Liver Cancer

What is liver cancer?

Liver cancer is a life-threatening illness, and it can be classified as primary or secondary liver cancer.

Primary liver cancer refers to cancer that originates in the liver, and the common types include:

• Hepatocellular carcinoma (HCC): hepatocellular carcinoma, the most common type of primary liver cancer, accounts for 75% to 85% of cases. This is the 5th most common cancer in males in Singapore. HCC starts in the liver cells known as the hepatocytes, often developing in patients with chronic liver diseases such as hepatitis B or C, liver cirrhosis, or fatty liver disease.
• Intrahepatic cholangiocarcinoma (ICC): intrahepatic cholangiocarcinoma is a cancer that forms in the bile ducts of the liver and accounts for 10% to 20% of primary liver cancer.
• Hepatoblastoma: hepatoblastoma is rare and usually occurs in children under 5. Developing from immature liver cells, it is typically treatable with a combination of chemotherapy, surgery, and liver transplantation.
• Angiosarcoma: angiosarcoma is another rare type of primary liver cancer that develops in the liver’s blood vessels. Although it accounts for only a small percentage of all primary liver cancers, it is usually aggressive.

Meanwhile, secondary liver refers to when cancer from another organ, such as the breast, lung, stomach, colon, or pancreas, metastasises to the liver. 

What causes liver cancer?

Every cell in our body carries genetic instructions encoded within its DNA, dictating its functions, including when to divide and when to cease growth. However, occasionally, mutations arise within the DNA, leading to uncontrolled cell division and survival even when abnormal. As a result, cells accumulate, eventually forming a mass known as a tumour. 

In liver cancer, the majority of cases originate in the hepatocytes, the primary cell in the liver substance – a type of cancer referred to as hepatocellular carcinoma (HCC), the most common type of primary liver cancer.

What are the symptoms of liver cancer?

Liver cancer symptoms may not be felt or seen in its initial stages. However, the following symptoms may begin to show as the disease progresses:

• Abdominal swelling, pain, or discomfort
• A hard lump, located on the right side, just below the rib cage
• Bruising or bleeding
• Chalky and white stool
• Dull pain in the back 
• Fatigue
• Jaundice
• Loss of appetite
• Nausea and vomiting episodes
• Unexplained weight loss

Although these are the most common liver cancer symptoms, it should be noted that they do not provide a definitive diagnosis for liver cancer. It is important to inform your doctor if you experience any symptoms, especially if you have a history of liver disease or liver cancer, so that the symptoms will be investigated.

Is liver cancer painful?

In its early stages, liver cancer is often asymptomatic. As a result, it may not be painful initially, as the tumour is small and has not spread. However, as liver cancer progresses to later stages, such as advanced liver cancer, it can be painful. 

While the pain and other accompanying symptoms may not indicate liver cancer, it is important to have it checked, especially when you experience persistent symptoms. 

Make an appointment with Lee Surgery & Endoscopy to check your symptoms and receive a proper diagnosis.

Who is at risk of liver cancer in Singapore?

The risk of getting primary liver cancer is increased with certain risk factors such as:

• Genetics: like most cancers, a family history of liver cancer increases the risk of an individual developing it. Additionally, certain inherited diseases like haemochromatosis (excessive build-up of iron in the body), Wilson’s disease, and autoimmune liver diseases also increase the risk of developing liver cancer.
• Liver diseases: fatty liver disease, liver fibrosis, and liver cirrhosis increase an individual’s risk of developing liver cancer.
• Excessive alcohol consumption: liver damage occurs with heavy alcohol consumption, increasing the risk of liver cancer.
• Hepatitis infection: hepatitis, particularly chronic hepatitis B (HBV) and hepatitis C (HCV), is strongly linked to the development of liver cancer, specifically hepatocellular carcinoma (HCC). 
• Exposure to aflatoxins: aflatoxins, toxins produced by certain moulds that contaminate foodstuffs such as grains and nuts, are known carcinogens and can increase the risk of liver cancer.
• Obesity: obese or overweight individuals are at an increased risk of liver cancer, particularly HCC. 
• Smoking: smoking has been linked to an increased risk of developing many types of cancer, including liver cancer.

What are the stages of liver cancer?

• Stage 0 (Carcinoma in situ): at this stage, cancerous cells are present only in the top layer of cells lining the liver. It is often considered precancerous, with a high chance of successful treatment.
• Stage I: in stage 1 liver cancer, the cancer is small <4cm, confined to the liver, and has not spread to nearby blood vessels.
• Stage II: in stage 2 liver cancer, the cancer has grown larger and may have spread to blood vessels, but it is still confined to the liver.
• Stage III: at stage 3 liver cancer, the cancerous cells are divided into two sub-stages:
  • Stage IIIA: more than one tumour with at least one >5cm but no spread to lymph node or distant organ
  • Stage IIIB: the cancer has spread to a large vein in the liver with no spread to lymph nodes and distant organs.
• Stage IV: stage 4 liver cancer is considered advanced liver cancer and has spread or metastasised to lymph nodes or distant organs. It is divided into two sub-stages:

• Stage IVA: the cancer has spread to lymph nodes but not to distant organs.
• Stage IVB: the cancer has spread to distant organs, such as the lungs or bones.

How is liver cancer diagnosed?

Beyond reviewing your medical history and performing a physical examination, the diagnostic process of liver cancer may include:

• Blood tests: blood tests are typically conducted to assess liver function and check for the presence of tumour markers, such as alpha-fetoprotein (AFP). Although elevated levels of AFP may indicate the presence of liver cancer, not all liver cancers produce AFP.
• Imaging tests: imaging tests help create detailed images of the liver, which aid in identifying the presence of tumours and providing information about their size and location. Some of the common imaging tests are ultrasound, computed tomography (CT) scan, magnetic resonance imaging (MRI), and positional emission tomography (PET) scan.
• Liver biopsy: if the imaging tests are not conclusive of the presence of liver cancer, a liver biopsy may be conducted to confirm the diagnosis. A small piece of tissue is removed from the liver and examined under a microscope.

What are the treatment options for liver cancer in Singapore?

There are a few treatment options available for liver cancer. However, your doctor will consider several factors before recommending a treatment plan, including:

• The size, location, and number of tumours present in your liver
• How well your liver is functioning
• Any presence of liver cirrhosis
• If the cancer is confined or spread elsewhere

Once all the necessary information has been obtained, your specialist may suggest one or a combination of the following treatment options:

• Surgery: surgery may be an option if the cancer is detected early and is confined to a specific area of the liver. This offers the best chance for a cure if suitable. A partial hepatectomy, or in some cases, liver transplant, may be performed.
• Liver-directed therapies:
  • Ablation: techniques like radiofrequency (RFA), microwave ablation (MWA), or cryoablation may be used to destroy the tumour. These techniques are less invasive and only possible for smaller tumours.
  • Trans-arterial chemoembolisation (TACE): trans-arterial chemoembolisation works when an anti-cancer drug is injected directly into the liver tumour, along with a gel or tiny plastic beads, to deprive the tumour of blood. This prevents the tumour from growing.
  • Radiation therapy: radiation therapy uses high-energy rays, such as stereotactic body radiation therapy, to kill cancer cells. It can deliver precise doses of radiation to the tumour while minimising damage to the surrounding tissues.
• Systemic Treatment:
  • Chemotherapy: chemotherapy involves anti-cancer drugs that are used to either kill the cancerous cells or slow down their growth. The drug is either given orally or intravenously.
  • Targeted therapy: targeted therapy uses specific drugs to target specific abnormalities within cancer cells, allowing them to grow and divide. However, this treatment is only possible if the cancer cell has specific genetic mutations.
  • Immunotherapy: immunotherapy drugs help the body’s immune system recognise and attack cancer cells. 

Frequently asked questions

How long can you live with liver cancer?

The prognosis and life expectancy for individuals with liver cancer can vary widely depending on various factors, including the cancer stage at diagnosis, the extent of tumour involvement, the underlying liver function, the effectiveness of treatment, and the overall health of the patient. It's important to note that liver cancer is often diagnosed at an advanced stage, which can affect prognosis.

Can liver cancer be cured?

Liver cancer, particularly hepatocellular carcinoma (HCC), can be cured in some cases, particularly when it is detected at an early stage and is amenable to curative treatment options. However, the likelihood of a cure depends on several factors, including the stage of cancer, the extent of tumour involvement, the underlying liver function, and the overall health of the individual. Cancer treatment can be stressful. It is important to discuss with your specialist so that an individualised treatment can be provided. 

What can I do to reduce the risks of liver cancer?

Some of the steps that you can take to reduce the risk of liver cancer are keeping a healthy weight or lifestyle, getting the Hepatitis B vaccine, avoiding smoking and avoiding drinking too much alcohol.