HCC

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Does TACE prior to liver transplant for HCC result in inferior post-transplant survival ?

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No

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Which chemotherapeutic combinations are suitable for second line HCC?

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Gemcitabine plus cisplatin
Doxorubicin plus cisplatin
Gemcitabine plus oxaliplatin

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What are the Milan criteria for liver transplantation for HCC?

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Single lesion less than 5 cm, 3 different lesions, maximum with each less than 3 cm diameter
No vascular invasion, no lymphadenopathy, no distant metastases

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Generally, is resection or transplant preferred for HCC?

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Resection

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For liver transplant patients who are listed, how often do they need need serial scans for
lesions size surveillance?

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Every 3 months

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What are some pretransplant management options for HCC?

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Radiofrequency ablation and TACE

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What type of liver transplant is preferred for liver cancer?

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OLT > LDLT/DDLT

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If focal ablation is not an option, what’s a second option for local control of HCC?

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TACE

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Which type of TACE is preferred?

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Drug-eluting beads

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What are some contraindications for TACE?

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Bilirubin greater than or equal to 2, LDH greater than or equal to 425, AST greater than or
equal to 100, tumor burden greater than 50% of liver parenchyma, cardiac disease, renal
disease, ascite, variceal bleeding, thrombocytopenia

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How would you perform a TACE for 3 lesions?

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Each 1 month apart

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With this imaging show for an HCC lesion following local regional therapy?

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Nodularity–thickness

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What the 2 major side effects of sorafenib?

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Diarrhea, hand-foot syndrome

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Which 4 drug regimen is used for very good performance status liver cancer patients?

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PIAF – cis-platinum, interferon, doxorubicin, 5-FU

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If chemotherapy is required for liver cancer, which doublet is preferred?

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Gemcitabine and cisplatin.

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Which immunotherapy agents are active in HCC?

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IFN-alpha, PD-L1 directed therapies including nivolumab and pembrolizumab

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What is the size cut-off on ultrasound for liver cancer screening to consider further imaging
such as MRI or CT?

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1 cm

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How do you manage a suspected HCC lesions that is less than 1 cm?

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Repeat imaging in 3 months

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The expression of which proteins on HCC histology, predicts for a chemotherapeutic
resistance?

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P53, P-glycoprotein, glutathione transferase, heat shock proteins

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What is characteristic of HCC on arterial and venous phase imaging?

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Enhanced arterial imaging and delayed venous washout

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What are the 4 features of HCC paraneoplastic syndrome?

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Hypoglycemia, erythrocytosis, diarrhea, hypercalcemia

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What is the child Pugh class limit for HCC on sorafenib therapy?

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Class C

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What is TACE most commonly used for in the setting of HCC?

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Bridge to transplantation

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What is a major contraindication to TACE?

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Portal vein thrombosis

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What agent is used for radio embolization in liver cancer?

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Yttrium-90

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What are HCC transplant “bridge” options?

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RFA, TACE, radio embolization, radiation, ethanol ablation, local resection

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How often are liver transplant patients imaged?

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Every 3 months

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For patients with HCC, awaiting transplant, what type of bridge is recommended, and when is
it recommended?

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RFA, if the transplant weight is greater than 6 months

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What is the size cut-off for radiofrequency ablation for HCC?

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3 cm

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Which single agent chemotherapy is good for older patients with HCC?

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Doxil and Xeloda

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Which hormonal agents are active in HCC?

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Tamoxifen, megestrol, octreotide

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What is the role of sunitinib or axitinib in HCC stage IV?

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It is not recommended

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Which pathways are most active in hepatocellular carcinoma?

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RAS-RAF-ERK

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What benefit is there to adding doxorubicin to sorafenib?

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None

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What is the major side effect of sorafenib that should prompt consideration of medication
discontinuation?

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Elevated liver enzymes

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Which phase 3 clinical trial showed superiority of sorafenib in HCC?

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SHARP

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What is the largest diameter in HCC lesion can have with regards to TACE?

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5 cm

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How do you manage an HCC patient with resectable HCC, but have + portal vein thrombosis?

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Portal vein embolization

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What are the 2 delivery methods for TACE?

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Lipidiol and beads (polyethylene)

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When would you consider cryoablation versus radiofrequency ablation?

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More peripheral lesions

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Is HCC radiosensitive or radioresistant?

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Radiosensitive

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What is anticipated maximum waiting time for liver transplant that would warrant bridge
therapy?

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6 months

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What is the smallest HCC lesion size required to get on a transplant list?

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2 cm, T2 2-5cm, max 3×3, no lymph node involvement, no vascular involvement, no
metastatic disease

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What is the role of radiation in liver cancer?

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Bridge, nontransplant non-resection candidate, palliative treatment

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What are the 2 available radio-embolization methods?

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Yttrium-90 and iodine-131

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How can you manage a liver lesion from HCC, with a portal vein thrombosis?

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Yttrium-90 radio-embolization

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Which chemotherapies are useful for TACE?

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Doxorubicin, cisplatin, mitomycin

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Which child Pugh class can get TACE?

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Only class A/B

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When is TACE superior to resection for HCC?

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Never

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When is TACE performed?

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When a lesion is too large for RFA, a bridge to transplant, multifocal HCC

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What did the REFLECT trial assess in HCC ?

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Non-inferiority of Lenvatinib in first-line advanced HCC

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What did the CELESTRIAL trial assess in HCC ?

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Cabozantinib in advanced HCC following 1-2 lines of therapy including sorafenib

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Were Hepatitis B or C patients enrolled in the CheckMate – 040 trial ?

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Yes, anti-virals allowed

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What did the CheckMate-040 trial assess in HCC ?

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Nivolumab after progression on sorafenib

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What did the REACH-2 trial assess ?

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Ramucirumab in advanced HCC following progression on sorafenib when AFP > ng/mL

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What did the RESORCE trial assess ?

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Regorafenib after progression on sorafenib in advanced HCC

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Is surgical resection an inferior approach for single HCC lesions that are larger than 5cm?

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No, similar outcomes

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What are survival outcomes for HCC patients who are denied transplant for non-tumor reasons and undergo liver directed therapies ?

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Similar if Childs-Pugh Class A cirrhosis

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