Liver Cancer:
Diagnosis and Staging

This page covers tests that are often used to help diagnose and stage liver cancer.
Depending on the symptoms you have, you may also be asked to undergo other tests and investigations.

“Beating cancer is a personal battle. It was one of the toughest opponents
I have faced so far, and I think I did reasonably well.”

Yuvraj Singh

Diagnostic Tests to Determine Cancer Type

Once the doctor is sure of an abnormality, the following tests are done to determine further details about the type of cancer present.

These tests are used to supplement blood tests such as the complete blood count (CBC), liver function test (LFT) and certain tumour marker tests.

Abdominal Ultrasound

What to expect

An abdominal ultrasound is a painless procedure that utilizes sound waves to make images of the internal body organs. Ultrasounds are often used to detect if suspicious area is a fluid-filled sac (cyst) or a solid mass which might be cancerous. They also pinpoint the position of a tumour and this guides the physician to the exact spot to insert a needle during biopsy.

During an abdominal ultrasound

First, you may be asked to undress the upper part of your body (down to your waist) and lie on your back on a bed or examination table. Ask for a robe or blanket to cover yourself while you wait for the specialist to arrive.

The specialist may instruct you to lie on your side, or change sides during the scan. He or she may also ask you to raise your arms over your head.

Next, the specialist will cover a small instrument (called a transducer) with a special gel, and move it around your abdomen and the surrounding area. If the abdominal tissue is dense, the specialist might use some pressure to get a clearer image.

The ultrasound should take about 10-15 minutes. If you experience any pain, be sure to inform your doctor.

Biopsy

What to expect

Biopsy involves the removal of a sample of liver cells or tissues for laboratory testing and is the only definitive method to diagnose liver cancer. It is a way to evaluate a suspicious area in your liver to determine whether it is cancerous.

Typically, biopsies will be done along with the abdominal ultrasound. It is important that you choose a doctor and clinical team that you are comfortable with to perform your procedure.

For a few days after the biopsy, your abdominal area may feel sore and bruised. Don’t hesitate to talk to your clinical team about pain medication if you feel you might need it. The pain and bruising will generally subside in a couple of weeks. If it persists, please contact your doctor immediately.

There are two types of biopsy used for liver cancer:

  • Fine-needle aspiration (FNA) biopsy is a quick, simple test in which a thin needle is used to remove tissue or fluid for examination under a microscope.
  • Core biopsy which involves the removal of a tissue sample using a wide needle for examination under a microscope. This procedure is also called core needle biopsy. Before your doctor starts the procedure, he or she will typically inject a local anaesthetic into the area to numb it. You may feel a little pain or a sensation of pressure for a short time during the biopsy.

Diagnostic Tests to Determine
Stage and Spread of Cancer

CT Scan

What to expect

A CT (computerized tomography) scan is an imaging study and is generally painless. It uses X-rays to take multiple images of the body from different angles to recreate three-dimensional pictures of your internal organs on a computer. It is important that you choose a doctor and clinical team that you are comfortable with to perform your CT scan.

You may be asked to refrain from eating or drinking for a few hours before your scan. Be sure to inform your doctor prior to your scan if

You are pregnant or breastfeeding

You have any metal or electronic
devices implanted in your body (such
as a pacemaker or metal pins)

You are afraid of enclosed spaces
(claustrophobic)

You have previously had an allergic
reaction to contrast material

You are taking any vitamins, ayurvedic
medicines or homeopathic medicines

During a CT scan

You may be asked to change into a hospital gown and remove your jewellery, watch, body piercings or any other accessory that contains metal. You may also be asked to empty your bladder.

You may be given a special dye (called contrast material) which can help highlight the areas of your body that are being examined. The dye can be given to you by mouth (in a drink), by injection through a vein in your arm or by an enema in your rectum. You may need to wait for 30 minutes to an hour for your body to absorb the dye.

Next, a nurse or technician will take you to the room which contains the CT scanner. You will be asked to lie on a narrow, motorized table that will slide you into the machine. The nursing staff may use straps to keep you in position. You can ask for a pillow if you are feeling uncomfortable. You will be asked to remain still for the duration of the scan.

As the table moves you into the CT scanner, various detectors and X-ray tubes will rotate around you. Each rotation will produce several cross-section images of your body. You may hear some buzzing or whirring noises – try not to be alarmed and remember to stay still.

The technicians will be seated in a separate room, but they will be able to see and hear you. You may be asked to communicate with them via intercom. They may ask you to hold your breath at certain times to improve image quality.

The scan will usually take 20-30 minutes to complete.

After the scan, you may receive special instructions regarding the contrast material. For example, your technician or doctor may ask you to wait for a few minutes to ensure that you do not have an allergic reaction. You may also be told to drink plenty of fluids to help your kidneys to flush out the contrast material through your urine.

PET Scan

What to expect

PET (Positron emission tomography) scan is a process that uses radioactive glucose to detect malignant tumour cells in the body. Malignant tumour cells show up brighter in the picture because they are more active and take up more glucose than normal cells do. The scan is generally painless. It is important that you choose a doctor and clinical team that you are comfortable with to perform your PET scan. Some hospitals have a combined PET/CT scanner.

You may be asked to refrain from eating or drinking for a few hours before your scan. Be sure to inform your doctor prior to your scan if:

You are pregnant or breastfeeding

You have any metal or electronic
devices implanted in your body (such
as a pacemaker or metal pins)

You are afraid of enclosed spaces
(claustrophobic)

You have previously had an allergic
reaction to contrast material

You are taking any vitamins, ayurvedic
medicines or homeopathic medicines

During a PET scan:

You may be asked to change into a hospital gown and remove your jewellery, watch, body piercings or any other accessory that contains metal. You may also be asked to empty your bladder.

You may be given a special dye (called contrast material) which can help highlight the areas of your body that are being examined. The dye can be given to you by mouth (in a drink), by injection through a vein in your arm or by an enema in your rectum. You may need to wait for 30 minutes to an hour for your body to absorb the dye.

Next, a nurse or technician will take you to the room which contains the PET scanner. You will be asked to lie on a narrow, motorized table that will slide you into the scanner. The nursing staff may use straps to keep you in position. You can ask for a pillow if you are feeling uncomfortable. You will be asked to remain still for the duration of the scan.

As the table moves you into the PET scanner, the machine will begin to rotate around you. Each rotation will produce several cross-section images of your body. You may hear some buzzing or whirring noises – try not to be alarmed and remember to stay still.

The technicians will be seated in a separate room, but they will be able to see and hear you. You may be asked to communicate with them via intercom.

The scan will usually take about 30 minutes to an hour to complete.

After the scan, you may receive special instructions regarding the contrast material. For example, your technician or doctor may ask you to wait for a few minutes to ensure that you do not have an allergic reaction. You may also be told to drink plenty of fluids to help your kidneys to flush out the contrast material through your urine.

MRI Scan

What to expect

Magnetic resonance imaging (MRI) scan is a procedure in which an MRI scanner uses a high-powered magnet and a computer for comprehensive images of the internal organs and surrounding structures. MRI scans normally add supplementary information about liver anomalies and may be recommended only in select cases. The scan is generally painless. It is important that you choose a doctor and clinical team that you are comfortable with to perform your MRI scan.

You may be asked to refrain from eating or drinking for a few hours before your scan. Be sure to inform your doctor prior to your scan if:

You are pregnant or breastfeeding

You have any metal or electronic
devices implanted in your body (such
as a pacemaker or metal pins)

You are afraid of enclosed spaces
(claustrophobic)

You have previously had an allergic
reaction to contrast material

You are taking any vitamins, ayurvedic
medicines or homeopathic medicines

During a MRI scan:

You may be asked to change into a hospital gown and remove your jewellery, watch, body piercings or any other accessory that contains metal. You may also be asked to empty your bladder.

You may be given a special dye (called contrast material) which can help highlight the areas of your body that are being examined. The dye is typically administered by injection through a vein in your arm. You may need to wait for 30 minutes to an hour for your body to absorb the dye.

Next, a nurse or technician will take you to the room which contains the MRI machine. You will be asked to lie on a narrow, motorized table that will slide you into the machine. The nursing staff may use straps to keep you in position. You can ask for a pillow if you are feeling uncomfortable. You will be asked to remain still for the duration of the scan.

As the table moves you into the MRI machine, the machine creates a strong magnetic field around you and radio waves are directed at your body. You may hear repetitive noises such as thumping or tapping – try not to be alarmed and remember to stay still. You can request earplugs or have music playing to help you block out the noise.

The technicians will be seated in a separate room, but they will be able to see and hear you. You may be asked to communicate with them via intercom.

The scan will usually take about 30 minutes to an hour to complete.

After the scan, you may receive special instructions regarding the contrast material. For example, your technician or doctor may ask you to wait for a few minutes to ensure that you do not have an allergic reaction. You may also be told to drink plenty of fluids to help your kidneys to flush out the contrast material through your urine.
How liver cancer is staged

The results of your diagnostic tests will help your doctor determine the size and position of the cancer, and whether it has spread. This is called staging. Knowing the stage and grade of your cancer will help your doctor plan the best course of treatment for you.

The results of your diagnostic tests will help your doctor determine the size and position of the cancer, and whether it has spread. This is called staging. Knowing the stage and grade of your cancer will help your doctor plan the best course of treatment for you.

THE TNM STAGING SYSTEM

The TNM staging system gives the complete stage of the cancer

T describes how far the tumour has grown into the wall of the liver.

N describes whether the cancer has spread to the lymph nodes and which nodes are involved. For example, N0 means no lymph nodes are affected. N1 means there are cancer cells in 1 to 3 of the lymph nodes.

M describes whether the cancer has spread to another part of the body. For example, M0 means the cancer has not spread (metastasised) to other parts of the body.

Sometimes the final TNM staging may not be certain until surgery is completed, since the tissue samples removed during the procedure will need to be analysed further.


THE NUMBER STAGING SYSTEM

Liver cancer can also be divided into four number stages.

Stage I Liver cancer is further divided into stages IA or IB. In stage IA, a single tumour (2cm or less in size) has formed in the liver. Stage IB is used to represent a single tumour of 2cm or more in size.

Stage II is used to represent liver cancers that have either a single tumour (larger than 2cm) that has grown into the blood vessels, or more than one tumour (but none larger than 5cm across).

Stage III liver cancer is sometimes called locally advanced liver cancer. It is further divided into stages IIIA or IIIB, depending on where the cancer has spread. In stage IIIA, there is typically more than one tumour, with one tumour being larger than 5cm across. Stage IIIB is used to represent liver tumours of any size that have grown into a large vein of the liver (such as the portal or hepatic vein).

Stage IV liver cancer is also called secondary or metastatic liver cancer. It is further divided into stages IVA or IVB, depending on where the cancer has spread. Liver cancer is classified as stage IVA when a tumour of any size has spread to nearby lymph nodes. Liver cancer is classified as stage IVB when it has spread to other parts of the body, such as distant lymph nodes, bones or the lungs.

GRADING

The grade of a cancer gives an idea of how slowly or quickly it might grow. The grade is based on how the cancer cells look under a microscope when they are compared with normal cells.

Grade 1 (low grade cancer)
The cancer cells look similar to normal cells (they are well differentiated). They usually grow slowly. These cancer cells are less likely to spread.

Grade 2 (moderate or intermediate-grade cancer)
The cancer cells look more abnormal and grow slightly faster than grade 1 cells.

Grade 3 (high-grade cancer)
The cancer cells look very different from normal cells (they are poorly differentiated). They may grow more quickly than grade 1 or 2 cells.

Treatment options for LIVER cancer

The decision about the best course of treatment is based on these test results and the type, stage, grade and size of your tumour. Treatments like surgery, chemotherapy and radiation therapy are some of the options used for liver cancer. Refer to this section to understand the types of cancer treatments for liver cancer and possible side effects. Read more

Your cancer journey

Everyone deals with a cancer diagnosis and treatment in a different way. Refer to this section to understand
various aspects of your cancer journey and the road to recovery. Read more

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