Liver Cancer Treatment and Diagnosis in Singapore

What are the Liver Cancer Treatments in Singapore?

Depending on your specific medical condition, different treatments may be prescribed by a liver specialist for patients with liver cancer (hepatocellular carcinoma), biliary (bile-duct) cancer (cholangiocarcinoma), or other associated cancers of the gallbladder, and surrounding organs. The type of treatment the doctor recommends depends on the stage of the cancer, the extent of metastasis (i.e. if the cancer has spread to other organs) and the patient’s health condition. Your oncologist may prescribe different hepatobiliary treatment regimes such as surgery, tumour ablation, chemotherapy, targeted cancer therapy, and radiotherapy to address your condition.

Hepatobiliary Cancer Treatment: Surgery

Surgery is typically the treatment of choice for patients with early stage liver cancer because it has a high probability of treating hepatobiliary cancer, especially if only parts of the liver are affected with cancer.

For more severe cases where a greater part of the liver is cancerous, a liver transplant may be recommended. A liver transplant is a type of surgery where the liver is removed and replaced with a healthy, donated liver. This surgery may only be considered if the cancer is contained within the liver, if a donor liver is available, and if the attending doctor believes the cancer is likely to be eliminated by surgery. During transplant surgery, anti-rejection drugs (immunosuppressants) are used to prevent organ rejection after the transplant.

Hepatobiliary Cancer Treatment: Radiation Therapy

In radiation therapy, high-energy rays are used to potentially destroy cancer cells and prevent them from growing. External radiotherapy uses a machine outside the body to direct radiation towards cancer cells. This type of treatment is not commonly used to treat liver cancer because the liver cannot tolerate high doses of radiation. 

A specialist may also recommend internal radiation as part of radiation therapy. This process involves implanting radioactive substances into the cancer-infected area through the hepatic artery, which is a blood vessel that carries blood to the liver.

Hepatobiliary Cancer Treatment: Chemotherapy

Chemotherapy uses anti-cancer drugs to potentially kill hepatic cancer cells and prevent them from dividing and growing. Chemotherapy can also help control symptoms by shrinking the cancer or slowing its growth. The attending doctor usually administers these drugs via injections into veins, although they can sometimes be given as tablets. 

Chemotherapy may also be given as part of a treatment called chemoembolisation. This involves the injection of chemotherapy drugs directly into the liver cancer, together with a gel or tiny plastic beads to block blood flow to the tumour.

Hepatobiliary Cancer Treatment: Targeted Therapy

Targeted therapy uses drugs that potentially prevent the growth and spread of cancer by interfering with specific molecules involved in cancer development. These drugs target liver, gallbladder, or bile-duct cancer cells by stopping them from growing their own blood vessels. Since cancer cells need blood supply to receive nutrients and oxygen, this may limit the cancerous cell’s ability to grow.

Hepatobiliary Cancer Treatment: Tumour Ablation

Tumour ablation is a specific regimen that potentially destroys primary liver cancer cells using either heat or alcohol. During the procedure, the specialist performing the surgery will utilise computed tomography (CT) to guide a needle into the liver to eradicate the cancer cells. A local anaesthetic is given to patients at the beginning of the procedure to alleviate pain. 

There are 2 types of tumour ablation treatments that your doctor may recommend based on your condition: Radio Frequency Ablation (RFA) and Percutaneous Ethanol Injection (PEI). 

  • RFA treatment uses laser light or radio waves passed through the needle to destroy cancer cells by heating them to a very high temperature. 
  • PEI treatment uses alcohol injected through the needle into the cancer to destroy the cancer cells.

Are there any Side Effects of Hepatobiliary Cancer Treatment?

Side Effects of Surgery:

Experiencing pain is a common side effect of surgery for liver cancer. However, discomfort can be managed with medication prescribed by your specialist and the use of anaesthesia.

Side Effects of Radiation Therapy:

The side effects of radiation therapy include nausea and vomiting, diarrhoea, tiredness, hair loss, and skin changes.

Side Effects of Chemotherapy:

The side effects of chemotherapy commonly include the following:

  • Nausea and vomiting
  • Diarrhoea
  • Constipation
  • Tiredness
  • Pain
  • Loss of appetite
  • Hair loss
  • Skin and nail changes
  • Numbness and tingling
  • Swelling

Side Effects of Targeted Therapy:

The side effects of targeted therapy may include nausea and vomiting, diarrhoea, constipation, swelling of hands and feet, rash and other skin changes, and vision problems.

Side Effects of Ablation Therapy:

The side effects of ablation therapy are varied and may include:

  • Abdominal pain
  • Infection in the liver
  • Fever

What do I need to do if I have Hepatobiliary Cancer?

If you suspect that you or your loved one have liver or bile-duct cancer, it is advisable to get the support you need from a liver cancer specialist. Early detection, diagnosis, and treatment of liver cancer is key to managing this disease.

Regardless of what stage your hepatobiliary cancer may be, you should schedule an appointment to see an oncologist specialising in hepatobiliary cancer as soon as possible. With the speed of developments in hepatobiliary cancer diagnosis and treatment, novel emerging treatment options could be explored by your medical oncologist.

What is Hepatobiliary Cancer?

Definition of Liver Cancer

Hepatobiliary cancers are cancers that appear in the liver, gallbladder, bile ducts or bile. They normally occur as tumours on these organs. Also known as hepatocellular carcinomas (HCC), liver cancer affects about one million people globally each year.


Given the complexity and severity of hepatobiliary cancers, seeking support from a liver cancer specialist is crucial for accurate diagnosis and personalised therapy tailored to individual needs.

What are the Signs and Symptoms of Hepatobiliary Cancer?

The most common symptoms of hepatobiliary cancer are:

Many people do not show any signs or symptoms of hepatobiliary cancer, especially in the early stages of primary liver cancer. 

When signs and symptoms appear, they normally include:

  • Weight loss
  • Loss of appetite
  • Upper abdominal pain
  • Nausea and vomiting
  • General weakness and fatigue
  • Abdominal swelling
  • Yellow discolouration of skin and eyes (jaundice)
  • White, chalky stool

Screening for Hepatobiliary Cancer

Screening is normally used to diagnose cancer before patients experience any signs or symptoms. The goal of cancer screening is to:

  • Lower the number of people who lose their lives to hepatobiliary cancer
  • Lower the number of people who develop hepatobiliary cancer

Conditions like Hepatitis B, Liver Cirrhosis or Hepatitis C may increase one’s risk of developing liver cancer. Therefore, individuals with these conditions are advised to consider screening.

Hepatobiliary cancer screening tests include:

Screening options for hepatobiliary cancer include testing your blood for a substance called alpha-fetoprotein (AFP), which may be produced by cancer cells. Your doctor may also conduct imaging tests like an ultrasound, computed tomography (CT or CAT) scan, or magnetic resonance imaging (MRI) to determine if you have liver cancer.

How Hepatobiliary Cancer is Diagnosed

Cancer specialists normally use a battery of tests to diagnose liver cancer. Your oncologist may also conduct tests to understand whether hepatobiliary cancer has spread to other organs in the body. For most types of cancer, a biopsy is the only definite way for a liver cancer specialist to know whether an area of the body has cancer. Biopsies are done under general anaesthesia and involve your cancer specialist taking a small sample of tissue for testing in a laboratory. 

A hepatobiliary doctor may consider the following factors when choosing a diagnostic test:

  • Patient’s signs and symptoms
  • Age and medical condition
  • Results of earlier medical tests

Tests to diagnose hepatobiliary cancer include:

  • Physical examination: Your doctor will look for an abnormal buildup of fluid in the abdomen and for signs of jaundice, including yellowing of the skin and eyes. He or she may also feel the abdomen to check for lumps, swelling, or other changes in the liver, spleen, and nearby organs. 
  • Blood tests: Your liver specialist will do a blood test to look for a substance called AFP. Higher levels of AFP are found in patients who have hepatobiliary cancer. Doctors will also test the patient’s blood to see if there are any signs of Hepatitis B or Hepatitis C. 
  • Ultrasound: Your doctor may perform an ultrasound to examine your liver. The ultrasound uses sound waves and a small amount of radiation to create a picture of the organs inside the body.
  • Computed tomography (CT or CAT) scan: A CT may be conducted to check for any abnormalities or tumours. This scan creates a 3-dimensional picture of the inside of the body using X-rays taken from different angles.
  • Magnetic resonance imaging (MRI): To enable your doctor to measure the size of the tumour in your liver, an MRI may be performed. This is an imaging test that uses magnetic fields to produce detailed images.
  • Angiogram: An angiogram may be conducted to get an X-ray image of your blood vessels.
  • Laparoscopy: If your doctor requires to see the inside of the body, they may perform a laparoscopy which uses a tube called a laparoscope.
  • Biopsy: A biopsy may be performed to help the cancer specialist better understand the condition of your liver. During this procedure, a small amount of tissue in the liver will be removed and then examined under a microscope.

What are the Causes and Risk Factors of Hepatobiliary Cancer?

The following factors may increase the risk of primary liver cancer:

Chronic infection with HBV or HCV: Chronic infection with the Hepatitis B virus (HBV) or Hepatitis C virus (HCV) increases the risk of liver cancer.
Cirrhosis: This irreversible condition causes scar tissue to form in the liver which increases the chance of developing liver cancer.
Certain inherited liver diseases: These include hemochromatosis and Wilson’s disease.
Diabetes: Diabetes is a disease that affects the body’s ability to produce or use insulin. Diabetics are more likely to develop liver cancer than those without diabetes
Non-alcoholic fatty liver disease: An accumulation of fat in the liver increases the risk of liver cancer.
Exposure to aflatoxins: Aflatoxins are poisons produced by molds that grow on crops that are stored poorly.
Excessive alcohol consumption: Consuming more than the recommended amount increases your risk of getting liver cancer.

Primary liver cancer begins in the tissue of the liver. There are two main types of primary liver cancer: hepatocellular carcinoma and cholangiocarcinoma (cancer of the bile duct).

Secondary metastatic liver cancer occurs when the cancer spreads to the liver from other parts of the body.

Before deciding the stage of hepatobiliary cancer, liver cancer specialists consider:

  • The overall function and condition of the liver
  • The severity of the patient’s symptoms
  • Whether or not the liver cancer has spread to other organs

The above factors, combined with results from diagnostic imaging tests, will help doctors determine the stage of hepatobiliary cancer.

Stage 1 Liver Cancer

There are two sub-stages for Stage 1 liver cancer:

  • Stage 1AWhen there is a single tumour that is 2 cm or less in size, which may or may not have grown into surrounding blood vessels.
  • Stage 1BWhen there are larger tumours above 2 cm which have not affected the blood vessels.

Stage 2 Liver Cancer

In Stage 2 liver cancer, the solitary tumour has started to grow into the blood vessels that permeate the liver organ.

Stage 3 Liver Cancer

Stage 3 liver cancer is normally subdivided into 2 further stages:

  • Stage 3A: Here, there is more than one tumour, and they are more than 5cm in diameter.
  • Stage 3B: At this stage, the cancer has grown into one of the main blood vessels, which either supply blood to or carry blood away from the liver.

Stage 4 Liver Cancer

Like the earlier stage, there are two sub-stages here:

  • Stage 4A: At this stage, the cancer may be of any size. Additionally, patients may have multiple tumours which may have grown into the blood vessels or other organs or spread to the lymph nodes.
  • Stage 4B: This stage is similar to stage 4A, except the cancer has spread to other parts of the body (e.g. the lungs, bones or other surrounding bones).

TNM Staging System

To describe the progression of your hepatobiliary cancer, a liver specialist may use the TNM staging system. This system comprises of the following: 

  • T to describe the size of the tumour
  • N to describe whether there are cancer cells in the lymph nodes
  • M to describe whether the cancer has spread to a different part of the body (M is an acronym for metastasis)

Liver Specialists at OncoCare with Clinical Interests in Hepatobiliary Cancers

Oncologists are trained in diagnosing and treating all types of hepatobiliary cancers, including liver, pancreatic, and bile duct cancer. They are also able to address other cancers, such as esophageal cancer, colorectal cancer and stomach cancer.

Senior Consultant, Medical Oncologist

MBBS (Delhi) – American Board Certified (Int Med) – American Board Certified (Hematology) – American Board Certified (Med Oncology)

Before joining OncoCare Cancer Centre at Mount Elizabeth Hospital, Singapore, Dr Akhil Chopra was a Senior Consultant in Medical Oncology at Johns Hopkins Singapore, Tan Tock Seng Hospital and Adjunct Associate Professor at Lee Kong Chian School of Medicine. 

Dr Chopra has experience addressing multiple cancer types including breast cancer, lung cancer, cancers of the stomach, colon, rectum, liver, prostate, kidney, testicular and bladder, gynaecological cancers such as ovarian and uterine/cervical cancers; as well as Sarcomas and chronic leukaemia/multiple myeloma. Besides his clinical and research work, he has been involved in teaching medical students from the Lee Kong Chian School of Medicine as well as medical residents and students from Johns Hopkins University, Baltimore, USA. 

MEDICAL PROFILE

  • Graduated from Delhi in 2001
  • Received American Board Certification for Internal Medicine
  • Received American Board Certification for Medical Oncology
  • Received American Board Certification for Hematology
  • Completed fellowship Training at Hahnemann University Hospital/Drexel University College of Medicine in Philadelphia, USA

Cancer Specialities: breast cancer, lung cancer, cancers of the stomach, colon, rectum, liver, prostate, kidney, testicular and bladder, gynaecological cancers such as ovarian and uterine/cervical cancers

Senior Consultant, Medical Oncologist

MBBCH, BAO (Ireland) – MRCP (United Kingdom) – FRCP (Edinburgh) – FRCP (Medical Oncology)

Prior to entering private practice, Dr Benjamin Chuah was actively involved in postgraduate teaching and research. He was the principal or co-investigator in international trials involving the use of novel and targeted therapy drugs for colorectal and pancreatic cancer. His research work includes small cell gallbladder cancer with paraneoplastic hyponatremia and has led to several 1st author publications in high-impact medical and oncology journals, including Gastroenterology, GUT and Annals of Oncology. 

Dr Chuah has also held the position of Director for Postgraduate Medical Education (Medical Oncology) and was a Core Faculty member of the Residency Program (Internal Medicine). He was also awarded the National University Hospital Postgraduate Teaching Excellence Award in 2011. In addition, he was awarded the NUH Innovative Grant for research in warfarin pharmacogenomics and honoured with the inaugural Kobayashi Foundation Award for his work on serial changes in the expression of breast cancer-related proteins in response to neoadjuvant chemotherapy.

MEDICAL PROFILE

  • Graduated from Trinity College, University of Dublin, Ireland in 1998
  • MRCP (UK), Royal Colleges of Physicians of the United Kingdom, 2002
  • Awarded the Professor’s Prize in Physic (Surgery) 1998, Arthur Ball Prize (2nd place) 1998, NUH Innovative Grant 2007, the Kobayashi Foundation Award 2010 and NUH Postgraduate Teaching Excellence Award 2011
  • Appointed as the Director of Post Graduate Medical Education (Medical Oncology) and Core Faculty for the Residency Program (Internal Medicine) at National University Hospital

Cancer Specialities: Gastrointestinal Cancers, including oesophageal, gastric, biliary tract, pancreatic, liver (hepatocellular carcinoma), neuroendocrine cancers and colorectal cancers

Senior Consultant, Medical Oncologist

MBBS (Singapore) – MRCP (United Kingdom)

Dr Soh believes in the delivery of quality healthcare and was the lead and co-lead in several healthcare improvement projects. He has received multiple awards for his involvement in the Clinical Practice Improvement Programmes which he implemented at NUH. Between 2013-2015, he served as Honorary Secretary of the Executive Committee, Singapore Society of Oncology.

He is actively involved in both research and education in cancer medicine. His research focuses on colorectal cancer and chemotherapy drugs Regorafenib, FOLFIRI regimen (irinotecan, 5-fluorouracil and folinic acid). He was also the principal investigator in several multi-centre gastrointestinal cancer clinical trials and his research has led to over 10 publications in high-impact medical and oncology journals.

MEDICAL PROFILE

  • Graduated from the National University of Singapore in 2003
  • Obtained Membership to the Royal College of Physicians (United Kingdom) in 2007
  • Awarded Teaching Excellence Award in 2014, NCIS
  • Awarded NUH UMC Undergraduate Teaching Best Tutor Award in 2015
  • Received research funding from the National Medical Research Council (NMRC), Singapore
  • Awarded the Clinical Investigator Salary Support Program (CISSP) award thrice
  • Published research work in more than 10 publications relating to hepatocellular carcinoma, colorectal cancer, pancreatic cancer and other gastrointestinal cancers
  • Sub-specialty oncology interest in gastrointestinal (oesophageal, stomach, colon and rectal cancers) and hepatobiliary cancers (liver, pancreas, bile duct and gallbladder cancers)

Cancer Specialities: Gastrointestinal (oesophageal, gastric, colon and rectal cancer) and Hepatobiliary Cancer (liver, pancreas, bile duct and gallbladder cancers) 

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