Liver Cancer

Common GI Condition > GI Tract > Liver Cancer

Liver Cancer

Primary liver cancer encompasses hepatocellular carcinoma (HCC) and bile duct cancer (cholangiocarcinoma). Sometimes, cancer from other sites can spread to the liver (e.g colon cancer), in these cases, the liver is a secondary site of metastases (spread). The focus of this article will be adult hepatocellular carcinoma (HCC).

HCC is the most common primary liver cancer. It is the 5th most common cancer worldwide (1), and is the second leading cause of cancer related death (2).

The following are known risk factors for HCC:

  • Hepatitis B or Hepatitis C
  • Liver cirrhosis (liver hardening), causes of which include:
    • Hepatitis B or Hepatitis C
    • Non-alcoholic steatohepatitis (NASH). This if the form of non-alcoholic fatty liver associated with chronic inflammation of the liver and progressive fibrosis
    • Autoimmune hepatitis
    • Alcoholic cirrhosis
    • Haemochromatosis
  • Environmental factors
    • Alfatoxin (a fungal toxin which can be found on certain grains and nuts)

Locally in Singapore, Hepatitis B is the most common risk factor for HCC. Patients who have hepatitis B or liver cirrhosis should have regular surveillance for the development of HCC.

How is HCC detected? what investigations may be ordered? 

HCC may be detected as part of a surveillance regime (periodic assessment in individuals with an increased risk for HCC e.g. Hepatitis B or liver cirrhosis) or as part of the evaluation of symptoms. Your doctor as part of the evaluation, will take a history and perform a physical examination.

If you have Hepatitis B or liver cirrhosis, your doctor may order:

  • Blood tests including liver function tests, alphafetoprotein
    • Other blood test to assess the function and if there are complication of liver cirrhosis, may include a full blood count or a clotting tes
  • Imaging: Typically an ultrasound is used as the baseline surveillance tool

If a new suspicious lesion is seen on ultrasound, or if there is already a high suspicious of cancer your doctor may order:

  • CT Scan of the liver
  • MRI Scan of the liver
  • Contrast enhanced ultrasound scan of the liver

HCC may be diagnosed by imaging criteria alone. Only in cases of uncertainty, may a liver biopsy which involves using a thin needle to obtain a sample of liver tissue to look for cancerous cells. In this context, it is usually done under imaging guidance.

If HCC that is detected, treatment options depends on: a) the size and whether there is evidence of spread, b) the severity of liver cirrhosis (if present) and c) the overall functional status.

Treatment options include:

  • Surgery
    • This involves surgical removal of a portion of liver affected by HCC. This is an option if the liver is otherwise healthy (no cirrhosis, or early cirrhosis).
    • If the HCC is too large or if there is advanced/decompensated cirrhosis, surgery may not be possible or even unsafe.
  • Radiofrequency/Microwave ablation
    • High energy is delivered via a thin probe to an area of HCC to cause injury to cancerous cells
  • Transarterial chemoembolization (TACE)
    • This involves thin wires fed into the specific arteries supplying the tumour. Chemotherapy is delivered via a selected artery supplying the tumour, followed by an agent used to block flow in this artery. This allows chemotherapy to be delivered locally to the cancer and allows blood supply to the cancer to be cut off as well.
  • Y-90 Radioembolization
    • This involves localized delivery of specially coated glass or resin beads treated with the radioactive isotope yttrium Y-90. This is delivered via the blood supply feeding the tumour.
  • Liver transplant
    • This may be an option in the event of tumour recurrence, or if the underlying liver has advanced/decompensated cirrhosis or if there are several lesions.
    • There are several criteria to be met for liver transplant as an option. Your doctor will advise you if Liver Transplant is an option
    • Liver transplant is not an option if there is evidence of spread (metastases)
  • Chemotherapy
    • This is an option if there is evidence of spread (metastases) of the HCC
    • Chemotherapy is typically not used, or used in caution when the underlying liver is not healthy (advanced cirrhosis)
    • Your doctor will discuss the chemotherapy options available

In summary, HCC is the most common primary liver cancer. Patients who are at increased risk for HCC such as patients with Hepatitis B or Liver cirrhosis should undergo regular surveillance to detect HCC early. HCC is largely diagnosed by imaging (CT or MRI of the liver).

Once HCC is diagnosed, options for treatment depends on the size of the tumour or if there is spread, the health of the underlying liver (if there is cirrhosis), and the overall functional condition of the patient.

  1. BW S, CP W. World Cancer Report 2014. International Agency for Research on Cancer http://publicationsiarcfr/Non-Series-Publications/World-Cancer-Reports/World-Cancer-Report-2014 Accessed 03/07/17. 2014.
  2. Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA: a cancer journal for clinicians. 2005;55(2):74-108.