CC March 2012 Hepatocellular carcinoma

mrezadabiri's version from 2015-05-28 18:51


Question Answer
Hepatocellular carcinoma (HCC) is the ____ leading cause of CA death worldwide?third
In the developing world, what are the 2 most common causes? In industrialized nations, what are the causes?1. Developing nations: hepatitis B, aflatoxin (mycotoxin contaminant in corn, soybeans and peanuts) 2. Industrialized nations: hepatitis C, alcohol related cirrhosis
Overall, viral hepatitis is the primary etiology,w ith ____ most common in the US?hepatitis C
What is the gender ratio?Males predominate with 4:1 ratio
Median age of onset?62 years of age
How many cases of HCC occur yearly in the US?15,000-20,000
In hep C pts, what precedes development of HCC? cirrhosis
In the 30% of hep C pts who progress to cirrhosis, the risk of HCC Is ___ to ___ per year?1% - 4%
In contrast, 40% of chronic hep B patients who develop HCC do not have underlying _____?cirrhosis
The presence of what marker increases the risk of HCC 5 fold compared to HBV carriers who do not have this marker?Hepatitis B e-antigen (HBeAg) which is a marker of viral replication
In Taiwan, where HBV-related HCC is prevalent, what has significantly reduced the incidence of childhood HCC?neonatal immunization
What substance accelerates the development of cirrhosis in HCV infection and increases the risk of HCC?alcohol
Alcohol-related cirrhosis WITHOUT viral infection is also associated with an increased risk of what?HCC
Patients with what 2 medical conditions have a 35% risk of developing HCC?1. hemochromatosis 2. iron-induced cirrhosis
Does treatment with phlebotomy reduce the risk of HCC after cirrhosis has developed in hemochromatosis?no
Alpha-1-antitrypsin deficiency is associated with a lifetime risk of _________ to _________ for the development of HCC?5-10%
** Certain populations are at high risk for HCC and should have surveillance screening including what 2 tests? Screening for HCC can reduce mortality by ___ to _________% in those w/ HCV and cirrhosis?1. alpha-fetoprotein (AFP) 2. liver US every 6 months 3. 35-40%
** List the populations at high risk for HCC and who should have surveillance screening?1. Asian male hepatitis B carriers > 40 years of age 2. Asian female hepatitis B carrier > 50 years of age 3. hepatitis B carrier wtih family hx of HCC 4. African / North American blacks with hepatitis B 5. Chronic hepatitis B carriers 6. Hepatitis C cirrhosis 7. Stage 4 primary biliary cirrhosis 8. genetic hemochromatosis and cirrhosis 9. alpha-antitrypsin deficiency with cirrhosis 10. other cirrhosis
** List the populations at increased risk fro HCC but efficacy of screening has not been demonstrated?1. hepatitis B carriers < 40 years of age (male) or < 50 years (females) 2. hepatitis C and stage 3 fibrosis 3. noncirrhotic, nonalcoholic fatty liver disease (NAFLD)
For HCC screening of pts with different types of chronic liver disease, an AFP cut-off of ___ ng/mL is generally used (sensitivity 60%, specificity 91%)?20 ng/mL
Unfortunately 40% of HCC patients have a ____ AFP? 40% of HCC cases with tumor diameter < 2 cm also have a normal AFP (< ___ ng/mL)?normal; 20
If the AFP is > 400 ng/mL in a patient w/o HBV carrier state, what does this mean? the presence of HCC is certain
What imaging protocol is indicated for rising serial AFP? What results confirms HCC and a biopsy is not needed?1. a three-phase liver protocol CT or MRI 2. if a hypervascular mass is present with classic enhancements
Screening should be carried out only in what patients?in those who would be eligible for treatment
What is the Child-Pugh classification for?to guage the severity of the liver disease
List the Child-Pugh classification parameters and points assigned as well as how it is scored and what that score means?1. Ascites (absent = 1, slight = 2, > moderate = 3) 2. bilirubin mg/dL (< 2 = 1 point, 2-3 = 2 points, > 3 = 3 points) 3. albumin g/dL (> 3.5 = 1 pont, 2.8-3.5 = 2 points 3. < 2.8 = 3 points) 4. INR (< 1.7 = 1 point, 1.8-2.3 = 2 points, > 2.3 = 3 points) 5. encephalopathy (none = 1 point, grade 1-2 = 2 points, grade 3-4 = 3 points). SCORING: 5-6 total points (Class A meaning well compensated) 7-9 points (Class B meaning significant functional compromise) 10-15 (Class C meaning decompensated diseaes)
What Child-Pugh classification class is screening indicated? 1. A and B should have screening 2. Class C should have screening only if transplant option is considered because average survival of these patients is 6 months after development of HCC.
Studies show that what type of therapy reduces the risk of HCC in pts w/ HCV liver disease even when cirrhosis is present?interferon-based therapy
There is a ___ fold reduction in the incidence of HCC in sustained and transient responders compared to pts who don't respond to or never receive interferon therapy?5
What are the s/s present in 2/3 of HCC patients?1. abdominal pain 2. weight loss 3. early satiety 4. symptoms of decompensating cirrhosis (ascites, jaundice, splenomegaly, edema, variceal bleeding and encephalopathy)
If metastses is present, what are the most frequenc sites?1. lung 2. intra-abdominal lymph nodes 3. bone 4. adrenal gland
Why is the treatment of HCC difficult?complicated by the underlying cirrhosis and hepatic dysfunction
60% of newly diagnosed pts are in advanced stages due to what?due to large hepatic reserve preserving liver function and lack of pathognomonic symptoms
Explain the CLIP score?Hepatocellular carcinoma (Italian Investigators for Cancer of the Liver Program = CLIP score). Child-Pugh class A = 0 points, Class B = 1 point, Class C = 2 points. Tumor morphology (uninodular and < 50% liver involved = 0, multinodular and < 50% liver involved = 1, massive and > 50% liver involved = 2). Alpha fetoprotein (AFP)(< 400 ng/mL = 0, > 400 ng/mL = 1)
Explain the CLIP score and prognosis?0 = 31-36 months survival. 1 = 22-27 months. 2 = 9-13 months. 3 = 7-8 months. 4 = 2-5 months. 5 = 2-3 months.
What is the treatment for Child-Pugh classes A and B, single lesions < 5 cm without metastases, major vascular invation or portal hypertension (hepatic vein pressure gradient < 10 mm Hg?treated by excision or transplant
Patients with 2 lesions < 3 cm are also candidates for what?United Network for Organ Sharing (UNOS) candidates for transplant with similarly good outcomes
Is systemic chemotherapy largely effective in HCC treatment?no
What is a viable option for treatment of HCC?1. transarterial embolization (given perfusion of normal liver cells is through the portal vein, while malignancies in the liver receive almost all their blood supply from the hepatic artery). 2. Gelfoam microspheres and/or chemoembolization with cisplatin and/or doxorubicin (Adriamycin) which improve response rates compared to placebo and overall survival
What 2 treatment can slow HCC progression as well as "bridging" patients until transplant is available and prolong survival?1. radiofrequency ablation (directed hyperthermia) 2. percutaneous alcohol injection
** What treatment can be used to inhibit vascular endothelial growth factor?Sorafenib (Nexavar)
** Describe what Sorafenib (Nexavar) is approved for what type of patient?it is the first palliative oral agent approved for unresectable HCC in patients with Child-Pugh classes A and B
** What is the median survival increase with use of Sorafenib (Nexavar)?3 months
Name a opthalmic vascular endothelial growth factor (VEGF) inhbitor?Aflibercept