (AFP) >500ng/mL ➔ highly suggestive of HCC
USS: identifies site and cause of obstruction
Needle biopsy to confirm HCC diagnosis
ERCP to diagnose ampullary and bile duct carcinomas
PTC to diagnose intrahepatic biliary tumours
CT to assess local spread, LN, and metastases
What surgical treatment is available for primary liver cancer?
Partial hepatectomy (HCC)
Liver transplant (HCC associated with chronic hepatitis)
Embolisation. Percutaneous thermal or radio frequency ablation
What is the prognosis of HCC?
44% 5yr survival if surgically resectable
20% resectable at diagnosis
What types of cholangiocarcinoma exist?
Ductal adenocarcinoma (>90%)
Squamous cell carcinoma
Where can cholangiocarcinomas occur?
Perihilar region "Klatskin tumour" (commonest)
Distal: upper border of pancreas to ampulla of Vater
Describe the epidemiology of cholangiocarcinoma
Rare: 1-2 per 100,000 population per year
Most occur in over 60s
High incidence in SE Asia due to liver flukes parasite
Name 2 risk factors for cholangiocarcinoma
Primary sclerosing cholangitis
Liver flukes infection
Industrial chemical exposure
Congenital bile duct abnormalities
Caroli's disease - dilatation of intrahepatic biliary tree
How is cholangiocarcinoma managed?
Radical excision of bile duct with reconstruction
Pancreaticoduodenectomy (distal cholangiocarcinoma)
Endoscopic/percutaneous stenting (palliative)