Hepatobiliary

Liver Cancers

Hepatocelluar Carcinoma

fibrolamellar variant

  • uncommon variant of HCC
  • has better prognosis compared to conventional (controversial)
  • rarely associated with cirrhosis
  • more present with positive lymph nodes

Typical HCC

  • higher local-regional failure than metastatic

Tumors of the Gallbladder

Overview

  • Female > Male
  • gallstones and porcelain gallbaldder are risk factors
  • Surgery primary treatment, but only minority resectable

Biospy and Cytologic Analysis

  • cholecystectomy before definitive resection is unacceptable
  • definitive resection at the time of initial exploration should be the goal.

Trials

Biliary Tract Cancers

Etiology

Development of cholangiocarcinoma is liked to

  • liver fluke infestation
  • hepatolithiasis
  • pyogenic cholangitis
  • congenital bile duct cysts
  • exposure to thorium dioxide
  • typoid carrier state
  • ulcerative coliits

primary sclerosing cholangitis

  • 10% incidence of developing cholangiocarcinoma
  • risk is lessened 10 years after cholecyctectomy (may have some common pathway with gallbladder cancer).

Review

Intrahepatic Extrahepatic
Hilar (Klatskin’s) extrahepatic Distal/ ampullary
Presentation
Incidence 67% (most common)
Treatment
Surgery • Few achieve negative margins
• Transplant not successful
• 14-40% respectable • Distal tumors are usually respectable
• Roux-en-Y hepaticojejunostomy
• 90% resection rate
• pancreaticoduodenectomy
Radiation • external and radiolabeled immunoglobulin have not shown to have long term survivors • Local recurrence after complete resection is 25-40%see below
• Recurrences are most often locoregional, but 33% fail distantly (lung, liver, peritoneum)
• Ampullary cancers have 50% local failure with any of these features (Willett): invasion of pancreas, nodes +, poor differentiation, margins +
• Consider 45 Gy with boost to 50-55 Gy for pos margins/ high risk.
• Can also consider Ir 192 implant through biliary stent dosed to 20-25 Gy at 0.5-1.0 cm as a boost.
Chemotherapy • as monotherapy for unresectable is largely ineffective
Results
Median Survival • 12-28 mo. w/ resection
• 7 months regardless of treatment w/o resection
• ?22 mo. with resection
• 6 months for patients treated palliatively (ie. non-surgical)
• 9-12 mo. for palliative patients treated with EBRT to 45-50 Gy with CT. but there were few long term survivors
• 22 month with resection
OS-5 • 22-36% w/ resection
• 0% w/o resection
• 20-25% with surgical resection with R0 being better
• < 10 % 3 year survival for patients treated palliatively w/o resection
• 14—50% with surgical resection with R0 being better
• < 10 % 3 year survival for patients treated palliatively w/o resection
• 30-40% with resection
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