The American Association for the Study of Liver Diseases recommends liver cancer screening for those thought to have a high risk, including people who have hepatitis B and also fall into one or more of the following categories:
an Asian male older than 40, an Asian female older than 50, or an African older than 20 with liver cirrhosis or a family history of liver cancer. Other high risks include: liver cirrhosis from alcohol use; hepatitis C; an inherited form of hemochromatosis; and primary sclerosing cholangitis. Screening typically involves blood tests and an ultrasound exam once or twice each year.
Albumin: Serum albumin levels measures the main protein made by the liver and tells how well the liver is making this protein. Albumin, produced only in the liver, is the major plasma protein that circulates in the bloodstream.
Ammonia: An ammonia test measures the amount of ammonia in the blood. Most ammonia in the body forms when protein is broken down by bacteria in the intestines. The liver normally converts ammonia into urea, which is then eliminated in urine. Ammonia levels in the blood rise when the liver is not able to convert ammonia to urea. This may be caused by cirrhosis or severe hepatitis.
Alpha-fetoprotein (AFP) test: If the patient has high levels of the alpha-fetoprotein in the blood, it may be a sign of liver cancer. Healthy adult males and non-pregnant females typically have less than 40 micrograms of alpha-fetoprotein per liter of blood. AFP is a protein normally made by the immature liver cells in the fetus. At birth, infants have relatively high levels of AFP, which fall to normal adult levels by the first year of life. Also, pregnant women carrying babies with neural tube defects may have high levels of AFP. In adults, high blood levels (over 500 nanograms per milliliter) of AFP are seen in only three situations: hepatocellular cancer, germ cell tumors (cancer of the testes and ovaries), and metastatic cancer in the liver.
Bilirubin: Bilirubin is a waste product made from old blood cells broken down in the liver; it is a yellow compound that causes jaundice and dark urine when present in increased amounts. Tests for bilirubin levels help determine if the liver is functioning appropriately.
Liver enzymes: Another blood test may be performed to check for elevated levels of liver enzymes contained in liver cells, such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST). These enzymes leak into the bloodstream when liver cells are injured. Also, alkaline phosphatase (ALP) levels may be checked. ALP is an enzyme related to the bile ducts. ALP levels are often increased when they are blocked.
Transferrin saturation test: The transferrin saturation test reveals how much iron is bound to the protein that carries iron in the blood. Transferrin saturation tests are used in determining if hemochromatosis exists. Transferrin saturation values higher than 45% are considered too high. The total iron binding capacity test measures how well the blood can transport iron, and the serum ferritin test shows the level of iron in the liver. If either of these tests shows higher than normal levels of iron in the body, doctors can order a special blood test to detect the gene responsible for hemochromatosis, which will confirm the diagnosis. If the mutation is not present, hereditary hemochromatosis is not the reason for the iron buildup and the doctor will look for other causes.
Ultrasound: An ultrasound test uses sound waves to produce a picture of internal organs, including the liver. Ultrasound is painless and usually takes less than 30 minutes. While the individual lies on a bed or examining table, a wand-shaped device (transducer) is placed on the body. This wand emits sound waves that are reflected from the liver and transformed into a computer image. Ultrasound provides information about the shape, texture and makeup of tumors.
Computerized tomography (CT) scan: Computerized tomography (CT) uses x-rays to produce cross-sectional images of the body. A variation of a CT, called the CT angiogram, may also be performed instead of a CT. In a CT angiogram, a contrast dye is injected into an artery in the liver. X-rays then track the dye as it flows through the blood vessels in the liver. This type of angiogram, which may take up to an hour to perform, can provide detailed information on the number and location of liver tumors. However, some individuals may experience an allergic reaction to the contrast dye.
Magnetic resonance imaging (MRI): Magnetic resonance imaging (MRI) creates images using a magnetic field and radio waves. Sometimes a contrast dye also may be used. The test can take from 15 minutes to an hour. Newer MRIs can show images of the ducts that transport bile from the liver to the upper part of the small intestine (duodenum) as well as of the arteries and veins within the liver. Sedatives, such as alprazolam (Xanax®) may be used in individuals sensitive to being in closed in spaces. In these cases, a friend or relative needs to drive the individual home from the MRI scan. Sedatives may cause drowsiness and impair the ability to drive an automobile.
Liver biopsy: A liver biopsy may be performed to determine the extent of cellular liver damage and to determine the best treatment option for the patient. During the procedure, a needle is inserted into the liver and a small tissue sample is removed. The tissue is then analyzed under a microscope in a laboratory.
Staging tests help designate the size and location of cancer and whether it has spread. Liver cancer may be staged in different ways. One method uses the Roman numerals I through IV, with higher numbers indicating cancers that are more advanced, such as spreading to other organs. A stage I tumor is small and confined to one lobe of the liver. By stage IV, several tumors may exist in different lobes, or malignant cells may have metastasized (spread) to other parts of the body.
Doctors may also use the following stages to describe primary liver cancer in adults:
Localized resectable: When liver cancer is at the localized resectable stage, the tumor is confined to one lobe of the liver and can be completely removed in an operation. Resectable means a tumor that can be surgically removed.
Localized unresectable: A localized unresectable cancer is found in only one part of the liver. Localized unresectable cancer cannot be completely removed, either because the noncancerous portion of the liver is not healthy enough or because the cancer is located too near the liver's main arteries, veins, and bile ducts and cannot be removed without causing serious damage to the organ.
Advanced: In advanced liver cancer, the cancer has spread throughout the liver or to other parts of the body, particularly the bones or lungs. The individual is more likely to have advanced cancer if they also have cirrhosis or chronic hepatitis.
Recurrent: Recurrent liver cancer means the cancer has returned to the liver or to another part of the body after being treated.
signs and symptoms
Most individuals do not have signs and symptoms in the early stages of liver cancer. Unfortunately, the disease may not be detected until it is in an advanced stage. When symptoms do appear, they may include: loss of appetite and weight; abdominal pain, especially in the upper right part of the abdomen, which may extend into the back and shoulder; nausea and vomiting; general weakness and fatigue; an enlarged liver and abdominal swelling (ascites); and jaundice, or a yellow discoloration of the skin and the whites of the eyes.
Liver failure: Liver failure means that the liver is losing or has lost all of its function. It is a life-threatening condition that demands urgent medical care. The first symptoms of liver failure are often nausea, loss of appetite, fatigue, and diarrhea. Because these symptoms can have any number of causes, it may be hard to tell that the liver is failing.
As liver failure progresses, the symptoms become more serious. The individual may become confused and disoriented, and extremely sleepy. There is a risk of coma and death. Immediate treatment is needed. The medical team will try to save whatever part of the liver that is still working. If this is not possible, the only option may be a liver transplant.
Kidney failure: The kidneys may lose their ability to filter fluids and waste, causing dangerous levels of toxic substances to accumulate in the body. Blood pressure may rise; the body may retain excess fluid and not make enough red blood cells.
Metastasis: Metastasis is when cancer that spreads to areas outside the affected organ and becomes more difficult to treat. Liver cancer most commonly spreads to the lungs and bones. The liver is the second most commonly involved organ by metastatic disease, after the lymph nodes.
causes and risk factors
Liver cancer occurs when liver cells begin to grow abnormally. It is not completely understood why this happens, but researchers believe that cancer starts with damage to DNA. DNA is the material that contains the instructions for every chemical process in the body, including the rate of cellular growth. DNA damage causes changes in these instructions. One result is that cells may begin to grow out of control and eventually form a tumor (a mass of cancer cells).
Men are more likely to develop primary liver cancer than are women, although the reasons why are not clear.
Age: In the United States and Europe, liver cancer diagnosis occurs on average at about age 60. People in Asia and Africa tend to be diagnosed with liver cancer at younger ages, between ages 20-50.
Chronic infection with HBV or HCV: Chronic infection with hepatitis B virus (HBV) or hepatitis C virus (HCV) is a risk factor for developing liver cancer. Hepatitis infections can damage liver cells and alter DNA, leading to cancer development.
Cirrhosis: Cirrhosis is a progressive and irreversible condition that causes scar tissue to form in the liver and increases the individual's chances of developing liver cancer. Causes of cirrhosis include alcoholism, hepatitis, and exposure to environmental toxins.
Diabetes: Individuals with diabetes have a greater risk of liver cancer. Having both diabetes and hepatitis C infection increases the risk even more. Diabetes can damage small capillaries that deliver blood and nutrients to organs such as the liver and kidney. Toxins may build up in the liver, causing further damage.
Exposure to aflatoxins: Aflatoxins are toxic metabolites produced by certain fungi in or on foods and animal feeds. Consuming foods contaminated with fungi that produce aflatoxins greatly increases the risk of liver cancer. Crops such as corn, soybeans, and peanuts can become contaminated with aflatoxins.
Excessive alcohol consumption: Consuming more than a moderate amount of alcohol can lead to irreversible liver damage and increase the risk of liver cancer. Moderate consumption is defined as no more than two drinks a day for men and one drink for women. A drink is one 4-5 ounce glass of wine, 12 ounces of beer, or a 1.5-ounce shot of 80-proof distilled spirits.
Smoking: Cigarette smoking increases the chances of developing liver cancer. Risks of developing liver cancer are also found to increase significantly with increasing number of years of cigarette use and with earlier age at the start of cigarette smoking.