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

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. If you go to your doctor when you first notice symptoms, your cancer might be diagnosed and treated while it is curable. Or, at the least, you could live longer with a better quality of life. 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
• constant pain in the abdomen
• 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. Still, if you have any of these problems, 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 (eyrthrocytosis) which can cause someone to look red and flushed

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 if they are caused by liver cancer or something else.

Medical history and physical exam

Your doctor will take your complete medical history to check for risk factors and 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.

If symptoms and/or the results of the physical exam suggest liver cancer might be present, 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 a suspicious area that might be cancerous, to learn how far cancer may have spread, and to help determine if treatment has been effective.

Ultrasound

This test is used 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 procedure that produces detailed cross-sectional images of your body. This test 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.

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.

Before any pictures are taken, 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.

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 moves 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.

For a CT scan with portography (pictures of the portal vein, which is the large vein leading into the liver from the intestine), contrast material is injected into veins that lead to the liver, to help find tumors in the area.

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. A contrast material called gadolinium is often injected into a vein before the scan to see details more clearly.

MRI scans can be 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 often take 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, more open MRI machines can help with this if needed. The MRI machine makes buzzing and clicking noises that you may find disturbing. Some places will provide earplugs to help block these noises 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 can be useful in showing the arteries that supply blood to a liver cancer. This can help surgeons decide whether a cancer can be removed and if so, it can help in planning the operation.

Angiography can be uncomfortable because you must stay very still while the doctor puts 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 give information about the blood vessels in the liver without the need for a catheter, although you may still need an IV line so that a contrast dye can be injected into the bloodstream during the imaging.

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

Other procedures

Laparoscopy

In this procedure, a doctor uses a thin, lighted tube with a small video camera on the end 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 tissue samples (biopsies) to look at under the microscope.

Laparoscopy is usually done at an outpatient center but it is still 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, you should not have 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 in the liver that is probably cancerous and a blood test reveals the AFP level is very high, a biopsy may not be needed.

Several biopsy methods can be used to take samples of liver tissue.

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 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 large or has spread throughout the liver, a hollow needle can be 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. This can usually confirm a cancer, but it doesn't provide much information about how the cancer cells are arranged. For this reason, doctors often use a slightly larger needle to get a bigger sample. This is known as a core needle biopsy.

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

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

• to help diagnose liver cancer

• to determine 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 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, although it is not accurate in every case. A low or normal value on this test does not mean that cancer isn't present, but a very high level can mean that liver cancer is there. It can also be useful in people diagnosed with liver cancer. The alpha-fetoprotein (AFP) level can help determine what treatment options might be appropriate. The test can also be used to help give an idea of how well a treatment is working, 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

Liver function tests (LFTs): Because liver cancer often develops in damaged livers, doctors need to know the condition of your liver before starting your treatment. A series of blood tests can help with this. These tests can assess the condition of the part of your liver not affected by the cancer. They measure levels of certain substances in your blood, such as bilirubin, albumin, alkaline phosphatase, AST, ALT, and GGT. If your liver is not healthy, you may not be able to have curative surgery, 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 assess this risk.

Tests for viral hepatitis: 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.

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 the bone marrow, a substance found inside certain bones where new blood cells are made, is functioning.

Electrolytes and blood chemistry tests: The blood calcium level may be checked, since liver cancer can cause this level to rise. Liver cancer can sometimes cause the cholesterol level to go up, so this may be checked as well.

Last Medical Review: 11/05/2009
Last Revised: 11/05/2009