Liver / Bile Duct / Gallbladder Cancer

The liver is the largest internal organ in our body. It performs more than 500 different vital functions. One of which is the liver act like a detoxifier of the body, helping the body to get rid of toxins. It has a system of tubes within it called the bile ducts which collects a chemical called bile that is produced by the liver. Bile is needed by us to help us to digest fat, along with the help of enzymes produced by the pancreas. This bile is transported by the bile ducts into a main tube outside the liver called the common bile duct, which connects the liver to the small intestine (duodenum). The gallbladder is a small bag-like organ that is attached to the common bile duct. Its function is to store excess bile.


Liver Cancer

What is Liver Cancer?


Liver Cancer is cancer of the liver cells called hepatocytes. The liver is actually made up of different cell types like liver cells, bile duct cells, blood vessels, etc. Liver cells (hepatocytes) make up 80% of the liver. The medically scientific term for this kind of cancer is called Hepatocellular Carcinoma (HCC) or Hepatoma for short. Liver cancer is the third most common cancer in the world. Most of the liver cancer cases are found in Southeast Asia, China and Taiwan due to high incidence of Hepatitis B infection in these parts of the world. In Singapore, liver cancer is the 4th most common cancer in Singaporean males.


What are the risk factors of developing liver cancer?


  • Hepatitis B infection. This is the most common cause of liver cancer worldwide. A Hepatitis B carrier is 100 times more likely to develop liver cancer compared to a non-carrier. Singapore has a number of Hepatitis B carriers.
  • Hepatitis C infection. Similar to Hepatits B. However this is not so common in Singapore.
  • Liver Cirrhosis – this is a hardening of the liver from repeated or persistent injury to the liver by various factors. This repeated injury or persistent injury leads to chronic inflammation. Over time, the liver scars up and hardens.
  • Chronic alcohol intake, which can cause cirrhosis
  • Fatty liver, which can cause cirrhosis
  • Certain inherited liver diseases or metabolic diseases like Wilson’s disease



What are the symptoms?


Most people do not have any symptoms in the early stages of the disease. When they begin to have symptoms, the disease is typically quite advanced already. Symptoms include:


  • Upper abdominal pain or discomfort, usually on the right side
  • Abdominal swelling
  • Appetite loss
  • Weight loss
  • Jaundice (yellowing of the whites of the eyes)
  • Easily tired


What will the doctor do to diagnose the cancer?


The doctor would usually order a specialized scan such as the CT scan or the MRI scan. He may also order a liver cancer marker, called alpha-feto protein (AFP). Sometimes, he may ask for a needle biopsy of the tumour.



What is the treatment of liver cancer?


Depending on what is the stage of the cancer, the doctor will then decide on the appropriate treatment. In addition, he also needs to check what is your liver function like, and if the liver is cirrhotic.


Surgery is the only treatment that can provide a long-term cure and it’s the best treatment if the cancer has not spread to other parts of the body. The aims of operation are to remove all the tumours in the liver, whilst leaving behind adequate liver to sustain life. The ideal surgery is liver transplant. However, due to the shortage of organs, resection (or surgical removal) of the tumour is the next best option.


Liver Resection (Hepatectomy) surgery is the operation to remove the cancerous part of the liver.

The liver has eight segments, each segment of the liver has its own independent blood supply and bile drainage.

The surgery can be performed by the traditional open method or by the laparoscopic (keyhole) method. Laparoscopic liver operations (Laparoscopic Hepatectomy) will depend on the size and location of the tumour.


However, not all liver cancer is suitable for surgical treatment. If the patient has liver cirrhosis (hardening of liver), surgery will be challenging as the patient may not do well or even die due to insufficient liver function from the liver that is left behind.


If the liver cancer cannot be treated by surgery, there are other treatment options such as RFA, TACE and SIRT.


  • Radiofrequency ablation (RFA) – using electrical current to destroy the cancer cells.
  • Radiation therapy – using radiation to kill the cancer cells. This radiation can be delivered using small radioactive beads delivered directly into the tumour (SIRT) or through an external radiation beam (radiotherapy).
  • Chemotherapy involves the use of cancer drugs to kill cancer cells. These drugs can be delivered directly into the tumour itself (TACE) or be administered through an intravenous injection or even oral tablets (systemic chemotherapy)


Are there any other types of liver tumour?


The answer is yes. Some of these tumours are:


Tumours may arise from the bile ducts within the liver (called bile duct cancer),

Tumours may arise from the blood vessels like the haemangioma; this is the most common benign tumour of the liver

Liver cysts

Benign liver tumours like adenoma (this may be linked to the intake of oral contraceptives). It may potentially turn cancerous

Tumours may be cancer spread from elsewhere. One common example is colon cancer which has spread to liver, and appeared as a tumour within the liver.



How to prevent liver cancer?


The most effective way is for people who have risk factors for liver cancer to go for regular screening. This is to allow the detection of the tumour when it is still early and therefore increase the chance for cure. High-risk patients include Hepatitis B or Hepatitis C carriers.


In Singapore, patients who have Hepatitis B or cirrhosis from any cause are advised to participate in a liver cancer screening programme. This is available at any polyclinic and includes 6-monthly check of alpha-feto protein (a blood test) and a 6-monthly or annual ultrasound of the liver.


In addition,


Eat healthily and avoid being overweight

Exercise regularly

Drink alcohol in moderation, if at all

Get yourself vaccinated against Hepatitis B


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Bile Duct Cancer

What is Bile Duct Cancer?


Bile Duct Cancer is cancer of the cells lining the bile ducts. The scientific term for this kind of caner is called cholangiocarcinoma.
Bile duct cancers are classified based on which part of the bile ducts the cancer occurs:

  • Intrahepatic cholangiocarcinoma occurs in the bile ducts located within the liver
  • Hilar cholangiocarcinoma occurs in the bile ducts just outside of the liver, at the junction where the right and left hepatic ducts join together
  • Extrahepatic cholangiocarcinoma occurs in the bile duct outside of the liver


Bile duct cancers are difficult to treat. Fortunately they are uncommon.


What are the risk factors of developing bile duct cancer?


  • Older age – this cancer tends to occur in older individuals
  • Smoking
  • Congenital bile duct problems like choledochal cyst – a condition where there is a abnormal dilatation of the bile duct
  • Infection by a liver parasite, which can occur from eating raw or undercooked fish


What are the symptoms?


  • The classical symptom is the development of painless jaundice (yellowing of the skin and the whites of the eyes). This is especially true for the hilar and extrahepatic types of cholangiocarcinoma
  • Along with jaundice, dark urine and pale stools
  • Itchiness of the skin
  • Abdominal pain
  • Weight loss


What will the doctor do to diagnose the cancer?


The doctor would usually order a specialized scan such as the CT scan or the MRI scan. He may also order a cancer marker, called CA 19-9.


What is the treatment of bile duct cancer?


Treatment will depend on how advanced the cancer is and the health of the patient. Bile duct cancer is a difficult cancer to treat and a multi-disciplinary approach is needed to determine the most appropriate treatment for the patient. Surgery offers the best chance of a long-term cure. Other treatment options include chemotherapy, biological therapy and radiation therapy.


In cases where surgery is not possible, and the patient is jaundiced, doctors may stent the bile ducts so as to relieve the jaundice.



How to prevent bile duct cancer?


  • Live healthily with regular exercise and balanced diet
  • Stop smoking
  • Drink alcohol in moderation, if at all
  • Do not consume raw fish from unreliable sources


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Gallbladder Cancer

What is Gallbladder Cancer?


Gallbladder cancer is cancer arising from the cells of the inner lining of the gallbladder. The scientific medical term for this cancer is gallbladder adenocarcinoma. It is an uncommon cancer. There are certain parts of the world there this cancer has a slightly higher incidence, like Central and South America, Central and Eastern Europe, and Northern India.


If detected at an early stage, the chance for a cure is good. However most gallbladder cancers are discovered at a late stage, when the cancer has already spread.


What are the risk factors of developing gallbladder cancer?


  • Female gender – tends to be more common amongst females
  • Older age
  • Gallstones, especially large stones >3cm
  • Gallbladder polyps, especially those which are larger than 1cm or sessile in shape
  • Chronic inflammatory condition of the gallbladder, called porcelain gallbladder. This is usually associated with gallstones


What are the symptoms?


By the times symptoms appear, the cancer is usually at an advanced stage. Symptoms include:


  • Abdominal pain, usually at the right upper part of the abdomen
  • Jaundice (yellowing of the skin and the whites of the eyes)
  • Weight loss
  • Loss of appetite
  • Abdominal bloating or distension


What will the doctor do to diagnose the cancer?


The doctor would usually order a specialized scan such as the CT scan or the MRI scan. He may also order a cancer marker, called CA 19-9.  Sometimes the doctor may perform a diagnostic laparoscopy, which is a tiny telescope inserted into the abdomen to check for cancer spread.


What is the treatment of gallbladder cancer?


Treatment will depend on how advanced the cancer is and the health of the patient. Surgery offers the best chance of a long-term cure. Surgery may just involve removing the gallbladder, but this is only applicable to the earliest cancer stage. If not, surgery usually involves removing the gallbladder and a portion of the liver next to the gallbladder.


If surgery is not possible, other treatment options include chemotherapy and radiation therapy.

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