Signs and Symptoms of Liver Cancer

Although signs and symptoms are usually not present until the late stages of liver cancer, sometimes they may show up early and lead to an early diagnosis. Many signs and symptoms of liver cancer are relatively non-specific – that is, they can be caused by other cancers or by non-cancerous diseases. Still, if you have any of the following problems, please see a doctor right away:

• unexplained, unintentional weight loss
• constant loss of appetite
• feeling very full after a small meal (early satiety)
• enlarged liver or a mass that can be felt in the area of the liver (the upper right side of the abdomen)
• enlarged spleen (mass that can be felt in the upper left side of the abdomen)
• persistent pain in the abdomen
• swelling or fluid build-up in the abdomen
• skin itching
• yellowing of the skin and eyes (jaundice)
• enlarged veins that become visible through the skin
• worsening of your condition 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 (hypercalcemia), which can cause weakness or muscle problems
• low blood sugar levels (hypoglycemia), which can cause fatigue or fainting
• enlargement of the breasts in men (gynecomastia)

These unusual findings may cause doctors to suspect a disease of the nervous system or an endocrine (hormone-producing) gland, rather than a liver cancer.

If you have one or more of these symptoms, your doctor will try to find out if they are due to liver cancer or some other cause.

History and Physical Exam

The doctor will take your complete medical history (medical interview) to check for risk factors and symptoms. Then the doctor will examine you to look for signs of liver cancer and other health problems. He or she will likely pay special attention to your abdomen.

Imaging Tests

These tests are used to create pcitures of the inside of your body. They allow doctors to look for abnormalities, such as masses.

Ultrasound (UT)

This is described in the section "Can Liver Cancer Be found Early?"

Computed tomography (CT)

The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. This test is very useful in identifying many types of liver tumors.

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 images of slices of the part of your body that is being studied. Often after the first set of pictures is taken you will get an intravenous (IV) injection of a radiocontrast agent, a special dye that helps better outline structures in your body. A second set of pictures will then be taken. 

You may need an IV line through which contrast "dye" is injected. 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 ever had a reaction to any contrast material used for x-rays.

CT scans take longer than regular x-rays. You need to lie still on a table for 15 to 30 minutes while they are being done. You might feel a bit confined by the machine you have to lie in while the pictures are being taken. But just like other computerized devices, they are getting faster. 

Magnetic resonance imaging (MRI)

MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed by the body and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Like a CT scanner, this produces cross-sectional slices of the body. An MRI can also produce slices that are parallel with the length of your body. A contrast material might be injected just as with CT scans.

MRI scans are very helpful in looking at liver cancers. Sometimes they can tell a benign tumor from a malignant one.

MRI scans may be a little more uncomfortable than CT scans. They take longer – often up to an hour. You may be placed inside a large cylindrical tube, which is confining and can upset people with a fear of enclosed spaces. Newer, "open" MRI machines can help with this if needed. The machine makes a buzzing noise that you may find disturbing. Some places will provide headphones with music to block this out.

Angiography

Angiography is an x-ray procedure for looking at blood vessels. Contrast medium, or dye, is injected into an artery before x-ray images are taken. The dye outlines the blood vessels on x-ray pictures.

Angiography is useful in showing the arteries that supply blood to a liver cancer. This information can help surgeons decide whether a cancer can be removed and if so provides help in planning the operation.

Newer techniques can help make the angiography pictures more accurate. Digital subtraction angiography uses computers to produce more detailed images of blood vessels. Dynamic sequential CT scanning combines CT scanning and angiography. It is not routinely used but is sometimes helpful in planning surgery.

Angiography can be an uncomfortable procedure because the radiologist who performs the procedure has to put a small catheter into the artery leading to the liver. 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.

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

Other Procedures

Laparoscopy

This procedure uses a thin, lighted tube connected to a video monitor which allows a doctor to look at the liver and other internal organs. The tube is inserted through a small incision in the front of the abdomen. Laparoscopy provides a view of organs, which can help in planning surgery or other treatments. Doctors can also use small instruments through this tube to remove small tissue samples (biopsies) to look at under the microscope.

Laparoscopy is usually done at an outpatient center but it is like an operation. You will be sedated (made sleepy), and the area where the incision will be made will be numbed. Because the surgeon only makes a small incision to insert the tubes, there is not much pain after surgery. You should be able to go home after you recover from the anesthesia.

Biopsy

In most cases, the only way to be certain that liver cancer is present is to take a biopsy (sample of the tumor tissue) and look at it under a microscope.But in some cases, if imaging studies (CT or MRI) show a tumor mass that is likely cancerous and a blood test reveals the AFP level is very high, a biopsy may not be needed.

There are several biopsy methods that can be used to take samples of liver tissue.

Surgical biopsies: An incisional biopsy (removing a piece of the tumor) or an excisional biopsy (removing the entire tumor along with some urrounding normal liver tissue) can be done during a surgical operation. But since doctors usually prefer to know the exact type of tumor before surgery, other types of biopsy methods are often used.

Needle biopsy: If the tumor is very large or has spread throughout the liver, a needle can be placed through the skin in the abdomen and anywhere into the liver. The skin where the needle is placed is first numbed with local anesthesia. Tumor cells can then be sucked into the needle with a syringe. If the tumor is smaller, the doctor may use ultrasound or CT scanning to guide the needle. 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 allows the doctor to see the surface of the liver and take samples of abnormal-appearing areas.

Lab Tests

Alpha-fetoprotein (AFP) Blood Test

This is described in the section "Can Liver Cancer Be found Early?" It can be helpful in determining if a liver mass might be cancer, although it is not accurate in every case. The AFP test can be useful in people diagnosed with liver cancer. The AFP level can help guide what treatment options might be appropriate. The test can also be used to help give an idea of how effective treatment is, as the AFP level should fall after treatment. It can be used after treatment as well, to look for possible signs that the cancer may have come back (recurred).

Other Blood Tests

Because liver cancer often arises in damaged livers, doctors need to know the condition of your liver before proceeding with treatment. A series of blood tests can help with this. These liver function tests (LFTs) can assess the condition of the part of your liver not affected by the cancer. The tests look at levels of certain substances in your blood, such as bilirubin, albumin, alkaline phosphatase, AST, ALT, and GGT. You may not be able to have curative surgery if your liver is not healthy, as the surgery might require the doctor to remove a good part of your liver. This is a common problem in people with liver cancer.

The liver also makes proteins that help blood to 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 assess this risk.

If liver cancer has not yet been diagnosed, your doctor may also order other blood tests, such as tests for hepatitis B and C. Results showing you have been infected with either of these viruses may make it more likely that liver cancer is present.