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Liver Cancer

Liver Cancer: Overview, Risk Factors, Symptoms, Treatment and More | National Cancer Centre Singapore

Liver Cancer - What it is

 
The liver is one of the major organs of the body, and is vital to life (hence the name “live-r”). It is involved in many processes of the body, such as manufacturing various essential proteins, processing and storing nutrients, destroying toxins and poisons among others. The liver is made up of many different cell types, but the two main ones are liver cells (hepatocytes) and cells lining the bile ducts (cholangiocytes). 

Liver Cancer

Like any other part of the body, the cells in the liver can undergo changes to form cancer. Liver cells that become cancerous form liver cancer (hepatocellular carcinoma, HCC). Cancerous cells that start from other parts of the body and spread to the liver, for example, colon cancer that has spread, does not constitute liver cancer, but rather, are known as secondary liver tumours or metastatic cancers to the liver.

How common is Liver Cancer?

Liver cancer is the sixth most common cancer worldwide. In Singapore, it is the fourth most common cancer among men. It affects about 24 individuals in every 100,000 people a year.

Liver cancer is mainly an Asian disease, and is common in South-East Asia, China, Japan and Korea. It is also common in parts of Africa and the Mediterranean (especially Italy).

Age of Onset

Liver cancer occurs in persons in the older age group, from 40 to 50 years old. It can affect a younger individual who has contracted chronic hepatitis B or C from birth or in those with certain congenital conditions.

Liver Cancer - 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. In some patients there may be vague symptoms of heaviness or discomfort in the right side of the abdomen. Pain and appetite or weight loss are usually late symptoms.

In a small group of patients, liver cancer presents itself as a sudden intense pain in the abdomen as a result of rupture of the tumour. This is usually a bad sign and is related to bleeding of the tumour inside the abdomen. 

Liver Cancer - How to prevent?

 
Family members of patients with hepatitis B are advised to check their hepatitis B status. If they are not-infected and are without protection, they should go for immunisation against hepatitis B. Children are currently advised immunisation at birth for hepatitis B as part of a national programme. There is currently no immunisation for hepatitis C.

As hepatitis B and C are spread by bodily fluids, it is associated with sexual transmission, intravenous drug abuse, and can also be associated with transfusion of contamined blood products

Chronic alcohol use is also a risk factor and can lead to liver cirrhosis which  increases the risk of liver cancer. Therefore, it is wise to drink in moderation. 

Liver Cancer - Causes and Risk Factors

 
The three main causative factors for liver cancer are hepatitis B carrier status, hepatitis C infection and alcoholic liver disease. Other rare causes include poisons (aflatoxin) from fungus growing in badly preserved food (especially grains), congenital conditions (alpha-1 anti-trypsin deficiency), and any cause of liver hardening or cirrhosis (e.g. haemachromatosis).

The risk of an individual with hepatitis B or C of getting liver cancer is 100 times more as compared to an individual without hepatitis B or C. The pattern of liver cancer worldwide follows closely with the pattern of hepatitis B and C infections. In countries where immunisation for hepatitis B is available, the number of liver cancers seen per year has decreased. Hepatitis B can be transmitted from an infected mother to her baby during pregnancy. In the adult setting, hepatitis B and C can be transmitted by contact with infected body fluids, for example saliva, blood, sperm and other secretions. Blood transfusion is no longer a risk factor because of adequate screening methods in Singapore.

Alcohol is a major cause of liver cancer in the Western population. The liver is damaged by repeated and excessive alcohol abuse leading to liver hardening (cirrhosis) and liver cancer.

Liver Cancer - Diagnosis

 
In patients with known risk factors, screening with a blood test for alpha-fetoprotein (AFP) and an ultrasound may be offered. In up to 30% of patients with liver cancer, the AFP can be normal. Other causes of a raised AFP include early childhood, liver damage from hepatitis, or tumours in the testes. An ultrasound has no radiation risk, and may be performed regularly on patients with known risk factors for screening. 

A CT scan may be performed in those with high suspicioun of liver cancer. In certain cases, a CT scan may be inconclusive, and additional investigations like an MRI and PET-CT may be performed.  An MRI is like a CT scan, but uses magnetic forces instead of radiation.

Liver Cancer - Treatments

 
 
Surgery is the treatment of choice for early liver cancer. However, because liver cancer is frequently associated with liver damage (cirrhosis) in the other parts of the liver due to alcohol damage or hepatitis, assessment by a hepato-pancreato-biliary (HPB) surgeon is essential, though for patient patients, surgery is difficult or impossible. 

In selected cases, liver transplant is another surgical option for definitive liver cancer treatment. Radiofrequency ablation (RFA) may also be possible for limited small-sized tumours in patients who are not suitable for surgery.

When surgery is not possible, there are other options that may help to control the tumour and attempt to prolong survival time but not “cure” the person. The many options available suggest that no single method is particularly effective. It is better to discuss these options with a trained liver cancer specialist who can advise you on the appropriateness of each method. Some of these options that are available at NCCS include transarterial methods such as transarterial chemotherapy (TACE) and transarterial radioembolisation (TARE) during which radiation beads are delivered directly to the liver tumour. Systemic treatment options through the use of oral targeted therapy such as sorafenib, has also been shown to prolong patients’ survival. Many new targeted treatments and immunotherapy options have also recently been shown to have early signs of efficacy. Clinical trial options may also be discussed where available and suitable. 

Prognosis of Liver Cancer

Liver cancer is the third most fatal cancer. If untreated, most patients do not survive beyond 6 months. Surgery is the only method that allows for a reasonable survival beyond 5 years. With curative surgery, the chance of survival beyond 5 years is more than 40%.
New tumour growth is common in liver cancer because of the underlying liver disease (i.e. hepatitis or cirrhosis). There are currently no effective means of preventing this new growth, and close follow-up after surgery is necessary to detect tumour regrowth at an early stage as it can still be treated effectively.

Screening

The risk groups for liver cancer are well defined and screening is targeted at this group. The aim is to try and detect cancer at an early stage when surgery is still possible for a cure. Based on MOH guidelines, patients with established hepatitis B or C carrier status or have liver cirrhosis would benefit from regular AFP  and ultrasound examinations. These tests are usually done at 6-monthly intervals depending on the severity of liver damage, i.e. cirrhosis.

Liver Cancer - Preparing for surgery

Liver Cancer - Post-surgery care

Liver Cancer - Other Information

 
I have blood relatives with liver cancer. Am I at higher risk of developing liver cancer?

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 physicians who have a special interest in diseases of the liver (hepatologists).

I developed hepatitis after travelling to a nearby country. Will I develop liver damage?

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. 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.

My father had colon cancer. Now he has liver cancer. Why does he have two cancers?

It may be wise to ask your father's physician again what he or she has found in your father. When a patient has colon cancer and this colon cancer later spreads to the liver, the patient is still suffering from colon cancer and not from liver cancer. 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.

American Cancer Society: www.cancer.org 
Cancer Care, inc.: www.cancercare.org 
Cancer Information Service (National cancer Institute, USA): www.nci.nih.gov 
CancerNet (National Cancer Institute, USA): www.cancernet.nci.nih.gov 

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