Liver cancer disease sysmptoms and treatment
Liver Cancer
By Dr. Lee Ser Yee
The most common type of primary liver cancer is hepatocellular carcinoma. This cancer begins in liver cells (hepatocytes) and starts as a small tumour that grows and spreads to other tissues and organs over time.

Most patients with liver cancer have risk factors or have a disease of the liver that causes inflammation and scarring (cirrhosis)

Liver cancer presents a challenge because most have no symptoms when the disease is starting and in its early stages. Therefore, it is important to have regular screening if you have any of the risk factors.

Treatment in the early stages provides the best chance of cure, especially with surgery. When tumours have become bigger and more advanced, liver cancer can obstruct the bile ducts and symptoms may start appearing.

Risk factors for liver cancer

  • Chronic infection with hepatitis B and C
  • Excessive alcohol intake
  • Fatty liver
  • Family history of liver cancer
  • Certain chemicals and toxins exposure
    • Aflatoxin, Arsenic, Vinyl chloride, hydrocarbons, solvents, nitrites
  • Long-term use of anabolic steroids
  • Inherited disorders that cause damage to the liver

When you have Hepatitis B, C or liver cirrhosis of any cause, the risk of getting liver cancer is about 50-100 times than of someone without these risk factors.

Most liver cancers can be prevented by lifestyle modifications and health measures that reduce the risk and/or exposure to known risk factors. See tips for a healthy liver to learn more.

Screening

When liver cancer is detected early, it is small, localised, and easier to treat. Survival rates are also better when liver cancer is detected early. Screening is advised for high risk groups e.g. liver cirrhosis, chronic hepatitis B/C infection, healthcare workers. Regular screening may involve blood tests for Hepatitis B/C, alpha-fetoprotein (AFP) and liver function, as well as an ultrasound scan every 6 months.

Symptoms

The majority of patients with liver cancer have no symptoms. It is very often detected by chance as a result of an ultrasound test or CT scan for other unrelated problems. However, some patients may experience one or more of the following:

  • Loss of appetite or weight, fatigue, or general weakness
  • Persistent or deep pain in the upper abdomen
  • Swelling or fluid build-up in the abdomen
  • Yellowing of the skin and the whites of the eyes (jaundice)
  • Generalised Itching, tea coloured urine
  • Nausea and vomiting

When liver cancer is suspected, a series of tests may be necessary e.g.

  • A full medical history and clinical evaluation
  • Blood Tests which would include liver function tests and liver cancer tumour marker- alpha-fetoprotein (AFP)
  • Imaging -Ultrasound, CT, and MRI scans to confirm the presence and extent and stage of the cancer

Treatment

Treatment options depend on many factors such as age, general health, location and extent of the tumour. Generally, surgery, loco-regional therapy, chemotherapy, and radiation therapy are the main methods of liver cancer treatment.

Surgery
  • Surgery is the treatment of choice for liver cancer if possible. All other methods have not been shown to be as effective as surgery. However, as liver cancer is often associated with liver damage, surgery for liver cancer is not always possible or safe for some patients.
  • Liver transplantation is another surgical option for curative liver cancer treatment, in selected cases.
Loco-regional therapy
  • Ablation – to “burn” the tumour – Microwave, Radiofrequency, Ethanol, Cryotherapy
  • Embolization - to reduce blood flow to the tumour and/or, or deliver anticancer agents to the tumour
    • Bland (Trans-arterial embolization, TAE)
    • Chemotherapy agents (Trans-arterial chemoembolization (TACE), Drug-eluting bead DEB-TACE)
    • ­Radiation beads (TARE) e.g. Yttirum -90
Systemic therapy
  • Targeted therapy – these block cell signals and proteins involved in tumour and blood vessel growth
  • Immunotherapy- these turns our body’s immune system against cancer cells
  • Chemotherapy – these destroy cancer cells but are not very effective in liver cancer
  • Clinical trials- new investigative medicines or different combination of drugs
Radiation
  • External beam radiation therapy (EBRT)
  • Stereotactic body radiation therapy (SBRT)
Combination
  • Some of the above treatments may be used in combination or staged to achieve optimal outcomes.

The many treatment options available suggest that there is no single best method for every situation, we advise patients to discuss these options with a liver cancer specialist who will explain the role and of each approach. The best treatment strategy requires a thoughtful balance of the associated risks and benefits, and should be personalized to each individual.

Frequently Asked Questions

Hepatitis B carriers who have blood relatives diagnosed with liver cancer have a higher risk of developing liver cancer themselves. They should be evaluated and seen regularly by a liver specialist (hepatologists).

There are many hepatitis viruses, such as hepatitis A virus, which are spread by eating contaminated food. The hepatitis A virus causes short term liver damage, after which the liver will repair itself and no further damage is done. It has not been associated with liver cancer. There are also many other viruses which do not specifically attack the liver, but can cause mild short-term liver infection, such as the dengue virus.

Hepatopancreatobiliary (HPB) Surgeons are general surgeons who subspecialize in the surgery of the Liver (hepato-), Pancreas (pancreato-), Bile ducts and gallbladder (biliary). As these group of organs form an intricate system, surgery in this area is highly complex and hence requires specialized training and experience.

Gastroenterologists are medical specialists who diagnose and treat diseases of the gastrointestinal tract e.g. stomach, intestines including the liver (Hepatologist). While they do not perform surgery for these conditions, their expertise lies in the medical treatment of these diseases e.g. anti-viral medication for hepatitis B infection.

Yes, if the tumour is early, surgery offers the best chance of cure, either with removal of the tumour (liver resection) or liver transplantation. Unfortunately, while some may be diagnosed at advanced stages, these patients can still benefit from good control of the disease with the various treatments, e.g. locoregional, systemic or radiation therapy.

The term “traditional” or “herbal” remedies or medicine can represent thousands of compounds, many of which are not well known. Unfortunately, most are not rigorously tested or well regulated by the companies that produce them. Some are likely safe but many more may be very harmful. More importantly, there is no current evidence of any of these “remedies” work for liver cancer. It is recommended that patients considering these alternative forms of medication discuss this with their liver specialist.

It may be wise to ask your father's doctors again what was discovered. When a patient has colon cancer and this colon cancer can and may spread to the liver at a later stage, the patient is still suffering from colon cancer and not from liver cancer per se. The cancer cells that are in the liver will behave like colon cancer cells. It is not a new cancer, but rather an advanced stage of colon cancer in which spread has occurred to other organs.

“Many people with liver cancer do well and survive the disease. Here, our goal is to cure your cancer and help you have best possible quality of life. At every step, we will work with you to determine the best treatment approach. Our team has vast experience and expertise in treating liver cancer and work together with other experts to achieve a comprehensive and personalised treatment strategy for the best outcome for you.”
liver cancer surgeon - Dr Lee Ser Yee
Dr Lee Ser Yee

Senior Consultant Hepatopancreatobiliary Surgeon

MBBS, MMed (Surgery), MSc, FAMS, FRCSEd

Prior to private practice, Dr Lee Ser Yee was a founding member and Senior Consultant at the Department of Hepatopancreatobiliary (HPB) and Transplant Surgery at Singapore General Hospital (SGH). He served as the Director of the Laparoscopic programme and the Director of the Surgical Skills Training Program and the SingHealth Surgical Skills Centre.

He started his medical training at the National University of Singapore in 1996 and completed his training in General Surgery, HPB surgery and Liver Transplantation at SGH and National Cancer Centre, Singapore.

He also completed dual USA-fellowships in Advanced Laparoscopic HPB surgery and Liver Transplantation under Professor Daniel Cherqui at the New York Presbyterian Hospital-Weill Cornell Medical Center and a Complex Surgical Oncology clinical fellowship at Memorial Sloan Kettering Cancer Center in New York.

liver cancer surgeon - Dr Lee Ser Yee
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