How is liver cancer diagnosed?
Your diagnosis will usually depend on whether you have secondary or primary liver cancer.
If you have secondary liver cancer it is quite possible that your liver cancer will be discovered when the primary cancer is diagnosed. For example, people with bowel cancer will also have tests to look for any spread to the liver. In this case your secondary liver cancer will usually be diagnosed by a specialist cancer doctor (oncologist) or a surgeon.
Primary liver cancer, including biliary tree cancer, is usually diagnosed in the following way:
- your GP will take your medical history – finding out about your symptoms – and perform a detailed clinical examination
- your GP will then take some blood samples and may arrange an abdominal ultrasound
- if blood tests and ultrasound indicate a tumour may be present, you will be sent to see a specialist doctor (surgeon or gastroenterologist/ hepatologist) who may take more blood tests and arrange for you to have special imaging of your liver to examine it more closely (see below)
- you may be sent for a biopsy (see below) if the imaging is not conclusive.
A blood test provides information on the general health of your liver. In addition, if HCC is suspected, a protein found in blood called alpha-fetoprotein (AFP) will also be measured.
In around five to seven out of ten people with HCC, AFP levels will rise as the disease progresses. AFP levels usually come down if a treatment is working, so it is a useful tool to measure how effective treatment is. However, around one in five HCC tumours do not produce an elevated AFP, even when large17.
In biliary tree cancer, blood tests for the tumour markers CA 19-9 and CEA may also be used4.
However, these do not give a certain diagnosis as other conditions may also cause these markers to be raised.
- why you need the treatment
- what will happen during the treatment
- the advantages and disadvantages of the treatment
- what the significant risks or side effects of the treatment are
- what the alternative treatments are
- what would happen if you did not have the treatment.
Ultrasound
Ultrasound, the same technology used to confirm that all is well in pregnancy, sends sound waves into the body. The echoes are picked up and used to build a picture of the condition of the liver, bile ducts and gallbladder. Ultrasound is painless. If the ultrasound highlights any areas of tissue which could be a tumour you should be referred to a specialist liver unit for a CT or MRI scan. You should be seen by a specialist within two weeks.
CT scan (computed tomography)
A CT machine takes X-ray pictures of the body from different angles that are then fed into a computer. The computer processes the pictures as a series of cross sections (or ‘slices’) giving a 3-dimensional image of the inside of your body enabling doctors to get an insight into the liver and other organs. This will show how far the tumour has spread and if it is present in other organs.
The scan is painless and takes approximately 20 minutes (even less with the latest fast scanners). Occasionally people may feel claustrophobic in a CT machine. If you think this may be a problem for you, discuss this with the radiographer beforehand so that they are aware. A dye, referred to as a contrast medium, is often used to help to make the images clearer. This may be given by injection or as a drink. You will be asked to drink lots of water after the scan to flush the dye out of your system. Rarely, some people may develop nausea or have an allergic reaction to the contrast dye. This can be treated immediately.
MRI (magnetic resonance imaging)
MRI uses radiofrequency waves and a strong magnetic field, not X-rays, to create a clear and detailed picture of internal organs and tissues and may be used where more detailed examination is required.
MRI is painless but rather noisy and some people may feel claustrophobic. Speak to the radiographer if this is a concern and ask about ear plugs or headphones through which you can listen to music. They may also be able to give you a sedative to help you relax if necessary. Because of the strong magnetic field, you must tell medical staff whether you have any piercings or have been fitted with anything metal, such as a pacemaker or pins.
When investigating possible bile duct cancer a particular form of MRI may be used called MRCP (magnetic resonance cholangiopancreatography)18.
Chest X-ray
You may also have a chest x-ray to detect the presence of any tumour spread to the lungs.
Hepatic angiography
Hepatic angiography is an X-ray study of the blood vessels that supply the liver and may be needed if the diagnosis is still doubtful after a CT and MRI scan. It may also be used as part of some treatment techniques such a chemoembolisation (see treatment section for further information). The procedure uses a catheter (a thin, flexible tube) that is placed into a blood vessel through a small cut in the groin. A dye is then injected through the catheter which ‘lights up’ the blood vessels in the tumour.
A hepatic angiogram is usually done under local anaesthetic and you are also likely to be given sedation. Because of this, you may be asked to stay in hospital overnight (the minimum stay is six hours). The test is usually uncomfortable, rather than painful. You should be able to drive the next day and continue with normal every day activities.
Endoscopic retrograde cholangiopancreatography (ERCP)
This technique is used if you have suspected biliary tree cancer, to examine your bile ducts in more detail. It uses a small camera on the end of a flexible tube (endoscope). The camera is gently passed down your throat guided by an X-ray scanner to the bile ducts. A liquid will be injected to make your bile ducts show up more clearly. A small needle may also be passed down through the endoscope to take a tissue sample for examination (biopsy)18.
Laparoscopy
A laparoscopy may be performed to assess damage to your liver and bile ducts and also to look for tumours in the abdominal cavity18. In this procedure a tiny camera with a light on the end of a flexible fibre optic tube is inserted into your side through a small cut in your skin (‘keyhole’) to take pictures of your liver. If needed, a biopsy of your liver can be taken at the same time.
A laparoscopy is performed under a general anaesthetic. Afterwards it can be painful, but tablet painkillers are usually enough to dull the pain. You should not drive for 24 hours afterwards. A laparoscopy is often performed as a day case but an overnight stay is occasionally necessary.
Liver biopsy
Usually diagnosis can be made using imaging techniques but occasionally a biopsy may be required3. During a liver biopsy, a tiny piece of the liver is taken for study. This usually involves a fine hollow needle being passed through the skin into the liver and a small sample of tissue being withdrawn. In some circumstances it can be done using an endoscope (see above).
The test is usually done under local anaesthetic and may mean an overnight stay in hospital, although some people may be allowed home later the same day. As the test can be uncomfortable and there is a very small risk of internal bleeding or bile leakage, a stay in bed of at least six to eight hours is required. Ask your doctor for more information on this.
There is a small risk of spreading the tumour cells during this procedure and so it is only undertaken after specialist review by a multidisciplinary team17.
Test results
When all the tests have been completed your consultant will review your test results with a medical team which may include specialists in surgery, liver disease (hepatologist), digestive diseases (gastroenterologist) and cancer (oncologist).
As well as diagnosing the presence of cancer, the tests will also provide information on how advanced the cancer is (size, number of tumours, location). This is referred to as ‘staging’ the cancer and is often measured using the TNM classification:
- Tumour (T) – the extent of the primary tumour
- Node (N) – whether the tumour has spread to your lymph nodes
- Metastases (M) – whether the tumour has spread to other organs.
The health of your liver will also be classified, using a scoring system called Child-Pugh (class A, B, C) which takes into consideration blood test results, the presence of fluid in the abdomen (ascites) and brain function (encephalopathy). A Child-Pugh class A, indicates the liver is working well, whereas class C indicates severe liver damage.
This information will help your medical team to decide on the most appropriate treatment options to discuss with you.