How is liver cancer found?

Liver cancer often does not cause symptoms until it is in its later stages, so it is seldom found early. Small tumors are hard to find by physical exams.

Screening tests are not advised for people at average risk for liver cancer, but they may be done in people at high risk.

Tests that may be done to find liver cancer

Many patients who develop liver cancer have had cirrhosis for a long time. If a patient with cirrhosis gets worse for no known reason, doctors should suspect that liver cancer may be the cause and do the tests needed to find out if this is the case.

AFP test

Liver cancers can sometimes be found using a blood test for a protein called AFP (alpha-fetoprotein). It is normal for AFP to be found in the blood of unborn babies, but it goes away shortly after birth. When it is found in the blood of adults, they may have liver cancer (or another kind of cancer).

Tests for AFP may be used to look for early tumors in people at high risk for liver cancer. Some tumors, though, do not make much of this protein. So by the time the AFP is high enough to be found, the tumor may be too large to be removed or may have spread outside the liver. Some liver diseases that are not cancer can also raise AFP levels. For these reasons, AFP blood tests are not advised for everyone.

Ultrasound

Ultrasound is a test that uses sound waves to make pictures of organs inside the body. For an ultrasound, you lie on a table while a wand is moved around on the skin over the part of the body being looked at. Ultrasound is sometimes used in people with certain liver cancer risk factors to help find cancers earlier. Any masses (tumors) seen in the liver can then be tested for cancer if needed.

Who should be tested?

People at higher risk for liver cancer may be helped by screening. (Screening is testing people for a disease before they have symptoms.) Many doctors recommend testing for certain high-risk groups. These include people with cirrhosis, especially if it is so bad that the patient is waiting to get a liver transplant. Otherwise a cancer may start during the wait and become so advanced that it can't be cured. Having liver cancer may also move the person up on the transplant waiting list.

Some people with chronic hepatitis B infections should also be screened, like those with liver cancer in the family. For other people at higher risk, the benefits of screening may not be as clear. If you think you are at high risk for liver cancer, talk to your doctor about whether screening is a good idea for you.

Symptoms of liver cancer

Most of the time liver cancer does not cause symptoms in the early stages. The symptoms below could be caused by liver cancer. They can also be caused by other cancers or conditions. Still, if you have any of these problems, see a doctor right away.

• Weight loss (when you're not trying to lose weight)
• Lack of appetite
• Feeling very full after a small meal
• Nausea or vomiting
• Fever
• A swollen liver or a mass that can be felt under the ribs on the right side
• A swollen spleen, felt as a mass under the ribs on the left side
• Pain in the belly or near the right shoulder blade
• Swelling in your belly (abdomen)
• Itching
• Yellowing of the skin and eyes (jaundice)
• Swollen veins on the belly that can be seen through the skin
• Becoming sicker if you have chronic hepatitis or cirrhosis

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

• High blood calcium levels that can cause nausea, confusion, constipation, weakness, or muscle problems
• Low blood sugar levels, which can make you feel very tired or faint
• Breast enlargement and/or shrinking of the testicles in men
• High counts of red blood cells which can cause someone to look red and flushed
• High cholesterol levels

These findings may cause doctors to suspect a disease of the nervous system or other problems, rather than liver cancer.

Tests to get a better look at liver cancer

If you have any symptoms or if there is any reason to suspect liver cancer, your doctor will use one or more tests to find out if you really have the disease. You will have a physical exam, and your doctor will ask you questions about your health. Some of the tests that may be done are described below.

Imaging tests

These tests create pictures of the inside of your body. They may be done to help find tumors that might be cancer, to learn how far cancer may have spread, or to help find out if treatment is working.

Ultrasound: This test is used to find tumors in the liver. Sound waves are used to make a picture of the inside of the body. Most people know about ultrasound because it is often used to look at a baby during pregnancy. This is an easy test to have. You lie on a table, a gel is put on your skin, and a kind of wand is moved over your belly (abdomen).

CT scan (computed tomography): A CT scan uses x-rays to take many pictures of your insides. The pictures are then put together to show images of slices of the part of your body being studied. CT scans can give precise information about the size, shape, and place of any tumors in the liver or other places.

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 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) is now used in many medical centers. This type of CT scan uses a faster machine and gives pictures with more details.

You may also have an IV (intravenous) line through which you get a dye. This helps better outline structures in your body. Some people are allergic to the dye and get hives or, rarely, problems like trouble breathing and low blood pressure. Be sure to tell the doctor if you have any allergies or have ever had a problem from any dye used for x-rays. You may also be asked to drink 1 to 2 pints of a liquid that helps outline the intestine so that it is not mistaken for tumors.

MRI (magnetic resonance imaging): MRI scans can be very helpful in looking at liver cancers. Sometimes they can tell a benign tumor from one that is cancer. 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 use radio waves and strong magnets instead of x-rays to take pictures. A computer makes the pattern of radio waves into a detailed picture of parts of the body. MRI scans take longer than CT scans. You may be inside a large tube-like machine for the scan, which some people do not like. Newer, more open MRI machines can sometimes be used instead.

Angiography: Angiography is an x-ray method used to look at blood vessels. A dye is put into (injected) an artery before the x-rays are taken. The dye outlines the blood vessels on the pictures, showing which ones take blood to the liver cancer. This can help surgeons decide whether the cancer can be removed and, if so, how best to plan the operation.

This test can be uncomfortable because a tiny tube (catheter) has to be threaded from the groin up into the liver artery. Usually drugs are used to make the area numb before this is done.

Angiography may also be done with a CT or MRI scanner. These are often used instead of x-rays because they can outline the blood vessels in the liver without the need for a catheter in the artery.

Bone scan: A bone scan can help look for cancer that has spread to bones. Doctors might not order this test unless you have symptoms such as bone pain, or if there's a chance could have a liver transplant to treat your cancer.

For this test, a small amount of low-level radioactive substance is put into a vein. 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. Bone changes appear as "hot spots" on the skeleton. This may suggest the cancer has reached the bones, but other bone diseases can also cause the same pattern. To find out for sure, other tests such as plain x-rays or MRI scans, or even a bone biopsy might be needed.

Other methods

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

Laparoscopy: In a laparoscopy the doctor uses a thin, lighted tube with a tiny camera on the end to look at the liver and other organs. The tube is put in through a small cut (incision) in the front of the belly (abdomen). This can help the doctor in planning surgery or other treatments. Also, doctors can use small instruments through this tube to take out tissue samples to be looked at under the microscope (see biopsy below).

This test is done in the operating room. You will be given drugs to make you relaxed or asleep during the test. You should be able to go home after you recover.

Biopsy: Other tests can suggest that you may have liver cancer, but sometimes the only way to be sure is to take out a piece of the tumor and look at it under a microscope. This is called a biopsy. (But in some cases, such as in people with cirrhosis whose CT or MRI tests show a liver tumor that is most likely cancer, a biopsy may not be done.)

There are different ways to get the tumor sample. In some cases, a biopsy sample may be taken during surgery that is meant to treat the tumor. Another option may be to place a hollow needle through the skin in the belly (abdomen) and into the liver to get a small biopsy sample. The skin where the needle is placed is first numbed. Biopsy samples can also be taken during laparoscopy (see above), when the doctor looks at the surface of the liver and takes samples from any areas that look abnormal.

Lab tests

Blood tests can be done to check for a substance called AFP (alpha-fetoprotein). AFP levels are often high in people with liver cancer. Doctors can compare the AFP levels before and after treatment to see how well the treatment is working.

Other tests can also help the doctor learn how well the part of your liver that is not affected by cancer is doing, and how well your other organs are working. This information can help doctors decide whether surgery is an option for you.