Liver Cancer

Overview

The liver is the largest internal organ in our body. It performs more than 500 different vital functions. One of which is the liver acts 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 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.

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

When to Seek Treatment

Generally there are 2 groups of people whom we see for liver cancer.

The first group are those who complained of one or more of the symptoms listed above. These people may have some risk factors that predispose them to liver cancer, such as Hepatitis B infection.

The second group are those who went for some form of medical check-up and were found by chance to have some abnormalities.

This may include elevation of cancer markers, in particular AFP (alpha-feto protein), or abnormalities in their liver function.

Or they may have gone for some scans, like an ultrasound scan or CT scan, and were discovered to have a growth in the liver.

Diagnosis

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.

Treatment

Depending on what the stage of the cancer is, the doctor will then decide on the appropriate treatment. In addition, he also needs to check what the person’s liver function is like, and if the liver is cirrhotic (hardening of the liver due to chronic scarring).

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.

Right Hepatectomy means the removal of segments 5,6,7 and 8

Left Hepatectomy means the removal of segments 2,3,4a and 4b

Central Hepatectomy means the removal of segments 4a, 4b, 5 and 8

Segments may also be removed individually. For example, monosegmentectomy 6 means the removal of just segment 6

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 person has liver cirrhosis (hardening of liver), surgery will be challenging as the patient may not do well or may 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)

Causes

​​Cancers, including cancer of the liver, are due to genetic mutations of the cells.

As a result of these gene mutations, the liver cells start to multiply uncontrollably. These cells also have the ability to detach from the liver and invade into the bloodstream and spread to other parts of the body, or invade into the adjacent organs around the liver.

Any recurrent injury to the liver cells can potentially bring about such mutations. As a result of repeated injury and inflammation, cirrhosis of the liver happens.

Liver cirrhosis is a hardening of the liver from repeated or persistent injury to the liver by various factors. Because of this repeated injury or persistent injury, there is chronic inflammation. Over time, the liver scars up and hardens. Cirrhotic livers are prone to developing liver cancer.

What are some of the factors that can cause repeated or persistent liver injury leading to liver cirrhosis? We have listed some of the common factors:

Risk Factors

  • 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 fairly high number of Hepatitis B carriers, or about 3.6%of the population aged 18-79. That is according to an article published in the Straits Times on the 21st Aug 2018, titled “Hepatitis: The silent killer”.
  • Hepatitis C infection. Similar to Hepatitis B. However this is not so common in Singapore.
  • Chronic alcohol intake, which can cause cirrhosis
  • Fatty liver, which can cause cirrhosis if there is concomitant liver inflammation
  • Certain inherited liver diseases or metabolic diseases like Wilson’s disease

Consult Our Doctor

Dr Ho Choon Kiat
Senior Consultant HepatoBiliary, Pancreas & General Surgeon

MBBS (Singapore), FRCS (Edin), FRCS (Glasg), M.Med (Surgery), FRCSEd (Gen), FAMS (Surgery) Adjunct Assistant Professor, NUS Yong Loo Lin School of Medicine

Liver Cancer Symptoms & Treatment FAQs

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 increases the chance for cure. High-risk persons include Hepatitis B or Hepatitis C carriers.

In Singapore, persons who have Hepatitis B or cirrhosis from any cause are advise to participate in a liver cancer screening programme. This is available at any polyclinic and includes a 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 vaccinated against Hepatitis B

Unfortunately, when liver cancer shows signs, the disease is usually already quite advanced. The few scenarios when a liver cancer is detected before the patient complains of any symptoms or shows any signs are perhaps when the patient has a blood test or an abdominal scan as part of a check-up, and these reported some abnormality in the liver.

Therefore it is highly recommended for those with high-risk of developing liver cancer to go for regular screening. One such group is the Hepatitis B carriers.

No. In fact, the patient usually has no symptoms from the cancer when it is in the early stages

In Singapore, the leading cause of liver cancer is Hepatitis B infection. However, the number of liver cancer due to Hepatitis B is expected to drop due to the inclusion of Hepatitis B vaccination in the Singapore National Childhood Immunisation Schedule. Consequently, since 1985, all new-borns in Singapore has received the Hepatitis B vaccination at birth, and would have completed the full course usually by the time they are 6 months old.

As a result, the number of liver cancer due to non-Hepatitis B will rise comparatively. One of such causes is fatty liver. If fatty liver is left unchecked, it can lead to liver inflammation (steatohepatitis). This can then lead to liver cirrhosis. Once a liver becomes cirrhotic, it is prone to develop cancer.

Liver cancer is usually confirm by a contrast-enhanced CT scan or a MRI scan. Contrast is a sort of dye injected into the patient’s vein during the scan to see the characteristics of how the blood flow through the tumour. Liver cancer has a peculiar pattern of blood flow.

There is also a cancer marker called Alpha-Feto Protein, or AFP for short, which can be raised in liver cancer. This is a blood test. However, the AFP can be normal in about one-third of cases of liver cancer. Therefore by itself, it is not conclusive.

Sometimes, even with a CT scan or a MRI scan, the findings are not conclusive. In such situations, a needle biopsy of the tumour may be required.

This depends on the stage of the liver cancer. For early-stage liver cancer, based on a publication* by Singapore General Hospital, the median survival is 18.6 months, versus 3.8 months for late stage.

* GBB Goh et al. Deciphering the epidemiology of hepatocellular carcinoma through the passage of time: A study of 1,401 patients across 3 decades. Hepatology Communications 2017;1:564–571

The type of treatment will depend on the stage of the cancer, the function of the liver as well as the health and fitness of the patient. Surgery has the best survival benefit, if the cancer stage is suitable and the patient can tolerate the operation. Alternatives to surgery include trying to destroy the tumour using heat energy (radiofrequency ablation) or chemotherapy (TACE) or radiation (SIRT). Chemotherapy can also be given orally or intravenously.

The liver is an amazing organ with many vital functions. Some of these functions include: – removal of toxins, production of bile and excretion of bile, production of proteins including clotting factors, which are needed for the clotting of blood.

When a liver is not functioning well, the production of proteins become affected, and a person may start to retain water leading to leg swelling. He may be prone to bruising due to lack of clotting factors. Due to problems with the metabolism of bile, the person’s skin and eyes will appear yellow (jaundice). Due to the accumulation of toxin, the person may become less and less alert and may even go into a coma.

There are clinical scores that doctors use to measure the extent of liver damage. MELD and Child-Pugh scores are 2 such examples. MELD score is used by transplant doctors to assess how quickly a person needs a liver transplant. Child-Pugh score tells doctors how serious is the chronic liver disease and whether this person’s liver has enough reserve to undergo a surgery to remove the tumour.

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