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Medical oncology > Liver Cancer > Flashcards

Liver Cancer Flashcards

1
Q

What is the indo-cyanine green test?

A

Correlates with MELD score.

RR of mortality for major hepatectomy increase 3x if ICG retention at 15 minutes >14%

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2
Q

What is the adequate future liver remnant percentage?

A

Normal liver: FLR of at least 25% to prevent postop liver failure
Cirrhotic liver: FLR up to at least 40% necessary

Inadequate FLR is the most common factor precluding curative LR

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3
Q

What is the Milan Criteria?

A

1) Single lesion, 5cm or less

2) No more than 3 nodules, each

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4
Q

Which is better in early HCC?
Liver Resection or Liver Transplant.
Why

A

Liver Transplant

  • Better survival with liver transplant if HCC within Milan criteria
  • Lower recurrence rate, but poorer long-term outcome
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5
Q

What is the 5-yr OS in liver transplant for HCC?

A

N=4500
Pelletier 2009

5yr OS within Milan 65%
5yr OS outside Milan 40%

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6
Q

Describe RFA

A

1) Most efficacious for small volume HCC (No more than 3 lesions, each no more than 3cm)
2) 5yr OS 30-60%
3) risk of Mortality 1%, Complx risk 3-7%
4) No diff in OS & DFS compared to resection. Less Complx with RFA
5) RFA superior to PEI in RR, OS, RFS

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7
Q

Describe TACE

A

TACE = Trans-arterial Chemoembolisation
1st line Tx for unrest table, large/multi focal HCC w/o vascular invasion/etrahepatic spread

Can be used prior to resection/bridging therapy prior to transplant

Doxorubicin/CDDP

CR 2%, Disease control rate 40%.

ORR 20-60%

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8
Q

What is the post-embolization syndrome?

A

~90% following TACE.

Fever, malaise, RUQ pain, nausea+vomiting

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9
Q

Contra-indications to TACE

A

Absolute:

  • Thrombus in main portal vein and portal vein obstruction (high risk of liver failure)
  • Encephalopathy
  • Biliary Obstruction
  • CP score C

Relative:

  • BIL >34
  • LDH >425
  • AST >100
  • Tumor burden >50% of liver
  • Cardiac/renal insufficiency
  • Ascites, recent variceal bleed, significant thrombocytopenia
  • Transjugular inhtrahepatic portosystmic shunt (TIPS)
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10
Q

Conventional TACE vs DCBeads TACE

A

PRECISION V Trial

  • Phase II, n=200
  • TACE (Doxorubicin) vs DC Beads (Doxorubicin)
  • non-significant results. Trend towards improved RR and disease control rate
  • Significant: Less liver toxicity, less Doxorubicin toxicity with DC beads
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11
Q

What is the role of combining Sorafenib + TACE in intermediate HCC?

SPACE (Sorafenib or Placebo in combination with TACE in HCC)

A

Phase II, RCT, 2 arms:

  • DC TACE + SORAFENIB
  • DC TACE + Placebo

Incl criteria:
- unrest table HCC

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12
Q

Role of Chemoimmunotherapy in HCC

- using PIAF regimen

A

PIAF = CDDP, Doxorubicin, IFNa, CI 5FU

  • Phase III compared PIAF to doxorubicin.
  • n=200
  • RR 20% vs 10%, not significant. No CRs
  • Med Survival 8.7m vs 7m
  • Sig more toxicities: 80% neutropenia, 60% thrombocytopenia
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13
Q

What is the EACH study?

A

Phase III, RCT, n=370. 2 arms:

- FOLFOX4 vs Doxorubicin group

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14
Q

Role of XELOX in HCC?

A

Phase II study, n=50
ORR 6%, DCR 70%
Med OS 9.3m

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15
Q

Describe the SHARP trial

A

Llovet NEJM 2008
N=300

Advanced HCC, CPA, ECOG 0-2, Life expectancy at least 12 months
Randomized to Sorafenib vs Placebo

RR 2%vs 1%
TTP 5.5 m vs 3m
0S 10.7m vs 8

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16
Q

Describe the Asia-Pacific study

A

Advanced HCC, ECOG 0-2, CP A
2 groups: Sorafenib vs placebo
-N=226

RR 3% vs 1%
TTP: 3m vs 1.5 m
OS 6.5m vs 4m

17
Q

Side-effects of Sorafenib

A

Diarrhea
HFS
Fatigue
Rash

18
Q

Any Role for Adjuvant Therapy in HCC?

A

No!
STORM trial was negative.
N=1100
Sorafenib as adjuvant tx in prevention of Recurrence of HCC

Prior tx of:

  • Resection
  • RFA
  • PEI
19
Q

In Whom is HCC Screening & Surveillance is Recommended?

A

1) Hepatitis B Carriers (HBsAg +)
- Asian males >40yo; Females >50yo
- All cirrhotic Hep B carriers
- FHx of HCC
- Africans >20yo
2) Non-Hep B Cirrhosis
- Hep C
- Alcoholic Cirrhosis
- Genetic hemochromatosis
- Primary Biliary Cirrhosis
- possibly: AAT deficiency, NASH, Autoimmune hepatitis

20
Q

Name some Staging systems for HCC

A

1) Okuda Staging
2) Child-Turcotte-Pugh (for cirrhosis)
3) BCLC staging
4) CLIP staging (Cancer of the Liver Italian Program)
5) CUPI

21
Q

Describe the Okuda Staging

A

Uses Tumor size, presence of Ascites, Bilirubin and serum Albumin

Stage I: No + factors
Stage II: 1-2 positive factors
stage III: 3-4 positive factors

22
Q

Describe the CLIP Staging.

- Cancer of the Liver Italian Program

A

1) Components:
- Child-Pugh Score,
- Tumor morphology and % of involvement of liver
- AFP
- Portal Vein thrombosis

Does not adequately assess those undergoing radical therapies (eg. Resection/transplantation)

23
Q

Describe HBV cancer-promoting actions:

A

1) Insertional mutagenesis
2) p3 inhibition
- explains why it can induce HCC in non-cirrhotic liver

24
Q

What are the variables that affect risk of recurrence following resection of HCC?

A

1) Tumor size
2) Number of tumors
3) Vascular invasion
4) Width of resection margin

25
Q

What are the methods of Percutaneous Ablation for HCC?

A

1) Percutaneous Ethanol Injectino
2) RFA
3) Injection of acetic acid
4) Injection of boiling saline
5) Cryotherapy
6) Microwave therapy
7) Laser therapy

26
Q

Usage of TACE is limited to what group of patients?

A

Preserved liver function
Absence of extra hepatic spread
Absence of vascular invasion
No significant cancer-related symptoms

TACE may offer palliative benefits for patients with intermediate stage HCC, with 5-yr survival rates > 50%

27
Q

Explain TACE

A

TACE = Transarterial Chemoembolization

Induce ischemic tumor necrosis via acute arterial occlusion

Emboli station may be done alone (Transarterial embolization) or combined with selective intraarterial chemotherapy (TACE)

28
Q

What are the factors in the CUPI score?

A

CUPI = Chinese University Prognostic score
(A.A.A.A.T.T)

Variables include:

1) TNM stage
2) Asymptomatic disease on presentation
3) Ascites
4) AFP
5) Total bilirubin
6) ALP

29
Q

What are the factors in Okuda staging

A

1) Tumor Size
2) Ascites
3) Albumin
4) Bilirubin

30
Q

What are the risk factors for HCC?

A 
Hep B, C
Alcohol
Genetic hemochromatosis 
NASH
Stage 4 primary biliary cirrhosis
Alpha1-anti trypsin deficiency 
Other causes of cirrhosis
31
Q

What are the risk factors for HCC?

A 
Hep B, C
Alcohol
Genetic hemochromatosis 
NASH
Stage 4 primary biliary cirrhosis
Alpha1-anti trypsin deficiency 
Other causes of cirrhosis
32
Q

What are the risk factors for HCC?

A 
Hep B, C
Alcohol
Genetic hemochromatosis 
NASH
Stage 4 primary biliary cirrhosis
Alpha1-anti trypsin deficiency 
Other causes of cirrhosis

Medical oncology (53 decks)

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