Case history: liver cancer
Hanson Yip was an energetic young man with a heart for helping others. But while studying for a university degree in social work, the 26-year-old Yip (whose full has been withheld for reasons of patient confidentiality) started feeling twinges of pain in his upper abdomen.
Initially he tried to ignore it, but the pain persisted for weeks. Uneasy, he went to his family doctor, who found that he had an enlarged liver, which was highly unusual for a man of his age. He was referred to a specialist, where a CT (computed tomography) scan showed he had a tumour the size of an orange lodged in his liver. Blood tests showed that Yip's levels for a cancer marker called alpha-fetoprotein (AFP) was off the charts. Normal levels should hover around 10 ng/ml (nanograms per millilitre), but Yip's reading was 120,000 ng/ml.
The CT scan and blood test indicated he had a very aggressive primary liver cancer, also known as hepatoma or hepatocellular carcinoma (HCC). A PET (positron emission tomography) scan to measure metabolic activity confirmed that the tumour in the left lobe of his liver was malignant.
The diagnosis was shocking. Although Yip tested positive for hepatitis B, which carries a risk for liver cancer, it was unusual for the disease to strike someone so young. Furthermore, there was no history of liver cancer in his family.
Liver cancer is the third biggest killer among cancers in Hong Kong. Its obscure symptoms thwart early detection of the disease.
Yip's best hope for a cure at the time was surgery and he was operated on at Hong Kong Sanatorium and Hospital in September 2011.
During the surgery, however, doctors discovered a number of smaller tumours in his liver. They removed three or four but more remained. At this point, 40 per cent of Yip's liver had been cut out, so the doctors were reluctant to remove any more. They used high frequency electric currents to heat and destroy the tumours in a procedure called radiofrequency ablation (RFA).
Although the surgery went ahead uneventfully and Yip appeared to recover well from the procedure, doctors were not optimistic about his prognosis. The multiple small tumours were a bad sign, and it was likely more remained.
Yip's AFP levels dropped to 13,000 ng/ml after surgery but while this was a vast improvement, the results were far from normal. It was not long before the AFP levels climbed further to 14,000 ng/ml.
Doctors attempted to use intra-arterial chemoembolisation, a conventional therapy for liver cancer in which chemotherapy is delivered directly to the liver via the hepatic artery while reducing blood flow to the tumours.
Unfortunately, this therapy failed to put a dent in Yip's AFP levels and it appeared he was out of options with a life expectancy of only three to four months.
He turned to Dr Thomas Leung Wai-tong, associate director of the sanitorium's comprehensive oncology centre, in a last-ditch attempt to rid himself of the cancer.
A MRI (magnetic resonance imaging) scan showed multiple recurrent cancers 2cm to 3cm in size barely two months after surgery.
Leung told Yip that any treatment he could offer would be palliative and the options were few. But Yip was ready to try anything - he had little left to lose.
They both decided on an aggressive approach, using both chemotherapy with cytotoxic drugs and a treatment called selective internal radiation therapy (SIRT).
SIRT uses millions of radiation-filled microspheres that are injected into the artery feeding the cancer. The microspheres, which are one-third the diameter of a human hair, then accumulate inside the tumours where the radiation is released, killing the cancer cells.
A study conducted at HKSH showed that after two months of treatment with SIRT, 36 per cent of patients had their liver tumours reduced in size. Their AFP levels also dropped. The one-year survival rate was about 31 per cent.
Other studies found that the median survival of patients who received SIRT was between 13.5 months and 16.4 months. In comparison, a 2008 British study found that patients receiving placebo treatment survived an average of just 7.9 months. Yip had one treatment of SIRT followed by six cycles of chemotherapy. Liver cancer cells are so notoriously resistant to medication that Leung used four types of drugs, instead of the typical one or two for chemotherapy. Because Yip was young and relatively strong, he could withstand the treatments, although he suffered hair loss, nausea and fatigue. He managed the pain in his liver arising from the SIRT treatment with analgesics. His liver had also regenerated 20 per cent to 30 per cent by this time, which also helped him tolerate the treatments better.
At the end of the six-month treatment, Yip's AFP levels dropped to a normal range - the first time since his diagnosis. MRI scans also showed that the cancer was in remission and there was no sign of the disease in his liver.
An elated Yip had beat the odds. He returned to school to complete his degree and has started working.
Leung continues to monitor Yip's AFP levels and liver scans every quarter and if the disease stays at bay for the next two to three years, Yip will be in the clear.