Liver and Biliary Tract Tumors for the PA Exam
Liver and Biliary Tract Tumors for the Physician Assistant Licensing Exam
Liver Tumors
- Hepatocellular Carcinoma (HCC):
- Epidemiology:
- The most common primary liver cancer, accounting for 80-90% of liver malignancies.
- Strongly associated with cirrhosis from chronic liver diseases like hepatitis B, hepatitis C, and alcoholic liver disease.
- Risk Factors:
- Chronic hepatitis infections (HBV, HCV), alcoholism, nonalcoholic steatohepatitis (NASH), and aflatoxin exposure.
- Hemochromatosis and alpha-1 antitrypsin deficiency are also linked to HCC.
- Clinical Presentation:
- Often asymptomatic in early stages.
- Common symptoms include abdominal pain, weight loss, jaundice, and ascites in advanced stages.
- May present with signs of decompensated cirrhosis or liver failure.
- Diagnosis:
- Imaging (multiphasic CT or MRI) shows arterial enhancement with venous washout, characteristic of HCC.
- Elevated alpha-fetoprotein (AFP) levels support the diagnosis.
- Treatment:
- Surgical resection or liver transplantation for early-stage disease.
- Ablative therapies (e.g., radiofrequency ablation) for small tumors.
- Transarterial chemoembolization (TACE) and sorafenib for intermediate and advanced stages.
- Hepatic Adenoma:
- Epidemiology:
- Benign liver tumor associated with oral contraceptive use and anabolic steroid use.
- More common in young women.
- Clinical Presentation:
- Asymptomatic unless large; may cause abdominal pain or hemorrhage.
- Diagnosis:
- MRI with gadolinium shows well-demarcated lesions.
- Treatment:
- Surgical resection is indicated if >5 cm or symptomatic due to the risk of rupture or malignant transformation.
- Focal Nodular Hyperplasia (FNH):
- Epidemiology:
- Second most common benign liver tumor, typically affecting women.
- Not associated with oral contraceptive use.
- Clinical Presentation:
- Usually asymptomatic and found incidentally.
- Diagnosis:
- Imaging (MRI) shows a central scar with arterial enhancement.
- Treatment:
- No treatment needed unless symptomatic.
Biliary Tract Tumors
- Cholangiocarcinoma:
- Epidemiology:
- Cancer of the bile ducts, divided into intrahepatic and extrahepatic types.
- Risk factors include primary sclerosing cholangitis (PSC), liver flukes, and chronic biliary inflammation.
- Clinical Presentation:
- Painless jaundice, pruritus, dark urine, and pale stools are common in extrahepatic cholangiocarcinoma.
- Intrahepatic cholangiocarcinoma often presents with abdominal pain and hepatomegaly.
- Diagnosis:
- Imaging (MRI/MRCP or CT) shows bile duct obstruction.
- Elevated CA 19-9 levels suggest cholangiocarcinoma.
- Treatment:
- Surgical resection offers the best chance for cure but is feasible only in early-stage disease.
- Adjuvant chemotherapy (gemcitabine, cisplatin) is often used.
- Gallbladder Cancer:
- Epidemiology:
- Rare but the most common malignancy of the biliary tract.
- Associated with chronic gallstone disease, porcelain gallbladder, and chronic cholecystitis.
- Clinical Presentation:
- Symptoms often appear late and include right upper quadrant pain, jaundice, and weight loss.
- Palpable gallbladder (Courvoisier sign) may be seen in advanced cases.
- Diagnosis:
- Ultrasound or CT detects gallbladder masses, with biopsy confirming the diagnosis.
- Treatment:
- Surgical resection for localized disease.
- Advanced disease may require chemotherapy or radiation.
Key Points
- Hepatocellular carcinoma (HCC) is the most common primary liver cancer, associated with cirrhosis from hepatitis B, hepatitis C, and alcohol use. AFP and imaging help in diagnosis, with surgical resection or transplant as curative options.
- Hepatic adenoma is linked to oral contraceptive use and requires surgical resection if large or symptomatic due to the risk of hemorrhage or malignant transformation.
- Cholangiocarcinoma presents with painless jaundice and is associated with primary sclerosing cholangitis. Surgery is the best chance for cure but is often limited by late diagnosis.
- Gallbladder cancer is associated with chronic inflammation and gallstones, with poor outcomes due to late-stage presentation.