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Primary Liver Cancer / Hepatocellular carcinoma (HCC)

Primary Liver Cancer / Hepatocellular carcinoma (HCC) - What it is

​The liver is largest solid organ in the body and is essential for life. It is involved in many processes of the body, such as producing essential proteins, processing nutrients and detoxification among others.

Primary Liver Cancer also known as Hepatocellular carcinoma (HCC) is a primary tumour of the liver cells (heptaocytes) that usually develops in the setting of chronic liver disease, particularly in patients with chronic hepatitis B and C or patients with a strong alcohol consumption history.

In Singapore, it is the 4th most common cancer among men. It affects about 20-30 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.

The other main cells in the liver are those lining the bile ducts (cholangiocytes), these can also develop in cancer. This is discussed in another section (See Bile duct cancer or Cholangiocarcinoma).

Cancer from other parts of the body can spread to the liver, for example, colon cancer. These are known as secondary liver tumours or metastatic cancers to the liver. This is discussed in another section as well. (See Secondary liver cancer or Liver Metastasis)

Primary Liver Cancer / Hepatocellular carcinoma (HCC) - Symptoms

​Most patients usually have no symptoms other than those related to their chronic liver disease. It is often detected by chance as a result of an ultrasound test or CT scan for other problems. Occasionally, there may be vague symptoms of heaviness or discomfort in the right side of the abdomen. Pain and poor appetite or weight loss or fatigue are usually late symptoms.

Suspicion for liver cancer should be raised in patients with previously compensated liver cirrhosis who develop decompensation such as water in the belly (ascites), mental change changes (encephalopathy), yellowing of skin and eye (jaundice), or vomiting of blood  or black stools (from variceal bleeding).

Other uncommon presentations include sudden pain in the abdomen as a result of rupture of the tumour, related to bleeding of the tumour. Jaundice can caused by invasion or compression of the bile ducts or early liver failure. Rarely patients can have bone pain or breathlessness due to the cancer spreading (metastasis) to the other parts of the body e.g. bone and lungs.

Primary Liver Cancer / Hepatocellular carcinoma (HCC) - How to prevent?

​You can lower your risk for developing liver cancer by leading a healthy lifestyle, such as regular exercise, controlling your weight, and eating a healthy balanced diet with limited amounts of alcohol.

It's also important to avoid infection with the hepatitis B and C viruses. Hepatitis B and/or C infection can lead to liver scarring (cirrhosis), liver failure and liver cancer.

Family members of patients with hepatitis B are advised to check their own hepatitis B status. Children are currently advised hepatitis B immunization at birth for as part of the Singapore national programme. Vaccines for hepatitis B are available for children and adults. If you are at risk for hepatitis B or C infection, consider undergoing a screening test.

If you have chronic hepatitis B, you might be a candidate for antiviral therapy, which can slow down the progression of liver disease and may decrease (but not eliminate totally) the risk of liver cancer.

There is no vaccine for hepatitis C currently but the right treatment may eliminate the virus.

If you have chronic hepatitis, you should visit your doctors for regular surveillance with imaging tests, such as ultrasound.

Primary Liver Cancer / Hepatocellular carcinoma (HCC) - Causes and Risk Factors

​Liver cancer usually occurs in persons in the older age group, above 40 to 50 years old and it is more common in Males. It can affect younger people who has contracted chronic hepatitis B or C from birth or those with certain congenital conditions.

The main risk factors for liver cancer are hepatitis B / hepatitis C infection, alcoholic liver disease and fatty liver (Nonalcoholic fatty liver disease). Other rare causes include poisons (aflatoxin) from fungus growing in badly preserved food, congenital conditions (alpha-1 anti-trypsin deficiency), and any cause of liver scarring or cirrhosis.

The risk of getting liver cancer of a person with hepatitis B or C is about 100 times more than one without hepatitis B or C. The pattern of liver cancer worldwide follows closely with the pattern of hepatitis B and C infections.

Hepatitis B can be transmitted from an infected mother to her baby during pregnancy. In the adults, 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 the main cause of liver cancer in the Western population and increasingly in Singapore. The liver is damaged by repeated and excessive alcohol abuse leading to liver hardening (cirrhosis) and liver cancer.

Fatty liver (Nonalcoholic fatty liver disease) is also increasingly common in Singapore, it associated with obesity, diabetes and hypertension.

Primary Liver Cancer / Hepatocellular carcinoma (HCC) - Diagnosis

​It is important to get an accurate diagnosis of primary liver cancer so that your condition can be treated the right way. Your doctor will ask questions about your medical and family history, lifestyle habits and perform a physical examination.

The simplest imaging study of the liver is an ultrasound. There is no radiation risk and can be done on a regular basis, especially in individuals who are at risk of liver cancer, for e.g. hepatitis B carriers. It is however not always accurate and or very specific.

A CT scan is a better way of detecting liver cancer and is crucial for treatment planning. This would be the basic imaging that will be done by the liver surgeon to detect and plan a treatment strategy. In certain cases, a CT scan may not be enough or is inconclusive, and additional investigations like MRI or a PET scan may be performed.

A blood test that measures the level of a protein produced by the liver called alpha fetoprotein (AFP) is associated with HCC but it should not be used in isolation or as a routine screening test.

Occasionally, a small amount of liver tissue may be sampled via a needle procedure (liver biopsy), this may be required to guide management and/or if the diagnosis is unclear.

Other scans or investigations may be required if necessary for diagnosis, staging and/or to guide treatment strategy.

Primary Liver Cancer / Hepatocellular carcinoma (HCC) - Treatments

​Surgery is often the best treatment for liver cancer when it is at an early stage and hasn't spread to nearby blood vessels. Other methods have not been shown to be as effective as surgery in treating liver cancer. However, because liver cancer is frequently associated with liver damage (cirrhosis) and surgery may not be possible for some patients.

As surgery is the only effective method for treating liver cancer, it is important that a person with suspected liver cancer has a proper assessment by a specialist team lead by a liver surgeon is known as a Hepato-Pancreato-Biliary (HPB) surgeon. Liver surgery is currently safe and effective in treating liver cancer if amenable.

Surgery for Liver cancer includes cutting out the liver tumor (Liver resection) or replacing the whole liver with a new liver (liver transplant)

  • Liver transplant – A small selected group of patients may be suitable for a liver transplantation.
  • Liver resection – This is the treatment of choice in patients with a solitary tumor and without liver cirrhosis
  • Ablation – This destroys the cancer by energy via a long needle (probe) inserted under guidance with intense heat, cold or alcohol. This may be suitable as first line treatment for a  small tumour in a suitable location
  • Embolisation – This uses the targeted delivery of chemotherapy drugs (chemoembolization) or radiation-laden micro-beads (radio-embolization) via a feeding blood vessel. This is performed as a procedure through the blood vessel in the groin. This can be effective in controlling the tumour and sometimes reducing the size as well.
  • Chemotherapy – Generally, liver cancer is quite resistant to chemotherapy. Targeted therapy such as Sorafenib has shown promise in large studies in advanced cases not suitable for surgery.
  • Clinical Trials – Clinical trials test new drugs, surgical techniques and strategies for advancing treatment. There may be suitable clinical trials available for selected patients. Please consult your specialist for advice.
  • Combination of various treatment options may be offered as well to optimise the treatment results

Primary Liver Cancer / Hepatocellular carcinoma (HCC) - Preparing for surgery

​Your surgeon will perform a comprehensive work-up including blood tests, scans to see if you are suitable for surgery and advise you on the risks involved. This treatment recommendation is often based on consensus by a group of different specialists' opinions (tumor board) which weighs the pros and cons of every treatment strategy.

Before surgery, the anaesthesia team will also assess your fitness for surgery and advise you on various aspects of general anaesthesia aspects and pain control after surgery.

Specialist nurses will also available for pre-surgery counselling.

Primary Liver Cancer / Hepatocellular carcinoma (HCC) - Post-surgery care

​After recovering from your surgery, you will be given regular outpatient appointments to see your team of doctors and these will include blood test and scans to check if the cancer recurs.

It is important to follow all your doctor's advice, clinic visits and tests so that timely treatment can occur if the cancer or other problems arises.

Primary Liver Cancer / Hepatocellular carcinoma (HCC) - Other Information

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