Chapter 088. Hepatocellular Carcinoma (Part 11) potx

Chapter 088. Hepatocellular Carcinoma (Part 11) Carcinoma of the Ampulla of Vater This tumor arises within 2 cm of the distal end of the common bile duct, and is mainly (90%) an adenocarcinoma. Locoregional lymph nodes are commonly involved (50%), and the liver is the most frequent site for metastases. The commonest clinical presentation is jaundice, and many patients also have pruritus, weight loss, and epigastric pain. Initial evaluation is performed with an abdominal ultrasound to assess vascular involvement, biliary dilatation, and liver lesions. This is followed by a CT scan, or MRI and especially MRCP. The most effective therapy is resection by pylorus-sparing pancreaticoduodenectomy, an aggressive procedure resulting in better survival rates than local resection. Survival rates are ~25% at 5 years in operable patients with involved lymph nodes and ~50% in patients without involved nodes. Unlike CCC, ~80% of patients are thought to be resectable at diagnosis. Adjuvant chemotherapy or radiotherapy has not been shown to be useful in enhancing survival. For metastatic tumors, chemotherapy is currently experimental. Tumors Metastatic to the Liver These are predominantly from colon, pancreas, and breast primary tumors but can originate from any organ primary. Ocular melanomas are prone to liver metastasis. Tumor spread to the liver normally carries a poor prognosis for that tumor type. Colorectal and breast hepatic metastases were previously treated with continuous hepatic arterial infusion chemotherapy. However, more effective systemic drugs for these cancers, especially the addition of oxaliplatin to colorectal cancer regimens, have reduced the use of hepatic artery infusion therapy. In a large randomized study of systemic versus infusional plus systemic chemotherapy for resected colorectal metastases to the liver, the patients receiving infusional therapy had no survival advantage, mainly due to extrahepatic tumor spread. 90 Yttrium resin beads are approved in the United States for treatment of colorectal hepatic metastases. The role of this modality, either alone or in combination with chemotherapy, is being evaluated in many centers. Palliation may be obtained from chemoembolization, PEI, or RFA. Benign Liver Tumors Three common benign tumors occur and all are found predominantly in women. They are hemangiomas, adenomas, and focal nodular hyperplasia (FNH). FNH is typically benign, and usually no treatment is needed. Hemangiomas are the commonest and are entirely benign. Treatment is unnecessary unless their expansion causes symptoms. Adenomas are associated with contraceptive hormone use. They can cause pain and can bleed or rupture, causing acute problems. Their main interest for the physician is a low potential for malignant change and a 30% risk of bleeding. For this reason, considerable effort has gone into differentiating these three entities radiologically. Upon discovery of a liver mass, patients are usually advised to stop taking sex steroids, since adenoma regression may then occasionally occur. Adenomas can often be large masses ranging from 8–15 cm. Due to their size and definite, but low, malignant potential and potential for bleeding, adenomas are typically resected. The most useful diagnostic differentiating tool is a triphasic CT scan performed with HCC fast bolus protocol for arterial-phase imaging, together with subsequent delayed venous-phase imaging. Adenomas usually do not appear on the basis of cirrhosis, although both adenomas and HCCs are intensely vascular on the CT arterial phase and both can exhibit hemorrhage (40% of adenomas). However, adenomas have smooth, well-defined edges and enhance homogeneously, especially in the portal venous phase on delayed images, when HCCs no longer enhance. FNHs exhibit a characteristic central scar that is hypovascular on the arterial-phase and hypervascular on the delayed-phase CT images. MRI is even more sensitive in depicting the characteristic central scar of FNH. Further Readings Furukawa H et al: Living- donor liver transplantation for hepatocellular carcinoma. J Hepatobiliary Pancreat Surg 13:393, 2006 [PMID: 17013712] Goin JE et al: Treatment of unresectable hepatocellular carcinoma with intrahepatic yttrium 90 microspheres. J Vasc Interv Radiol 16:161, 2005 Llovet JM et al: A molecular signature to discriminate dysplastic nodules from early hepatocellular carcinoma. Gastroenterology 131:1758, 2006 [PMID: 17087938] Parikh S, Hyman D: Hepatocellular cancer: A guide for the internist. Am J Med 120:194, 2007 [PMID: 17349437] Steel JL et al: Clinically meaningful changes in health- related quality of life in patients with hepatobiliary cancer. Ann Oncol 17:304, 2006 [PMID: 16357021] Thorgeirsson S et al: Molecular prognostication of liver cancer: End of the beginning. J Hepatol 44:798, 2006 [PMID: 16488507] Bibliography Bartlett D et al: Cancer of the Liver, in Cancer: Principles and Practice of Oncology , 7th ed, V DeVita et al (eds). Philadelphia, Lippincott Williams & Wilkins, 2005, pp 986–1009 Carr BI (ed): Hepatocellular Cancer: Diagnosis and Treatment . Totowa, NJ, Humana Press, 2005 Hepatocellular Carcinoma. NIH workshop. Gastroenterology 127:S1, 2004 Mizuta T et al: The effect of menatetrenone, a vitamin K2 analog, on disease recurrence and survival in patients with HCC after curative treatment. Cancer 106:867, 2006 [PMID: 16400650] . Chapter 088. Hepatocellular Carcinoma (Part 11) Carcinoma of the Ampulla of Vater This tumor arises within 2 cm of the distal end of the common bile duct, and is mainly (90%) an adenocarcinoma liver transplantation for hepatocellular carcinoma. J Hepatobiliary Pancreat Surg 13:393, 2006 [PMID: 17013712] Goin JE et al: Treatment of unresectable hepatocellular carcinoma with intrahepatic. to discriminate dysplastic nodules from early hepatocellular carcinoma. Gastroenterology 131:1758, 2006 [PMID: 17087938] Parikh S, Hyman D: Hepatocellular cancer: A guide for the internist.