How is liver cancer diagnosed?

Many liver cancers are not found until they start to cause symptoms, at which point they may already be at an advanced stage.

Signs and symptoms of liver cancer

Signs and symptoms of liver cancer often do not show up until the later stages of the disease, but sometimes they may show up sooner. If you go to your doctor when you first notice symptoms, your cancer might be diagnosed earlier, when treatment is most likely to be helpful. Some of the most common symptoms of liver cancer are:

• Weight loss (without trying)
• Loss of appetite
• Feeling very full after a small meal
• Nausea or vomiting
• Fever
• An enlarged liver, felt as a mass under the ribs on the right side
• An enlarged spleen, felt as a mass under the ribs on the left side
• Pain in the abdomen or near the right shoulder blade
• Swelling or fluid build-up in the abdomen
• Itching
• Yellowing of the skin and eyes (jaundice)
• Enlarged veins on the belly that become visible through the skin
• Worsening of your condition if you have chronic hepatitis or cirrhosis

Many of the signs and symptoms of liver cancer can also be caused by other conditions, including other liver problems. Still, if you have any of these symptoms, it's important to see your doctor right away so the cause can be found and treated, if needed.

Some liver tumors make hormones that act on organs other than the liver. These hormones may cause:

• High blood calcium levels (hypercalcemia), which can cause nausea, confusion, constipation, weakness, or muscle problems
• Low blood sugar levels (hypoglycemia), which can cause fatigue or fainting
• Breast enlargement (gynecomastia) and/or shrinking of the testicles in men
• High counts of red blood cells (erythrocytosis) which can cause someone to look red and flushed
• High cholesterol levels

These unusual findings may cause doctors to suspect diseases of the nervous system or other disorders, rather than liver cancer.

If you have one or more of these symptoms, your doctor will try to find if they are caused by liver cancer or something else.

Medical history and physical exam

Your doctor will ask about your medical history to check for risk factors and learn more about your symptoms. Your doctor will also examine you to look for signs of liver cancer and other health problems. He or she will probably pay special attention to your abdomen and may check the skin and the whites of your eyes for jaundice (a yellowish color).

If symptoms and/or the results of the physical exam suggest you might have liver cancer, more involved tests will likely be done. These might include imaging tests, lab tests, and other procedures.

Imaging tests

Imaging tests use x-rays, magnetic fields, or sound waves to create pictures of the inside of your body. Imaging tests may be done for a number of reasons, including:

• To help find suspicious areas that might be cancerous
• To help diagnose liver cancer
• To help a doctor guide a biopsy needle into a suspicious area to take a sample
• To learn how far cancer may have spread
• To help guide certain treatments in the liver
• To help determine if treatment has been effective
• To look for a possible recurrence of the cancer

People who have (or may have) liver cancer may get one or more of the following tests.

Ultrasound

This test uses sound waves to look for masses in the liver. It is described in the section "Can liver cancer be found early?"

Computed tomography (CT)

The CT scan is an x-ray test that produces detailed cross-sectional images of your body. A CT scan of the abdomen is very useful in identifying many types of liver tumors. It can provide precise information about the size, shape, and position of any tumors in the liver or elsewhere in the abdomen, as well as nearby blood vessels. CT scans can also be used to guide a biopsy needle precisely into a suspected tumor (called a CT-guided needle biopsy). If you are found to have liver cancer, a CT of the chest may also be done to look for possible spread to the lungs.

Instead of taking one picture like a standard x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these into detailed images of slices of the part of your body that is being studied.

For this test, you may be asked to drink 1 to 2 pints of a liquid called oral contrast. This helps outline the intestine so that certain areas are not mistaken for tumors. You may also receive an IV (intravenous) line through which a different kind of contrast (IV contrast) is injected. This helps better outline structures in your body. The injection can cause some flushing (redness and warm feeling). Some people are allergic and get hives or, rarely, more serious reactions like trouble breathing and low blood pressure. Be sure to tell the doctor if you have any allergies or ever had a reaction to any contrast material used for x-rays.

If your doctor suspects you may have liver cancer, you may have one set of CT scans of your abdomen taken before you get IV contrast. Other sets of scans may then be taken over the next several minutes as the contrast passes through the liver and other parts of the body. These sets of scans (together known as a 4-phase or multiphase CT scan) can help spot different types of liver tumors.

CT scans take longer than regular x-rays. You need to lie still on a table while they are being done. During the test, the table slides in and out of the scanner, a ring-shaped machine that completely surrounds the table. You might feel a bit confined by the ring you have to lie in while the pictures are being taken. Spiral CT (also known as helical CT), which uses a faster machine and yields more detailed pictures, is now used in many medical centers.

Magnetic resonance imaging (MRI)

Like CT scans, MRI scans provide detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body.

When MRI is used to look at liver tumors, several sets of images may be taken. After the first set is done, a contrast material called gadolinium is injected into a vein to help see details more clearly. Then other sets are taken over the next several minutes as the contrast moves through the liver and other parts of the body. This is known as dynamic contrast-enhanced MRI.

MRI scans can be very helpful in looking at liver tumors. Sometimes they can tell a benign tumor from a malignant one. They can also be used to look at blood vessels in and around the liver, and can help show if liver cancer has spread to other parts of the body.

MRI scans may be a little more uncomfortable than CT scans, and they often take longer. You may be placed inside a narrow tube, which is confining and can upset people with a fear of enclosed spaces. Newer, more open MRI machines can sometimes be used instead. The MRI machine also makes buzzing and clicking noises that you may find disturbing. Some places will provide earplugs to help block these noises out.

Angiography

An angiogram is an x-ray test for looking at blood vessels. Contrast medium, or dye, is injected into an artery to outline blood vessels while x-ray images are taken. Angiography can be used to show the arteries that supply blood to a liver cancer, which can help doctors decide if a cancer can be removed and to help plan the operation. It can also be used to help guide some types of non-surgical treatment, such as embolization (see "Embolization therapy").

Angiography can be uncomfortable because the doctor doing the test has to put a small catheter (a flexible hollow tube) into the artery leading to the liver to inject the dye. Usually the catheter is put into an artery in your inner thigh and threaded up into the liver artery. A local anesthetic is often used to numb the area before inserting the catheter. Then the dye is injected quickly to outline all the vessels while the x-rays are being taken.

Angiography may also be done with a CT scanner (CT angiography) or an MRI scanner (MR angiography). These techniques are often used instead of x-ray angiography because they can give information about the blood vessels in the liver without the need for a catheter in the artery. You may still need an IV line so that a contrast dye can be injected into the bloodstream during the imaging.

Bone scan

A bone scan can help look for cancer that has spread to bones. Doctors don't usually order this test for people with liver cancer unless you have symptoms such as bone pain, or if there's a chance you may be eligible for a liver transplant to treat your cancer.

For this test, a small amount of low-level radioactive material is injected into a vein (IV). The substance settles in areas of damaged bone throughout the entire skeleton over the course of a couple of hours. You then lie on a table for about 30 minutes while a special camera detects the radioactivity and creates a picture of the skeleton.

Areas of active bone changes appear as "hot spots" on the skeleton – that is, they attract the radioactivity. These areas may suggest the presence of cancer, but other bone diseases can also cause the same pattern. To distinguish between these conditions, other imaging tests such as plain x-rays or MRI scans, or even a bone biopsy might be needed.

For more information on these imaging tests, see the separate American Cancer Society document, Imaging (Radiology) Tests.

Other procedures

Other types of tests may be done if your doctor thinks you might have liver cancer but the imaging test results aren’t conclusive.

Laparoscopy

In this procedure, a doctor inserts a thin, lighted tube with a small video camera on the end through a small incision (cut) in the front of the abdomen to look at the liver and other internal organs. (Sometimes more than one cut is made.) This procedure is done in the operating room. Usually you are under general anesthesia (in a deep sleep), although in some cases you may be sedated (made sleepy) and the area of the incision will be numbed.

Laparoscopy can help plan surgery or other treatments, and can help doctors confirm the stage (extent) of the cancer. If needed, doctors can also insert instruments through the incisions to remove biopsy samples, which are then looked at under a microscope to make or confirm the diagnosis of cancer.

Laparoscopy is usually done at an outpatient surgery center. Because the surgeon only makes a small incision to insert the tubes, you should not have much pain after surgery. You should be able to go home after you recover from the anesthesia.

Biopsy

A biopsy is the removal of a sample of tissue to see if it is cancer. Sometimes, the only way to be certain that liver cancer is present is to take a biopsy and look at it under a microscope.

But in some cases, doctors can be fairly certain that a person has liver cancer based on the results of imaging tests such as CT and MRI scans. In these cases, a biopsy may not be needed. Doctors are often concerned that sticking a needle into the tumor or otherwise disturbing it without completely removing it might help cancer cells spread to other areas. This is a major concern if a liver transplant might be an option to try to cure the cancer, as any spread of the cancer might make the person ineligible for a transplant.

If a biopsy is needed, several methods can be used to take samples of liver tissue.

Needle biopsy: For a needle biopsy, a hollow needle is placed through the skin in the abdomen and into the liver. The skin is first numbed with local anesthesia before the needle is placed. Different sized needles may be used.

• For a fine needle aspiration (FNA) biopsy, tumor cells are sucked into a very thin needle with a syringe.
• A core needle biopsy uses a slightly larger needle to get a bigger sample.

There are pros and cons to both types of needle biopsies. FNA can usually confirm a cancer, but sometimes it doesn't provide enough information to be sure about the type of cancer. Some doctors prefer a core needle biopsy over an FNA, as it provides a larger sample and therefore, more information about the tumor. But the risk of complications is lower with FNA, especially when tumors are near large blood vessels.

The doctor may use ultrasound or CT scanning to guide the needle into the tumor. With this approach, the doctor slowly advances the needle while its position is checked by one of these imaging tests. When the images show that the needle is in the tumor, a sample is removed and sent to the lab to be looked at under a microscope.

Laparoscopic biopsy: Biopsy specimens can also be taken during laparoscopy. This lets the doctor see the surface of the liver and take samples of abnormal-appearing areas.

Surgical biopsy: In some cases, a biopsy sample may not be obtained until surgery that is meant to treat the tumor. An incisional biopsy (removing a piece of the tumor) or an excisional biopsy (removing the entire tumor and some surrounding normal liver tissue) can be done during an operation. But since doctors often prefer to know the exact type of tumor before surgery, other types of biopsy methods may be used.

Lab tests

Your doctor may order lab tests for a number of reasons:

• To help diagnose liver cancer
• To help determine what might have caused your liver cancer
• To learn how well the liver is working, which may affect what types of treatments you can have
• To get an idea of your general health and how well your other organs are working, which also may affect what types of treatments you can have
• To see how well treatment is working
• To look for signs that the cancer has come back after treatment

Alpha-fetoprotein blood (AFP) test

This test is described in the section "Can liver cancer be found early?" It can be helpful in determining if a liver mass might be cancer. A low or normal value on this test means it is less likely you have liver cancer, while a high value makes it more likely. But this test is not always accurate, so other test and exam results also have to be taken into account.

This test can also be useful in people already diagnosed with liver cancer. The AFP level can help determine what treatment options might be appropriate. During treatment, the test can be used to help give an idea of how well it is working, as the AFP level should go down if treatment is effective. The test can be used after treatment as well, to look for possible signs that the cancer has come back (recurred).

Other blood tests

Liver function tests (LFTs): Because liver cancer often develops in livers already damaged by hepatitis and/or cirrhosis, doctors need to know the condition of your liver before starting your treatment. A series of blood tests can help assess the condition of the part of your liver not affected by the cancer. They measure levels of certain substances in your blood that show how well your liver is working.

If your liver is not healthy, you might not be able to have surgery to try to cure the cancer, as the surgery might require removal of a large part of your liver. This is a common problem in people with liver cancer.

Blood clotting tests: The liver also makes proteins that help blood clot when you are bleeding. A damaged liver may not make enough of these clotting factors, which could increase your risk of bleeding. Your doctor may order blood tests such as a prothrombin time (PT) to help assess this risk.

Tests for viral hepatitis: If liver cancer has not yet been diagnosed, your doctor may order blood tests to check for hepatitis B and C. Results showing you have been infected with either of these viruses may make it more likely that you have liver cancer.

These tests are also done in people newly diagnosed with liver cancer, if they haven’t been done previously.

Kidney function tests: Tests of blood urea nitrogen (BUN) and creatinine levels are often done to assess how well your kidneys are working.

Complete blood count (CBC): This test measures levels of red blood cells, white blood cells (which fight infections), and platelets (which help the blood clot). It gives an idea of how well the bone marrow, where new blood cells are made, is functioning.

Blood chemistry tests and other tests: Blood chemistry tests check the levels of a number of minerals and other substances in the blood, some of which might be affected by liver cancer. For example, liver cancer can cause blood levels of calcium to rise, while blood glucose levels may fall. Liver cancer can also sometimes cause cholesterol levels to go up, so this may be checked as well.