Liver Cancer Surgeon
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 liver cancer 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.

Liver Cancer 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.

What are the Symptoms of Liver Cancer?

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

What are the Stages of Liver Cancer?

There are many staging systems for liver cancer, and not all doctors use the same system, as different staging system serves different purposes e.g. for decision making, treatment options and survival outlook. - A common staging system for liver cancer is the AJCC (American Joint Committee on Cancer) TNM system, which is based on 3 key pieces of information:

The extent (size) of the tumor (T):
How large has the cancer grown? Is there more than one tumor in the liver? Has the cancer reached nearby structures like the veins in the liver?

The spread to nearby lymph nodes (N): Has the cancer spread to nearby lymph nodes?

The spread (metastasis) to distant sites (M): Has the cancer spread to distant lymph nodes or distant organs such as the bones or lungs?

In summary, the stages of liver cancer can be described with the following characteristics:

  • Stage I (Early): In this early stage, there is a single tumour that is small (2cm or smaller) and the cancer has not spread to nearby blood vessels and lymph nodes yet.
  • Stage II (Intermediate): This stage involves a single tumour larger than 2cm, or multiple tumours not larger than 5cm, but has not spread to nearby blood vessels.
  • Stage III (Advanced): Stage III cancer occurs when the tumour has spread to nearby blood vessels or nearby organs, or has broken through the liver capsule; and/or when the tumour(s) is larger than 5cm.
  • Stage IV (End-Stage): At this stage, the cancer has spread beyond the liver to more distant parts of the body, such as the lungs and bones; as well as nearby lymph nodes and/or blood vessels.

    This staging system provides survival information but does not guide initial management. Upon initial diagnosis of liver cancer, a comprehensive evaluation of the extent of disease, liver health and patient’s general health will determine the optimal treatment strategy.


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.

Liver Cancer Surgery

  • Surgery is the treatment of choice for liver cancer if possible. All other methods have not been shown to be as effective as liver cancer 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


  • External beam radiation therapy (EBRT)
  • Stereotactic body radiation therapy (SBRT)
  • Some of the above liver cancer 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 surgeon 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 doctor (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 doctor.

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.

When it comes to treating liver cancer, surgery is often the best option if amenable as it provides the only chance of cure and/or best long-term outcomes in survival and quality of life. If surgery is not possible, non-surgical treatments are still available and can serve as complementary or supporting therapies. In cases when cure is possbile, a liver resecton (tumour resection) or a liver transplant will be recommended. Treatment strategies will be tailored accordingly to each patient’s condition, preferences and decisions made together with the patient during a multidisciplinary discussion. Liver cancer surgery may be considered in the following scenarios:

  • Early-stage liver cancer: If the cancer is detected at an early stage and the patient still has good liver function, surgery is usually the best option.
  • Localized tumours: Surgery will be considered if the tumours are localized and have not spread to other parts of the body surrounding the liver.
  • Acceptable overall health: The patient should be in acceptable overall health and have adequate liver volume and function to tolerate the surgery and recover well.
  • No response to other treatments: If the patient has not responded adequately to non-surgical treatments such as locoregional therapy e.g., ablation or embolisation (TACE or SIRT); or systemic treatment e.g immunotherapy, chemotherapy may be recommended and/or used in combination.

Liver cancer surgery, like any major surgical procedure, carries certain risks, which vary depending on the type of surgery, the individual's overall health, and more. Risks associated with liver cancer surgery include:

  • Bleeding: The liver has a rich blood supply, and surgery may lead to bleeding but most of the bleeding will be well controlled. In rare cause, excessive bleeding might then require additional procedures to control it.
  • Infection: As with any surgical procedure, there is a risk of developing an infection at the wounds or within the abdomen.
  • Blood Clots: Surgery and decreased mobility afterwards can increase the risk of blood clots forming. Pre-, intra and post-operative measures will be instituted to minimise these risks.
  • Liver Failure: In extensive surgeries, there is a risk of insufficient liver function leading to liver decompensation and failure, especially if the remaining liver tissue cannot regenerate sufficiently.
  • Bile Leakage: Surgery on the liver can sometimes lead to the leakage of bile, which is fluid produced by the liver.
  • Damage to Nearby Organs or Structures: Given the liver's proximity to other organs and blood vessels, there is a risk of injuring nearby structures during surgery.
  • Adverse Reaction to Anaesthesia: Some people might experience complications related to anaesthesia, such as allergic reactions.
  • Delayed Recovery: Recovery from liver cancer surgery in the minority of cases be lengthy and challenging, and some people might experience slow wound healing or prolonged recovery periods. Minimally invasive liver surgery can ameliorate many of these short-term issues.

Liver cancer surgery is a major operation and can take several weeks for full recovery. To ensure a smoother recovery, be sure to follow these advice:

  • Follow Medical Guidance: Adhere to post-surgery instructions regarding medication, wound care, diet, and activity levels.
  • Pain Management & Monitoring: Take prescribed pain relief, watch for signs of infection, and know when to seek medical attention.
  • Gradual Activity Resumption: Slowly reintroduce daily activities and following your doctor's advice.
  • Healthy Lifestyle: Maintain a balanced diet, stay hydrated, engage in light exercise, and avoid alcohol and smoking.
  • Attend Follow-up Appointments: Attend your scheduled follow-ups to monitor your recovery progress.

Enhanced Recovery Programme

Patients undergoing major surgery have been shown to benefit from measures and prehabilitation prior to and early after surgery to improve their physical condition and better tolerate and recover from the surgery. This multimodal perioperative care pathway starts a few weeks prior and immediately after the surgery, designed to achieve early recovery for patients undergoing major surgery and minimise complications. These include:

  • Excerises to improve strength and mobility – physiotherapy, prehabilitation
  • Lung excerises- deep breahting and incentive spirometry
  • Diet optimisation – nutritional supplements to boost immune system and provide an optimal diet to boost physiological reserves especially in patients who has loss of weight and appetite
  • Others e.g., - Preoperative smoking and alcohol cessation, medications review, Anti-thrombotic prophylaxis
  • Post-operative- Early mobilisation, early oral intake, nutritional supplementation, nausea and vomiting (PONV) prophylaxis, judicious fluid and pain management etc.

Surgical Associates has a comprehensive enhanced recovery programme and our team works closely with other specialists, nurses and allied health professionals (e.g. physiotherapist, dieitician ) for a tailored programme to cater to each individual patient’s needs and condition.

“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.”