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Liver Cancer Symptoms, Diagnosis and Treatment

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 hepatitis B being the most common risk factor in the region. 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].

Every year, liver cancer has led to approximately 1,500 deaths[2], with 80% of the cases related to hepatitis B virus[3]. Because most liver cancer cases are complicated with liver cirrhosis, the effectiveness and adoption of traditional cancer treatment for patients have been limited.

Thanks to rapid medical advances, there are increasingly more treatment options for liver cancer. Recent research studies even suggseted that the complete removal of a cancer tumor is no longer impossible for patients with late-stage liver cancer. Below is the latest information about liver cancer treatment and an overview of options, including frequently asked questions and answers regarding liver cancer symptoms.

What Is Liver Cancer?


In general, liver cancer can be classified as either primary or secondary. When liver cells become abnormal and begin to grow out of control, these accumulating cells become cancerous, leading to primary liver cancer. Primary liver cancer can have different growth patterns.

The first type of primary liver cancer starts out as a single tumor that grows larger before spreading to other parts of the liver, while another type begins as many small cancer nodules throughout the liver, which is seen most often in people with cirrhosis.

As for secondary liver cancer, cancer cells do not start from the liver but spread from somewhere else in the body. This is also known as metastatic liver cancer. The most common primary sites of cancer cells that spread to the liver are large intestines, pancreas, stomach, lung and breast.

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

Symptoms of liver cancer


肝癌的症狀

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

  1. Abdominal swelling – a lump in the right side of abdomen and pain near the right shoulder blade
  2. Fluid build-up in the abdomen (belly) – sometimes varicose veins are present in the stomach
  3. Yellow discoloration of skin and eyes (jaundice) – the tumor causes a blockage of the common bile duct, leading to the buildup of bilirubin and thus jaundice
  4. Itchy skin
  5. Dark urine, pale or grey feces
  6. Decreased blood clotting factors – bleeding happens more easily than normal
  7. Loss of appetite and unintended weight loss
  8. Nausea and vomiting
  9. High temperatures, fatigue and weakness

Risk Factors of Liver Cancer


導致肝癌的風險因素
  1. Hepatitis B virus infection – people chronically infected with hepatitis B are 100 times more likely to develop liver cancer than uninfected people[5]
  2. Hepatitis C virus infection
  3. Cirrhosis
  4. Alcohol – heavy alcohol use can lead to cirrhosis and an increased risk of liver cancer
  5. Obesity, diabetes and smoking
  6. A family history of liver cancer

Liver Cancer Staging and Treatment Approaches


The treatment approaches of liver cancer tend 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 will need to consider whether the remaining liver function of the patients will be able to handle liver cancer surgery without leading to liver failure after the procedure. Cancer staging, which is the size, number, location and the extent of the spread of the tumor, is also an important indicator for the devising of an appropriate treatment plan.

As with most of the cancer, the stages of liver cancer are determined according to how big the tumor has grown and whether or not cancer cells have invaded into 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 not all of the cases can be classified. Stage I and Stage II usually imply the tumor remains small and cancer cells have yet to invade blood vessels and spread to other parts of the body. For Stage III and Stage IV liver cancer, the tumor has already invaded blood vessels and surrounding organs.

Researchers from Li Ka Shing Faculty of Medicine, 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, according to the unique risk factors in Asian populations. Based on their general health conditions, liver functions and progression of the disease, the HKLC has classified liver cancer patients into five stages, rather than the current four in the TNM staging system widely adopted in western countries[7]. The objective of a new staging system specific to Asia’s populations is to encourage doctors and patients to adopt a more aggressive type of treatment to improve survival. For example, patients with liver cancer at locally advanced stage could choose to remove the affected area through surgery.

Common Liver Cancer Treatment Approaches


Surgery 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 clinically considered as suitable to undergo surgery and tumor removal[8]. Doctors will devise different treatment plans for patients according to the types of cancer cells and the stages of cancer, alongside their age and general health conditions, as well as how they react to particular treatments. Below are the common treatment approaches of liver cancer[9]:

Surgery


手術

Liver cancer surgery is normally used in patients whose liver functions remain largely unaffected and who are diagnosed with an early-stage liver cancer with cancer cells yet to spread to other organs.

The most ideal situation is to remove the part or parts of the liver that contains the tumor with surgery. After which, the liver can recover on its own to its original state without affecting liver functions. The risks of liver cancer surgery include infection, post-operative liver failure, coagulation, pneumonia and hemorrhage.

High-intensity focused ultrasound(HIFU)


射頻消融

HIFU treatment is normally used in patients with early-stage primary and secondary liver cancer. It can also be used in patients with liver cancer that is not operable because of poor liver function.

Ablation therapy aims to kill liver cancer cells using a number of different ways such as radiofrequency energy, thermal ablation, cryoablation and alcohol septal ablation. The side effects include abdominal pain, hemorrhage and liver infections. Besides, with the rise of HIFU[10], there will be fewer side effects. This treatment method uses high-frequency ultrasound energy, directing the waves at the tumor and destroying the cancer cells by heating the sound waves up to temperatures as high as 60-degree Celsius.

Transarterial chemoembolization, (TACE)


TACE treatment is appropriate for patients whose liver has tumors that have yet to spread to other organs, or whose one liver has a tumor which is not operable because of bad liver functions, or who cannot undergo ablation therapy because of the tumor growing larger than 5cm in size.

This method aims to destroy the cancer cells by cutting off the tumor’s blood supply which can be done through the injection of blocking materials into the arteries to feed the tumor. TACE treatment tends to be combined with chemotherapeutic drugs and radiation therapy to kill the cancer cells. Common side effects include infections, nausea, vomiting, frequent bowel movements, constipation, diarrhea, and hair loss.

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


Y-90 therapy is appropriate for patients whose tumors are hard to remove through surgery or focal therapy, and patients with late-stage liver cancer 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 tumor 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 tumor. 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 tumor under control for ten to sixteen months, much longer than the six months from TACE treatment. Other advantages of using the Y-90 therapy include being able to discharge from hospital right after surgery. To understand more about this therapy, please refer to radiation therapy servicesprovided in our clinic.

Targeted Therapy


標靶藥物殺死癌細胞

Targeted therapy is normally used in patients with liver cancer that is not operable and who cannot undergo ablation therapy or TACE treatment.

In the past ten years, first-line treatment of patients with late-stage liver cancer was limited to one type of targeted therapy medication. However, the therapeutic effectiveness of the drug has been less than promising, only extending the recipients’ lives to about three months on average. In 2018, lenvatinib became the latest addition to the treatment of advanced liver cancer and has 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 Asian 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 old type of targeted therapy medication. 40% of patients who receive a new type of targeted therapy have seen their tumor reduced three times in size, accounting for twice the size of tumor reduced by using the old type of medication and overall extending and improving the lives of liver cancer patients.

The side effects of targeted therapy are similar to those of chemotherapy but tend to be less severe, including fatigue, nausea, diarrhea, loss of appetite, hair loss, high blood pressure, nose or gum bleeding, dry and itchy skin and hand/foot skin reactions (tender, thickened areas sometimes with blisters on palms and soles).

Immunotherapy


癌症藥物

Immunotherapy represents a new development of cancer treatment. Cancer immunotherapy researchers have been 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 to 15-20% of cancer patients[11].

In Hong Kong, some universities have begun to study the effects of immunotherapy, focusing on late-stage liver cancer patients. According to the research results published by The University of Hong Kong in 2018, the median age of survival for liver cancer patients who received immunotherapy first is 8 months longer than that of those who were treated with targeted therapy first. This undoubtedly brings a new hope to patients battling with liver cancer[12].

Frequently Asked Questions About Liver Cancer Treatment


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), alpha-fetoprotein blood (AFP) test, ultrasound, CT scans, MRI, angiography, and biopsy

Liver transplant is not the most common and preferable treatment option for liver cancer, and generally used on patients whose tumor is less than 6cm in size and whose cancer cells have yet to show signs of spreading. 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 hemorrhage and infections. Some liver transplant recipients might develop acute organ rejection after the procedure. Because the supply of cadaveric livers for transplant is limited and the waiting time tends to be long, patients are normally advised to undertake other forms of treatment before the liver transplant.

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

References:

  • https://www21.ha.org.hk/smartpatient/SPW/static/migration/files/PDF/Hepatitis%20B_c.pdf
  • https://www21.ha.org.hk/smartpatient/SPW/zh-HK/Disease-Information/Disease/?guid=bbcc623b-85fd-4ec9-8d4d-6245d1b076c0
  • https://www.hku.hk/press/press-releases/detail/c_16803.html
  • https://www.cancer-fund.org/liver-cancer/?cat=278
  • https://www.cancer-fund.org/liver-cancer/?gclid=EAIaIQobChMI7ayI6v3g4QIVlwoqCh0bjwLgEAAYAiAAEgIZ1PD_BwE
  • https://www.cancer-fund.org/wp-content/uploads/2017/04/%E8%82%9D%E7%99%8C.pdf
  • 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
  • https://www.cancer-fund.org/liver-cancer/?cat=282
  • https://www.cancer-fund.org/wp-content/uploads/2017/04/Liver-tc-2017.pdf
  • 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
  • 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/

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