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How is liver cancer diagnosed?

Liver cancer may be diagnosed using several tests. These include blood tests and imaging scans. It is becoming more common for a tissue sample to also be tested. This is called a biopsy.

Blood tests alone cannot diagnose liver cancer, but they can help doctors work out what type of liver cancer may be present and how well the liver is working. Blood tests can also provide information on the type of liver disease that may be causing cirrhosis. Samples of your blood may be sent for the following tests.

Liver function tests (LFTs) – These tests measure the levels of several substances that show how well your liver is working. You may have liver function tests done before, during and after treatment.

Blood clotting tests – These check if the liver is making proteins that help the blood to clot. Low levels of these proteins increase your risk of bleeding.

Hepatitis and other liver tests – These check for hepatitis B and C, which can lead to liver cancer. Also, tests may be done to check for other possible causes of liver disease such as too much iron in the bloodstream (haemochromatosis) or autoimmune hepatitis (when the body’s own immune system attacks the liver).

Tumour markers – Some blood tests look for proteins produced by cancer cells. These proteins are called tumour markers.

The most common tumour marker for primary liver cancer is called alpha-fetoprotein (AFP). It may be higher in many, but not all, cases of primary liver cancer.

The AFP level may also be raised in people with conditions other than cancer, such as pregnancy, hepatitis and jaundice.

Tests that take pictures of the inside of the body are known as imaging scans. An ultrasound scan is usually the imaging scan first used to look for liver cancer and to monitor people with cirrhosis.

An ultrasound scan alone cannot confirm a diagnosis of liver cancer, so you will also have one or more other scans. You may have some imaging scans more than once during diagnosis and again during treatment.

Ultrasound – An ultrasound scan is used to show if there is a tumour in the liver and how large it is. You will be asked not to eat or drink (fast) for about four hours before the ultrasound.

You will be asked to lie on your back for the scan and a gel will be spread onto your abdomen (belly). A small device called a transducer will be moved across the area. The transducer creates soundwaves that echo when they meet something solid, such as an organ or tumour. A computer turns these echoes into pictures.

An ultrasound is painless and usually takes only 15–20 minutes. If a solid lump is found, you will need other scans to show whether the lump is cancer. It is common to find non-cancerous (benign) lumps in the liver during an ultrasound.

CT scan – A CT (computerised tomography) scan uses x-ray beams to take detailed, cross-sectional pictures of the inside of your body. It helps show the features of the tumour in the liver. It may also show if the cancer has spread beyond the liver.

During the scan, a liquid dye (called contrast) is injected into one of your veins. This helps ensure that anything unusual can be seen more clearly. The dye may make you feel flushed and cause some discomfort in your abdomen. These reactions usually go away in a few minutes, but tell the team if you feel unwell.

Some people have an allergic reaction to the dye. They may need to take medicine before the scan to prevent such a reaction or avoid CT scans with dye altogether. If you have had an allergic reaction to dye in the past, tell the radiology practice before your appointment.

The CT scanner is large and round like a doughnut. You will need to lie still on a table while the scanner moves around you. It can take 10–30 minutes to get ready for the CT scan, but the scan itself takes only a few minutes and is painless.

MRI scan – An MRI (magnetic resonance imaging) scan uses a powerful magnet and radio waves to create detailed cross-sectional pictures of the  liver and nearby organs. An MRI is used to show the size of the tumour and whether it is affecting the main blood vessels and bile ducts around the liver. This scan is particularly helpful for diagnosing small tumours.

During the scan, you will be injected with a dye (called contrast) that highlights the organs in your body. You will then be asked to lie on an examination table that slides completely into a large metal tube that is open at both ends.

The MRI scanner is noisy and narrow, and this can make some people feel anxious or uncomfortable (claustrophobic). If you think you may become distressed, mention this beforehand to your doctor or nurse. You may be given a mild sedative to help you relax, and you will usually be offered headphones or earplugs. A liver MRI scan may take up to 30 minutes.

Bone scan – If a liver transplant is a potential treatment and/or you have pain in the bones, you may need a bone scan to be sure the cancer has not spread (metastasised) to the bones.

Before having scans, tell the doctor if you have any allergies or have had a reaction to contrast during previous scans. You should also let them know if you have diabetes or kidney disease, or are pregnant or breastfeeding.

A biopsy is when doctors remove a sample of cells or tissue from the affected area, and a pathologist examines the sample under a microscope to see if it contains cancer cells.

A biopsy is not always needed for diagnosis or when surgery is planned. If the diagnosis is not clear after the imaging scans, a biopsy may be useful. In the future, a biopsy may also provide information about the best treatment for each person (personalised medicine).

The liver has many blood vessels and there can be risk of bleeding with a biopsy. Before a biopsy, your blood may be tested to check if it clots normally. If you are taking blood-thinning medicines, ask your doctor if you need to stop taking them before and after the biopsy.

The sample of cells is usually collected with a core biopsy. Before the procedure, you will be given a local anaesthetic to numb the area, so you will still be awake but won’t feel pain.

The doctor will then pass a needle through the skin of the abdomen to remove a sample of tissue from the tumour. An ultrasound or CT scan helps the doctor guide the needle to the right spot. You may need to stay in hospital for a few hours or overnight if there is a high risk of bleeding.

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This information is reviewed by

This information was last reviewed June 2022 by the following expert content reviewers: A/Prof Simone Strasser, Hepatologist, AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital and The University of Sydney, NSW; A/Prof Siddhartha Baxi, Radiation Oncologist and Medical Director, GenesisCare, Gold Coast, QLD; Prof Katherine Clark, Clinical Director of Palliative Care, NSLHD Supportive and Palliative Care Network, Northern Sydney Cancer Centre, Royal North Shore Hospital, NSW; Anne Dowling, Hepatoma Clinical Nurse Consultant and Liver Transplant Coordinator, Austin Health, VIC; A/Prof Koroush Haghighi, Liver, Pancreas and Upper Gastrointestinal Surgeon, Prince of Wales and St Vincent’s Hospitals, NSW; Karen Hall, 131120 Consultant, Cancer Council SA; Dr Brett Knowles, Hepato-Pancreato-Biliary and General Surgeon, Royal Melbourne Hospital, Peter MacCallum Cancer Centre and St Vincent’s Hospital, VIC; Lina Sharma, Consumer; David Thomas, Consumer; Clinical A/Prof Michael Wallace, Department of Hepatology and Western Australian Liver Transplant Service, Sir Charles Gairdner Hospital Medical School, The University of Western Australia, WA; Prof Desmond Yip, Clinical Director, Department of Medical Oncology, The Canberra Hospital, ACT.