Symptoms of primary liver cancer

In the early stages of primary liver cancer there are often no symptoms, or symptoms may be vague. If you have any symptoms that could be caused by liver cancer it's important to have them checked by your GP, but remember they are common to many other conditions and most people with these symptoms won't have cancer.

Jaundice

Jaundice can occur if the liver isn't working properly because of cancer or an underlying disease such as cirrhosis. It can also happen if the bile duct becomes blocked by cancer, which causes bile produced by the liver to flow back into the bloodstream. Jaundice makes the skin and the whites of the eyes go yellow and may make the skin very itchy. Other signs of jaundice are dark-coloured urine and pale stools (bowel motions).

Ascites

Sometimes fluid builds up in the abdomen and causes swelling known as ascites . There may be several possible reasons for this:

• If the liver is affected by cancer cells, this can cause an increase in pressure in the veins that lead into the liver and sometimes the main veins can become blocked by a clot (thrombosis). Fluid from the abdomen can't pass quickly enough through the liver, so it starts to collect in the abdomen.
• If the liver is damaged, it may produce less blood protein. This can upset the body's fluid balance, which causes fluid to build up in the body tissues, including the abdomen.
• Cancer cells may block the lymphatic system. The lymphatic system is a network of fine channels that runs throughout the body. One of its functions is to drain excess fluid, which is eventually passed out of the body in the urine. If some of these channels are blocked, the system can't drain efficiently and fluid may build up.
• If cancer cells have spread to the lining of the abdomen, they can irritate it and cause fluid to build up.

If ascites develops, a tube can be put into the abdomen to drain the fluid away.

Whatever the cause, jaundice or ascites will always indicate a condition that needs medical attention and should not be ignored. Always have these symptoms checked by your GP.

Pain

People sometimes notice a vague discomfort in the upper abdomen, which may become painful. This is due to enlargement of the liver. Pain can sometimes also be felt in the right shoulder. This is known as referred pain and is due to the enlarged liver stimulating the nerves beneath the diaphragm (the sheet of muscle under the lungs) which are connected to nerves in the right shoulder.

Other symptoms

Vague symptoms that might occur include:

• loss of appetite
• weight loss
• feeling sick (nausea)
• weakness and tiredness (lethargy).

Some people may also develop a high temperature and feel shivery.

Diagnosing primary liver cancer

Usually, you begin by seeing your family doctor (GP) who will examine you and arrange any tests that may be necessary. Your doctor may arrange some blood tests to check your general health.

If your GP isn't sure what the problem is, or thinks that cancer may be present, you will be referred to hospital for specialist advice. If your GP suspects that you might have a cancer you should be seen at the hospital within two weeks.

At the hospital

The specialist will ask you about your symptoms and your general health. You'll also be asked if you have any other health problems. The doctor will examine you by feeling your abdomen (tummy area). You may have a blood test and a chest x-ray to check your general health.

Several tests may be used to diagnose primary liver cancer. The tests may also show the stage of the cancer – whether or not it has spread to other parts of the body. These tests help your doctor to know the best way to treat the cancer. It can help to have a friend or relative with you when you go for any tests or to get your results.

Blood tests

As well as blood tests to check your general health you will have other blood tests, known as liver function tests (LFTs) to see how well your liver is working.

Another blood test checks the amount of a chemical called alpha-fetoprotein (AFP) in your blood. The amount of AFP in the blood can be higher than normal in people with hepatocellular cancer – HCC. The doctors may monitor the level of AFP before and after treatment of HCC as it can show how well treatment is working.

Liver ultrasound scan

A liver ultrasound scan uses sound waves to make up a picture of the liver. It's done in the hospital scanning department. You'll be asked not to eat anything for at least four hours before your appointment.

Once you are lying comfortably on your back, a gel is spread onto your abdomen. A small device like a microphone, which produces sound waves, is passed over the area. The sound waves are then converted into a picture by a computer.

This is a painless test and only takes a few minutes.

Abdominal CT (Computerized tomography) scan

A CT scan takes a series of x-rays of the abdomen which build up a three-dimensional picture of the inside of the body. It can be used to show the size and position of a cancer, and whether it has begun to spread.

The scan is painless and takes 10–30 minutes. CT scans use a small amount of radiation, which will be very unlikely to harm you and won't harm anyone you come into contact with.

Before the scan you'll be asked to drink a special liquid which shows up on x-ray and ensures that a clear picture is obtained. Once you are lying in a comfortable position, the scan will be taken. About halfway through the scan, a special dye may be injected into one of your veins to show up the blood vessels in the liver. For a few minutes, this may make you feel hot all over. If you are allergic to iodine or have asthma you could have a serious reaction to the injection, so it's important to let your doctor know beforehand.

You will probably be able to go home shortly after the scan is over.

MRI (magnetic resonance imaging) scan

This test is similar to a CT scan but uses magnetism instead of x-rays to build up a detailed picture of areas of your body.

Before the scan you may be asked to complete and sign a checklist. This is to make sure that it's safe for you to have an MRI scan (because the scanner is a powerful magnet). The checklist asks about any metal implants you may have, for example a pacemaker, surgical clips, bone pins etc. You should also tell your doctor if you have ever worked with metal or in the metal industry (as very tiny fragments of metal can sometimes lodge in the body). If you do have any metal in your body it's likely that you won't be able to have an MRI scan. In this situation another type of scan can be used.

Before having the scan, you'll be asked to remove any metal belongings including jewellery.

Some people are given an injection of dye into a vein in the arm, which doesn't usually cause discomfort. This is called a contrast medium and can help the images from the scan to show up more clearly. During the test you will be asked to lie very still on a couch inside a long cylinder (tube) for about 30 minutes. It is painless but can be slightly uncomfortable, and some people feel a bit claustrophobic during the scan. It's also noisy, but you'll be given earplugs or headphones. You will be able to hear, and speak to, the person operating the scanner.

Liver biopsy

The only way to be sure of the diagnosis is to take some cells or a small piece of tissue from the affected area to look at under a microscope. This is called a biopsy. A biopsy isn't always done and sometimes the diagnosis is confirmed after an operation to remove the tumour.

After the area has been numbed using a local anaesthetic injection, a fine needle is passed into the tumour through the skin. CT or ultrasound may be used at the same time, to make sure that the biopsy is taken from the right place.

You will need to stay in hospital for a couple of hours after a liver biopsy, and possibly overnight. This is because there is a risk of bleeding afterwards.

If your cancer hasn't already spread, and if there is a chance your tumour can be removed, you may not have a biopsy. This is because there is a small risk that the cancer can spread along the pathway of the needle when the biopsy needle is removed.

Laparoscopy

A laparoscopy is a small operation that allows the doctors to look at the liver and other internal organs in the area. It's done under a general anaesthetic and will mean a short stay in hospital. While you are under anaesthetic the doctor will make a small cut (incision) in the front of your abdomen and insert a thin tube containing a light and a camera (laparoscope). Using the laparoscope, the doctor is able to look at the liver and can take a small sample (biopsy) for examination under a microscope.

During the operation, carbon dioxide gas is passed into the abdominal cavity and this can cause uncomfortable wind and/or shoulder pains for several days. The pain is often eased by walking about or taking sips of peppermint water. After the laparoscopy you will have one or two stitches in your abdomen.

It will probably take several days for the results of your tests to be ready and a follow-up appointment will be made for you. Obviously this waiting period can be an anxious time. It will probably help if you can talk things over with a relative or friend. You can also contact one of our listed support organisations or call one of our cancer support specialists .

Further tests for primary liver cancer

If the tests described in the diagnosing primary liver cancer section show that you have primary liver cancer your doctor may need to do some further tests. These will tell the doctor more about the cancer and show whether it has begun to spread.

Hepatic angiogram

This test allows the doctors to see how the tumour is affecting the main blood vessels around the liver. A fine tube is inserted into an artery in your groin and a dye is injected through the tube. The dye circulates in the arteries to make them show up on x-ray. An angiogram is carried out in a room within the x-ray department.

Sometimes an MRI scan can be used to show up the blood vessels of the liver (which means that an angiogram will not be necessary).

Staging of primary liver cancer

The stage of a cancer is a term used to describe its size and whether it has spread beyond its original site. Once your doctor knows the type and stage of the cancer they can decide on the most appropriate treatment for you.

Generally, primary liver cancer is divided into four stages: small and localised (stage one); spread into surrounding structures (stages two or three); or spread into other parts of the body (stage four). If the cancer has spread to distant parts of the body this is known as secondary cancer (or metastatic cancer).

A commonly used staging system is

• Stage 1 The cancer is no bigger than 2cm in size and hasn't begun to spread to the blood vessels of the liver, nearby lymph nodes or other parts of the body.
• Stage 2 The cancer hasn't begun to spread to the lymph nodes or other parts of the body, but is bigger than 2cm in size, or the cancer is affecting the blood vessels in the liver, or there are multiple tumours in one of the lobes of the liver – each tumour is no bigger than 2cm in size.
• Stage 3 This stage is divided in two:
• Stage 3A The cancer is affecting the blood vessels in the liver but hasn't spread to lymph nodes or other parts of the body. Or the tumour is bigger than 2cm in size, or there are multiple tumours in one lobe of the liver.
• Stage 3B The tumour can be of any size and the blood vessels of the liver may or may not be affected, but the cancer has spread to nearby lymph nodes.
• Stage 4 The cancer has spread to parts of the body further away from the liver, such as the lungs.

If the cancer comes back after initial treatment this is known as recurrent cancer.

TNM staging system

Another staging system known as the TNM system is also used. This can give more precise information about the extent of the cancer.

• T describes the size of the tumour .
• N describes whether the cancer has spread to the lymph nodes .
• M describes whether the cancer has spread to another part of the body (secondary or metastatic cancer).

Your specialist can tell you more about the TNM system. However, it is more common for doctors to talk about primary liver cancer in terms of stages 1 to 4.