Diagnosing liver cancer

Tuesday 1 July, 2014

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On this page: Blood tests | Scans (imaging tests) | Biopsy | Further tests | Staging cancer in the liver | Prognosis | Which health professionals will I see? | Key points


Primary liver cancer and secondary cancer in the liver are diagnosed using a number of tests. These include blood tests and scans. Tissue examination (biopsy) is rarely done.

Blood tests

You will probably have a blood test to check how well the liver is working (liver function) and how well your blood clots. You may also have liver function tests before, during and after treatment.

If primary liver cancer is suspected, you will have blood tests to check for hepatitis B or C and various genetic problems. You may need a blood test to check the level of certain chemicals known as tumour markers, which are produced by cancer cells and can help identify some types of cancer. The tumour markers used to diagnose primary liver cancer include:

  • alpha-fetoprotein (AFP)
  • cancer antigen 19-9 (CA19-9)
  • carcinoembryonic antigen (CEA) – this is also helpful in diagnosing secondary cancer that has spread from the large bowel.

Tumour markers do not rise in all people with cancer. Also, some conditions, such as pregnancy, hepatitis and jaundice, can increase tumour marker levels without cancer being present. If the markers are high due to cancer, they should fall if the treatment works.

After blood tests, other tests will need to be done to confirm your diagnosis of primary liver cancer or secondary cancer in the liver.

Scans (imaging tests)

You will have at least one of these scans, but you may have more than one if the doctor needs further information about the cancer.

Ultrasound

An ultrasound is the most common scan used to look for primary liver cancer. It’s often used to monitor high-risk patients, such as people with cirrhosis.

The scan uses soundwaves to create a picture of a part of your body. It can show the size and location of abnormal tissue in your liver.

During the ultrasound, you will lie down and a gel will be spread over your abdomen to help conduct the soundwaves. A small paddle-shaped device called a transducer is then moved over the area. It creates soundwaves that echo when they meet something dense, like an organ or tumour.

The soundwaves are sent to a computer and turned into a picture. This process takes about 15 minutes and is painless.

If a solid lump is found, the scan will help show whether it is cancer. Non-cancerous (benign) tumours in the liver can also be found during an ultrasound. 

You will be asked to not eat or drink for about four hours before the ultrasound. 

CT scan

The CT (computerised tomography) scan is a type of x-ray that takes three-dimensional pictures of several organs at the same time. It helps doctors make a diagnosis and see if the cancer has spread. It can also help doctors plan surgery.

The test usually takes 10–30 minutes. You will need to drink a liquid dye (contrast) or have an injection of contrast into a vein beforehand to make the pictures clearer. The injection may be uncomfortable and the dye may briefly make you feel hot and sweaty. Some people can’t have this scan because of poorly functioning kidneys or an allergy to the contrast (see below). In this case, a different scan will be arranged.

You will lie on a table while the CT scanner, which is large and round like a doughnut, takes the pictures. The scan itself is painless. 

Some people are allergic to the contrast used in a CT or MRI scan. If you have any known allergies, let your doctor know in advance. You should also tell your health care team if you have a pacemaker or other metallic device in your body. These may interfere with the MRI scan.

MRI scan

An MRI (magnetic resonance imaging) scan uses both a magnetic field and radio waves to take detailed cross-sectional pictures of the body.

These show the extent of the tumour and whether it is affecting the main blood vessels around the liver. The pictures are taken while you lie on a table that slides into a metal cylinder – a large magnet – that is open at both ends. You may be given an injection of contrast into your veins to make the pictures clearer.

An MRI is painless but some people find that lying in the cylinder is too confined (claustrophobic) and noisy. If you feel uncomfortable, let your doctor or nurse know. They can give you medication to ease this feeling or earplugs to reduce the noise level. You can also usually take someone into the room with you for company.

"I had various scans when I was diagnosed with primary liver cancer. At first, I found the MRI was frightening, going in to the cylinder head first and having to hold my breath. But now when I have this scan during check-ups, I count to myself. This helps me feel more in control." Robyn
PET-CT scan

A positron emission tomography (PET) scan combined with a CT scan (see above) is a type of imaging test available at some major metropolitan hospitals. It produces a three-dimensional colour image that may show where cancers are in the body.

PET scans are most commonly used for secondary liver cancers, such as bowel cancer or melanoma that have spread to the liver. They are not often used to detect primary liver cancers.

For the PET scan, you will be injected in the arm with a glucose solution containing a small amount of radioactive material. It takes 30–90 minutes for the solution to go through your body. During this time you will be asked to sit quietly.

Your whole body will then be scanned for high levels of radioactive glucose. Cancer cells show up brighter on the scan pictures because they are more active and take up more of the glucose solution than normal cells.

During PET scans, you will be exposed to radioactive material, but doses are low and generally not harmful. The nuclear medicine staff who perform the scan will discuss this with you.

Biopsy

A biopsy involves removing a small amount of tissue to examine under a microscope. This can sometimes show if the cancer in your liver is a primary or secondary cancer. A biopsy is usually done for:

  • people without liver cirrhosis
  • people who have cirrhosis but have other inconclusive or abnormal test results
  • before surgery or other treatment, if there is uncertainty about the diagnosis.

A biopsy may not be needed if you are able to have a transplant.

Before a biopsy, you may have a test to check how well your blood clots. This is because the liver contains many blood vessels.

Biopsy is done either by fine needle aspiration or laparoscopy:

Fine needle aspiration

You will have a local anaesthetic to numb the area, then a thin needle is passed through the skin into the tumour. An ultrasound or CT scan will be done at the same time to help the doctor guide the needle. Cells are drawn into the needle and removed.

Afterwards, you will stay in hospital for a few hours. If there is a high risk of bleeding, you may need to stay overnight.

Sometimes the results of this biopsy are not clear and it will need to be repeated.

Laparoscopy

This operation is also called keyhole surgery. It allows the doctor to look at the liver and surrounding organs using a thin tube containing a light and a camera (a laparoscope). It is often done if your doctor thinks the cancer may be in other areas of the body.

A laparoscopy is done under general anaesthetic. A small cut is made in your lower abdomen for the laparoscope to be inserted.

During the procedure, carbon dioxide gas is used to increase the size of your abdomen to make space for the surgeon to see.

The surgeon can take tissue samples, then after the laparoscope is removed, the small cut is closed with a couple of stitches.

The most common risks of laparoscopy are wound infection and bruising. There is a slight risk of bleeding, but this is rare. The carbon dioxide can also cause shoulder pain and wind for a few days.

Usually you will need to stay in hospital overnight for monitoring. Some people need to stay in hospital for a few days. 

Further tests

If you have not been diagnosed with cancer and the tests described above show you have secondary cancer in the liver, you may need further tests to find out where the primary cancer started.

Some people have:

  • an examination of the bowel (colonoscopy), the stomach (endoscopy) and, for women, the breasts (mammogram)
  • blood tests to look for different tumour markers
  • a urine test to check the kidneys or bladder
  • other imaging tests, such as a PET-CT scan, to see different parts of the body.

In other cases, it will be clear where the primary cancer began, as you may have been diagnosed and treated for cancer in the past. This is common for people who have bowel cancer.

ICG test

An indocyanine green (ICG) test may be done for people who have primary liver cancer and cirrhosis. The test helps surgeons assess how well the liver is functioning and determine if surgery is a treatment option.

ICG may be done before surgically removing part of the liver. This is because healthy people can withstand an operation (the liver may regrow during recovery), but a person with cirrhosis has liver damage that can impair liver regrowth.

During an ICG test, green dye is injected into the blood. Over the next 15 minutes, readings are taken using a probe placed on the finger. The probe measures how quickly the liver clears the dye from the bloodstream.

If the dye is cleared quickly, this shows that the liver is working well. However, if it is slow, it may be too dangerous to remove parts of the liver. In this case, the medical team will discuss other available treatment options.

Staging cancer in the liver

The tests described on this page will show whether you have:

  • primary liver cancer
  • primary liver cancer that has spread
  • secondary cancer that has spread to the liver from elsewhere.

Working out whether the cancer has spread from the primary cancer site – and if so, how far – is called staging. This helps your doctor recommend the best treatment for you.

The different stages of cancer are based on how far away from the original tumour site the cancer is found. Different types of cancer have different staging systems. Secondary cancers in the liver are staged using the system relating to the primary cancer.

In primary liver cancer, generally stage 1 and stage 2 tumours are confined to the liver. Usually stage 3 and stage 4 describes cancer that has spread away from liver.

Ask your doctor to explain more about the stage of the cancer and how it relates to your diagnosis and treatment.

Prognosis

Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis with your doctor, but it is not possible for any doctor to predict the exact course of your disease. Factors used to assess your prognosis include:

  • test results
  • the type of cancer, where it is in the body, and the rate of growth
  • the treatment available
  • how well you respond to treatment
  • your age, fitness and medical history.

Doctors often use numbers (statistics) when considering someone’s prognosis. Statistics reflect the typical outcome of disease in large numbers of patients. While statistics give doctors a general idea about a disease, they won’t necessarily reflect your situation.

Liver transplantation or surgical resection (removal of the diseased section of the liver) may be an option to treat some people with primary liver cancer. These procedures may offer the chance of a cure.

Other treatments for primary liver cancer and secondary cancer in the liver may enable you to live for much longer than if you were to have no treatment.

Which health professionals will I see?

Your general practitioner (GP) will arrange the first tests to assess your symptoms. If these tests do not rule out cancer, you will probably be referred to a gastroenterologist who will organise further tests for you and advise you about treatment options.

You may need to see other specialists, such as a surgeon or a medical oncologist, who can discuss the different types of treatment with you.

A range of health professionals who specialise in different aspects of your treatment will care for you. This is called a multidisciplinary (MDT) team, and includes doctors, nurses and allied health professionals, such as a physiotherapist and dietitian.

Some people in non-metropolitan areas will have to travel to appointments with specialists. Your GP can be kept informed of all your test results and treatment. They can answer questions you have in-between appointments with specialists.

Health professional
 Role
hepatobiliary surgeon a doctor who specialises in surgery of the liver and its surrounding organs
gastroenterologist a specialist in diseases of the digestive system, including the liver
hepatologist a gastroenterologist who specialises in diseases of the liver
medical oncologist prescribes and coordinates the course of chemotherapy
radiologist and nuclear medicine specialists help to diagnose cancer by interpreting results of diagnostic tests, and delivers some treatments, including those with chemical compounds
cancer care coordinators and nurses
provide care, information and support throughout your treatment, and administer drugs, including chemotherapy
social worker, physiotherapist, occupational therapist
provide information and support with practical matters, such as mobility, and link you to community support services
dietitian
determines if you are getting enough nutrients, and recommends an eating plan for you to follow during treatment and recovery
palliative care team
assists you with symptom management and emotional support for you and your family

Key points

  • There are a number of tests used to diagnose primary liver cancer or secondary cancer in the liver.
  • Blood tests show how the liver is working and whether there are tumour markers in the blood that might indicate cancer in the liver.
  • Imaging tests include a range of scans that allow doctors to see your organs and determine whether there are any abnormal tissue or tumours. Sometimes noncancerous (benign) lumps are found.
  • A biopsy is when tissue is removed for examination under a microscope. This is not done very often. If it is done, it is done using a fine needle or during surgery.
  • If you have secondary cancer in the liver, you may also need tests such as a colonoscopy or endoscopy to find out where the primary cancer started.
  • All of these tests will help your doctor work out the best treatment options for you and whether it may be possible to try and cure the cancer.
  • Your doctor may tell you what stage the cancer is at. This describes how far the cancer has spread in your body.
  • You may wonder about the likely outcome of the disease (the prognosis). There are many factors in considering your prognosis, such as test results, the type of cancer you have and your medical history.
  • You will see many health professionals when you have tests and treatment. These include specialists, cancer care coordinators, nurses, and other health professionals, such as social workers.

Reviewed by: A/Prof Vincent Lam, Sydney Medical School Hepatobiliary, Pancreatic and Transplant Surgeon, Westmead Hospital, NSW; Prof Peter Angus, Medical Director, Director of Gastroenterology and Hepatology and Professorial Fellow, Austin Hospital and University of Melbourne, VIC; Jenny Berryman, Consumer; Ann Bullen, Cancer Care Coordinator, Royal Brisbane and Women’s Hospital, QLD; Prof Jonathan Fawcett, Director, Queensland Liver Transplant Service, Professor of Surgery, University of Queensland, QLD; Dr Dan Madigan, Interventional Radiologist, Royal Adelaide Hospital, SA; Dr Monica Robotin, Medical Director, Cancer Council NSW; and Dr Simon So, Interventional Radiologist, Westmead Hospital, NSW.

Updated: 01 Jul, 2014