Liver Cancer

The liver is located in the upper right part of your abdomen, above your stomach. It is a critical organ that supports metabolism, assists digestion and synthesises various components for your body’s immune system and blood clotting factors. It also aids in the detoxification of certain chemicals from your body, for example, alcohol.

Cancers in the liver can be divided into primary liver cancers (cancer which begins in the cells of the liver) or more commonly, secondary cancers that spread from other primary sites of cancer such as breast, lung or colorectal cancers.

According to the World Health Organisation, hepatocellular carcinoma (HCC) is the 5th most common cancer in men and 9th most common cancer in women worldwide. It is also the 2nd most common cause of cancer-related death. HCC accounts for about 80% of primary liver cancers.

The incidence of liver cancer is highest in eastern and south-eastern Asia. In Singapore, it is the 4th most common cancer in males with approximately 24.8 cases per 100,000 cancer cases.

The main causes/risk factors of liver cancer are Hepatitis B, Hepatitis C and alcoholic liver disease. While alcohol is the main cause of liver cancer in the West, infections, such as Hepatitis, are the main cause of liver cancer in Asian countries. Hepatitis can be transmitted through contact with infected bodily fluids like saliva, blood and sperm.

These risk factors typically lead to liver cirrhosis which is present in 80-90% of patients with liver cancer. However, liver cancer can develop even in the absence of underlying liver cirrhosis, especially in people with chronic hepatitis B infection. The risk of liver cancer increases further in a person with Hepatitis B if he:

• Is a male
• Is co-infected with Hepatitis C
• Concurrent heavy use of alcohol

Other risk factors include:

• Metabolic syndrome
• Non-alcoholic fatty liver disease
• Genetic syndromes such as hereditary haemochromatosis

Most patients with liver cancer have no specific symptoms. Non-specific symptoms may include upper abdominal pain, loss of appetite, and abdominal bloating.

Liver cancer is often detected by chance through a CT or ultrasound scan. Individuals with risk factors should go through regular blood tests and scans to detect any early damage to the liver, the presence of tumours or signs of liver disease.

Screening for liver cancer (HCC) increases the detection of early-stage HCC, which then increases the likelihood of adopting treatments with an intent to cure. Screening is recommended for:

• All individuals with liver cirrhosis and Child-Pugh A or B
• Individuals with no liver cirrhosis but have Hepatitis B with any of the following features:
  • Active hepatitis (e.g. elevated serum ALT) and/or high viral load (ie, >100,000 copies/mL [20,000 international units/mL])
  • Family history of liver cancer
  • Asian males over the age of 40 years
  • Asian females over the age of 50 years

Screening is recommended half-yearly, using an ultrasound of the abdomen, with or without tumour markers (AFP), based on the American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of the Liver (EASL) consensus statement.

The diagnosis of HCC in patients with underlying risk factors is usually made by dynamic contrast-enhanced CT or MRI without the need for biopsy. Occasionally, a biopsy may be required for cases with no risk factors for HCC, or lesions without the characteristic features of HCC on imaging.

Treatment of HCC depends on the tumour size, number of lesions and their location, presence of spread outside of the liver or invasion of the cancer into the blood vessels and underlying liver reserve.

The treatment of liver-confined HCC varies according to the number and size of lesions, presence of major portal vein invasion, liver function and availability of local resources. Options include liver resection (surgical removal of a portion of the liver), liver transplantation, liver-directed therapies or systematic therapy.

For most patients with HCC limited to the liver, but are not candidates for surgical resection or liver transplantation, liver-directed therapies are preferable to systemic therapy (therapy that targets the whole body) because of the reduced side effects. Examples of liver-directed therapies include transarterial embolization, radiofrequency ablation (RFA) and stereotactic radiotherapy.

When the cancer spreads beyond the liver, systemic therapy are usually considered instead of liver-directed therapies. Sorafenib, a cancer drug, has been the main systemic therapy for HCC, but recent years have seen newer agents including immunotherapy that improve survival.

Combination therapy with immunotherapy is becoming the new standard of care for fit patients.

Updated on 15/01/2020

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