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Liver cancer is one of the most common types of cancer in Hong Kong. People with hepatitis B, hepatitis C or cirrhosis have an increased risk of developing liver cancer, with the most common cause being hepatitis B in Hong Kong. According to the latest statistics published by the Hong Kong Hospital Authority, about 10% of the population are living with chronic hepatitis B virus (HBV)[1].

 

Liver cancer leads to approximately 1,500 deaths[2], annually, with 80% of the cases as related to hepatitis B virus[3]. The effectiveness and adoption of traditional cancer treatments for these patients have been limited due to most liver cancer cases as being complicated with cirrhosis of the liver.

 

Thanks to rapid medical advances, there are increasingly more treatment options for liver cancer. Recent research has even suggested that the complete removal of a cancer tumor is no longer impossible for patients with late-stage liver cancer. The latest information regarding liver cancer treatments and an overview of services follows below, including the frequently asked questions concerning patient diagnosis to their treatment, how symptoms present for the patient, the system for cancer staging and the treatment of liver cancer.

What Is Liver Cancer?

In general, liver cancer can be classified as either primary or metastatic. When normal liver cells begin to grow abnormally and out of control, these cells become cancerous, leading to primary liver cancer. Primary liver cancer can onset as either a single tumour or as multiple tumours, with the latter kind scattered all over the liver and most often in people with cirrhosis. By contrast, metastatic cancers spread from somewhere else in the body. This is also known as secondary liver cancer. The most common primary sites of cancer cells that spread to the liver are from the large intestines, pancreas, stomach, lungs and breasts.

 

Liver cancer is most often seen in people aged between 50 to 70. Men are at four times higher risk of liver cancer than women[4]. Liver cancer symptoms are not apparent in the early stages and only become so once the disease has progressed to an advanced stage.

Symptoms of liver cancer

If the following liver cancer symptoms persist, please consult your doctor as soon as possible:

 

  • Abdominal swelling – a lump in the right side of abdomen and pain near the right shoulder blade
  • Fluid build-up in the abdomen (belly) – sometimes blue veins are visible on the abdomen
  • Yellow discoloration of skin and eyes (jaundice) – the tumour causes a blockage of the common bile duct, leading to a build-up of bilirubin and then jaundice
  • Pruritus of the skin
  • Dark urine, pale or grey faeces
  • Decreased blood clotting factors – prone to haemorrhage on injury
  • Loss of appetite and weight loss for no reason
  • Nausea and vomiting
  • High temperatures, fatigue and weakness

Risk Factors of Liver Cancer

  • Hepatitis B virus infection – people chronically infected with hepatitis B are 100 times more likely to develop liver cancer than those who are uninfected[5]
  • Hepatitis C virus infection
  • Cirrhosis
  • Alcohol – heavy alcohol use can lead to cirrhosis and an increased risk of liver cancer
  • Obesity, diabetes and smoking
  • A family history of liver cancer

Liver Cancer Staging and Treatment Approaches

The treatment approaches for liver cancer tend to have to take into account more factors than other cancer types[6], mainly because the liver is one of the most important organs in the body with an extremely complex structure and over 500 different functions, including absorbing substances that are beneficial to our health and releasing toxic substances.

 

Before deciding on which treatment option is best for the patients, the doctor needs to consider whether the patient has enough remaining liver function to cope with a large scale resection of their liver and avoid liver failure following the procedure. Cancer staging, which is the size, number, location and the extent of the spread of the tumour, is also an important indicator for the devising of an appropriate treatment plan.

 

As with most cancers, the stages of liver cancer are determined according to how big the tumour has grown and whether or not cancer cells have invaded the blood vessels and spread beyond the liver to other organs. Based on TNM staging system, liver cancer can be divided into Stage I to Stage IV, although there are still some cases that cannot be classified. Stage I and Stage II usually imply the tumour remains small and cancer cells have yet to invade the blood vessels and metastasised to other parts of the body. For Stage III and Stage IV liver cancer, the tumour has already invaded the blood vessels and metastasised to the surrounding organs.

 

Researchers from the University of Hong Kong (HKU) have developed Asia’s first liver cancer staging system with treatment guidelines, namely the Hong Kong Liver Cancer (HKLC) staging system aimed at the unique risk factors in Asian populations. Based on the patient’s general health conditions, liver function and the progression of the disease, it classifies patients into five stages, rather than the current four in the TNM staging system widely adopted in Western countries[7]. The objective of the new staging system specific to Asia’s populations is to encourage doctors and patients to adopt more proactive treatments to improve survival rates, whereby patients with liver cancer at mid to advanced stages may elect to undergo surgical resection.

Common Liver Cancer Treatment Approaches

Surgical resection is the most ideal treatment option for liver cancer. However, because of concerns over potential impacts on liver function, only one-fifth of patients with liver cancer are considered clinically suitable for surgery and tumour removal[8]. Doctors devise different treatment plans for patients based on the types of cancer cells and the stage of the cancer, alongside their age and general state of health, as well as the degree of side effects they may be capable of bearing with particular treatment plans. The following are the more common treatment plans for liver cancer[9]:

Surgical Resection for Liver Cancer

surgery-in-operation-room

Is suited to patients whose liver function remain largely unaffected and who are diagnosed with an early-stage liver cancer in one of their two lobes, where the cancer cells have yet to metastasise to other organs.

 

Resection involves resecting the immediately affected cancerous portion and is the most ideal solution. After which, the liver can recover on its own to its original state without liver function being affected. Risks involved include infection, post-operative liver failure, thrombosis, pneumonia and haemorrhage.

High-intensity focused ultrasound(HIFU)

liver-ablation-therapy

Is suited to patients with early-stage primary and metastatic liver cancers; it is also suited for use in those patients where their liver cancer is inoperable from poor liver functionality.

 

Ablation therapy destroys liver cancer cells via a number of different ways such as radiofrequency energy, thermal ablation, cryoablation and alcohol septal ablation. The side effects include abdominal pain, haemorrhage and liver infections. Furthermore, in recent years the new generation of equipment sees fewer side effects with HIFU[10], This treatment method uses high-frequency ultrasound energy, directing waves at the tumour and destroying the cancer cells by heating them up to temperatures as high as 60-degree Celsius.

Transarterial chemoembolization, (TACE)

surgery

TACE treatment is suited to patients whose liver has tumours in both lobes that have yet to metastasise to other organs, or where one lobe has an unresectable tumour from poor liver function, or who cannot undergo ablation therapy from the tumour being larger than 5cm.

 

This method aims to destroy the cancer cells by “starving” the tumour’s feeder vessel supply of nutrients, and is achieved through the injection of blocking materials into the arteries such as special oils and drugs. TACE treatment tends to be combined with chemotherapeutic drugs and radiation therapy to kill the cancer cells. Common side effects include infections, nausea, vomiting, gastrointestinal discomfort (such as constipation and diarrhoea) and alopecia.

Intra-Arterial Yttrium-90 Radioembolization (Y-90) (new radiation therapy for the treatment of liver cancer)

Cancer-cell-in-colour-background

Y-90 therapy is suited to patients whose tumours are unsuited to surgical resection or focal therapy, and for those patients with mid-to-late-stage liver cancers with limited treatment options.

 

Y-90 therapy is one of the major breakthroughs in radiation therapy of liver cancer. It is a minimally invasive procedure that delivers a high dose of radiation to the tumour while sparing normal tissue, by placing a tiny glass or resin beads filled with the radioactive isotope yttrium Y-90 inside the blood vessels that feed a tumour. It has significantly fewer side effects and is more effective than most other traditional radiation therapy.

 

A number of clinical research studies have demonstrated that the Y-90 therapy is able to bring the tumour under control in ten to sixteen months, significantly longer than the six months of TACE treatment. Other advantages of using the Y-90 therapy include being able to be discharged from hospital immediately following the procedure. Please enquire at radiation therapy services in this clinic for more information.

Targeted Therapy

shutterstock_185401712

Is suited to those patients whose liver cancer is unresectable and who are unable to undergo ablation therapy or TACE treatment options.

 

In the past ten years, first-line treatment of patients with late-stage liver cancer has been limited to one type of targeted therapy. However, the clinical outcome for the drug has been less than promising with only extending lives about three months on average. In 2018, lenvatinib became the latest addition to the treatment of advanced liver cancer, having been approved by the US Food and Drug Administration (FDA) for first-line treatment of patients with unresponsive liver cancer.

 

This new drug is a tyrosine kinase inhibitor (TKI) that is taken orally. Clinical research findings have shown that the median overall survival time of liver cancer patients who took lenvatinib was extended to 13.6 months. The new drug has a relatively more significant effect on ethnic Chinese patients with liver cancer, with their median overall survival time extending to 15 months, representing an increase of 50% in the median overall survival time of patients who took the previous type of targeted therapy medication. 40% of patients who received the new type of targeted therapy saw their tumour reduced by three times in size, accounting for twice the size of tumour reduction in contrast with the previous medication. Additionally, the non-progression phase was likewise extended.

 

The side effects of targeted therapy are similar to those of chemotherapy but tend to be less severe and include fatigue, nausea, diarrhoea, loss of appetite, alopecia, hypertension, nasal mucosa or gingival bleeding, xerosis and pruritus, and blistering and swelling of the palms and soles).

Immunotherapy

Immunotherapy

Immunotherapy represents a new development of cancer treatment with researchers being awarded the Nobel Prize for Medicine or Physiology in 2018. A copious amount of research studies on immunotherapy suggests that this treatment method is effective in 15-20% of cancer patients[11].

 

Some universities in Hong Kong have begun studying the effects of immunotherapy in late-stage liver cancer patients and according to research published by The University of Hong Kong in 2018, the median age of survival for liver cancer patients who elected to receive immunotherapy was 8 months longer than the equivalent targeted drug cohort. Bringing new hope to liver cancer patients[12].

Frequently Asked Questions About Liver Cancer Treatment

  • Q1. Does a biopsy have to be performed for liver cancer diagnosis?

    Biopsy is one of the many types of tests doctors may perform for liver cancer diagnosis. There are a number of tests to detect liver cancer, including liver function tests (LFTs), an alpha-fetoprotein blood (AFP) test, ultrasound, CT scans, MRI, angiography, and examination via section biopsy.

  • Q2.Am I suitable for liver transplant?

    Liver transplant is not the most common or most preferable treatment option for liver cancer, and is generally only used in patients whose tumour is less than 6 cm in size and whose cancer cells have not yet shown signs of metastasising. Although liver transparent can replace a patient’s diseased liver with a whole, or partial healthy liver, the procedure does carry a risk of significant complications such as postoperative haemorrhage and infection. Some liver transplant recipients might develop acute organ rejection after the procedure. And due to transplant availability being limited, patients are usually advised to undertake other forms of treatment while awaiting their liver transplant.

  • Q3. What is the follow-up care after liver cancer treatment?

    Once patients have completed treatment, they still need to go to follow-up appointments on a regular basis for the close monitoring of their recovery to reduce the risk of recurrence. This usually involves blood and imaging tests. Patients should also follow a healthy lifestyle such as exercising regularly, refraining from alcohol and cigarettes and adjusting dietary habits under the guidance of a professional nutritionist. Patients who have received a liver transplant will need to take anti-rejection medications for the remainder of their lives to prevent their bodies from rejecting the donated liver.

References:

 

  1. https://www21.ha.org.hk/smartpatient/SPW/static/migration/files/PDF/Hepatitis%20B_c.pdf
  2. https://www21.ha.org.hk/smartpatient/SPW/zh-HK/Disease-Information/Disease/?guid=bbcc623b-85fd-4ec9-8d4d-6245d1b076c0
  3. https://www.hku.hk/press/press-releases/detail/c_16803.html
  4. https://www.cancer-fund.org/liver-cancer/?cat=278
  5. https://www.cancer-fund.org/liver-cancer/?gclid=EAIaIQobChMI7ayI6v3g4QIVlwoqCh0bjwLgEAAYAiAAEgIZ1PD_BwE
  6. https://www.cancer-fund.org/wp-content/uploads/2017/04/%E8%82%9D%E7%99%8C.pdf
  7. https://www.livercenter.com.hk/article/患上肝癌,怎麼辦:肝癌治療方法簡介繼發性肝癌
  8. https://www.cancer-fund.org/liver-cancer/?cat=282
  9. https://www.cancer-fund.org/wp-content/uploads/2017/04/Liver-tc-2017.pdf
  10. https://www.livercenter.com.hk/article/患上肝癌,怎麼辦:肝癌治療方法簡介繼發性肝癌
  11. https://health.mingpao.com/%E6%B8%AF%E5%A4%A7%E5%85%8D%E7%96%AB%E6%B2%BB%E7%99%82%E9%86%AB%E8 %82%9D%E7%99%8C-%E5%AD%98%E6%B4%BB%E6%9C%9F%E5%A4%9A8%E5%80%8B%E6%9C%88/