Devita, Hellman, and Rosenberg's Cancer

LWBK1006-20 LWW-Govindan-Review December 12, 2011 19:4

258 DeVita, Hellman, and Rosenberg’s CANCER: Principles and Practice of Oncology Review

programs are in place in endemic areas of HCC and in high-risk popula-

tions, it is unclear whether screening identifies patients at an earlier stage

or improves patient survival. Detection of HCC, through surveillance of

patients awaiting liver transplantation, results in increased priority for

orthotopic liver transplantation.

Answer 20.3.7. The answer is D.

In most patients, cholangiocarcinoma is sporadic and no precipitat-

ing factor can be identified. Risk factors that have been associated

with the development of cholangiocarcinoma can be divided into con-

genital (choledochal cysts, anomalous pancreatic-biliary tree junction),

autoimmune (primary biliary cirrhosis), infectious (clonorchis sinensis

andOpisthorchis viverriniinfestation, chronic portal bacteremia, and

portal phlebitis) and finally environmental exposures (thorotrast and pos-

sibly cigarette smoking).

Answer 20.3.8. The answer is B.

Approximately one-third of patients presenting with the suspected diag-

nosis of cholangiocarcinoma will have resectable disease. Operative mor-

tality averages approximately 8%, indicating the high-risk population

that this tumor affects and the complexity of the procedure. Some 10%

to 35% of patients survive 5 years after surgical resection. Recurrences

occur most commonly at the bed of resection, followed by retroperi-

toneal lymph nodes. Distant metastases occur in one-third of cases. The

most common site is the lung or mediastinum, followed by liver and peri-

toneum. Comparisons of outcome over time suggest improved outcome

in more recent series as a result of routine inclusion of liver resection.

Prognostic factors for survival include negative microscopic margin sta-

tus, lymph node metastases, tumor size, tumor grade, preoperative serum

albumin, hepatic resection, and postoperative sepsis.

Answer 20.3.9. The answer is B.

The patient’s pathology reveals a T2 NX stage IB gall bladder cancer.

Answer 20.3.10. The answer is A.

Numerous studies have demonstrated that simple cholecystectomy is

curative for stage I disease (T1, N0). Recent studies have suggested that

the prognosis is different for pT1a and pT1b tumors after simple chole-

cystectomy. Invasion of the muscular layer allows access to lymphatics

and vessels, providing the rationale for extended cholecystectomy in this

population. When an extended cholecystectomy is performed for T2 dis-

ease, the 5-year survival has been reported to be as high as 100%, but

probably falls in the range of 70% to 90% (PPOTable 39.8.13). Simple

cholecystectomy alone is associated with a 5-year survival rate of 20% to

40.5%. Lymph node metastases are seen in 46% of patients with T2 pri-

mary tumors, providing another reason in favor of radical repeat resection

after simple cholecystectomy. In series of extended cholecystectomies, the

operative morbidity ranges from 5% to 46%, and the mortality ranges