Diagnosing Liver Cancer

About Liver Cancer

At Penn Medicine, patients with liver cancer, or hepatocellular carcinoma (HCC), receive their care from a multidisciplinary team of nationally recognized experts in the diagnosis, treatment and research of gastrointestinal cancer.

The Abramson Cancer Center's interdisciplinary gastrointestinal cancer program was the first of its kind. Its close collaboration with Penn Medicine's transplant program provides access to comprehensive medical and surgical care for patients who require a liver transplant. Penn Transplant Institute has performed more than 1,500 liver transplants.

The liver is the largest solid organ in the body and is located on the right side of the abdomen. The liver is responsible for such functions as filtering the blood for excess toxins, helping regulate blood sugar, creating bile for digestion, and creating enzymes responsible for blood clotting.

There are two main types of liver cancer.

  • Primary liver cancer: Cancer that forms in the tissues of the liver. The most common type is hepatocellular carcinoma (HCC).
  • Secondary liver cancer: Cancer that spreads, or metastasizes, to the liver from another part of the body like the breast, lung, thyroid or other gastrointestinal cancers.

Penn Medicine's multidisciplinary approach to cancer diagnosis and treatment provides better outcomes and gives patients access to the most advanced treatment, surgical techniques and clinical trials.

Because navigating a cancer diagnosis and treatment options can be difficult, patients who wish to connect with a cancer specialist at Penn Medicine can speak with a cancer nurse, who can help them make an appointment with the right physician.

To connect with a cancer nurse at Penn Medicine, patients should call 800-789-PENN (7366).

Read more About Liver Cancer

Diagnosing Liver Cancer

An accurate cancer diagnosis from trusted cancer specialists is the first step in getting personalized treatment options to treat liver cancer.

Patients who choose Penn's Abramson Cancer Center, benefit from a multidisciplinary team of cancer specialists including gastroenterologists, radiologists, pathologists and surgeons who work together to provide a diagnosis and treatment plan designed specifically for each patient with liver cancer.

Cancer specialists at Penn Medicine are highly experienced in using the most advanced techniques for diagnosing cancer and are actively researching better and more precise ways to detect liver cancer.

Navigating a cancer diagnosis and treatment options can be difficult, patients who wish to connect with a cancer specialist at Penn Medicine can speak with a cancer nurse, who can help them make an appointment with the right person. Penn Medicine's contact center has experienced cancer nurses available and ready to guide patients in finding the cancer specialist right for them.

To connect with a cancer nurse at Penn Medicine, patients should call 800-789-PENN (7366).


Screening for Liver Cancer

Liver cancer usually does not cause any symptoms until the cancer is advanced. Currently, there are no approved and recommended screening tests for liver cancer like mammograms for breast cancer or colonoscopies for colon cancer.

One potential screening tool tests the blood for alpha-fetoprotein (AFP). AFP levels can be a marker for the development of liver cancer, but not all liver cancers produce high levels of AFP.

Some studies recommend people at high risk for developing liver cancer may have their AFP levels checked every six months and an abdominal ultrasound performed annually. Screening guidelines should be discussed by patients and their physicians.

Diagnostic Tools for Liver Cancer

If liver cancer is suspected, Penn Medicine’s team of gastrointestinal cancer physicians guide patients through the diagnostic process that can include:

  • Medical history and physical exam.
  • Imaging tests. Pictures of the inside of the body to help find out whether a suspicious area might be cancerous, to learn how far cancer may have spread, or to determine if treatment is working.
    • Computed tomography (CT). A CT scan creates a 3-D X-ray of the inside of the body. A computer combines the images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (dye) is used to provide better detail.
    • Ultrasound. Ultrasounds use sound waves to image an area of the body. This test is painless and does not expose patients to radiation.
    • Magnetic resonance imaging (MRI). Magnetic fields are used to create detailed images of the body. A contrast medium may be injected into a vein to create a clearer picture.
    • Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into the patient’s body. The tumor absorbs the radioactive substance at a different rate than normal cells, and a scanner detects the substance to produce images.
    • Angiography. A catheter is threaded along the blood vessels leading to the liver. Contrast is injected into the blood vessels and X-rays are taken that can show highly vascular liver tumors. This procedure is not regularly performed.
  • Laparoscopy. This minimally invasive procedure allows the physician to view the lymph nodes and other organs to see if cancer has spread. Biopsies may be taken of the organ tissue.
  • Biopsy. A sample of the suspicious area is removed and viewed under a microscope. Penn Medicine surgeons perform several different types of biopsies based on the amount of tissue being removed. Some biopsies use a needle, while others require a small surgical procedure to remove more tissue.
  • Lab tests. Lab tests can help a physician diagnose liver cancer, determine current liver function, learn how other organs may be affected, and look for signs of reoccurrence. Some types of lab tests include:
    • Alpha-fetoprotein (AFP) blood test
    • Liver function tests
    • Blood clotting tests
    • Tests for hepatitis
    • Kidney function tests
    • Electrolytes and blood chemistry tests

Staging Liver Cancer

Staging systems provide doctors with a common language for describing tumors. After cancer is first diagnosed, a series of tests are used to investigate the extent of the cancer and to see whether it has spread to other parts of the body from where it started. Staging is a way of recording the size and growth of a cancer, and determining the plan for treatment. By understanding the stage of their cancer, patients can make informed decisions about their treatment.

Liver cancer is most commonly stages using the TNM staging system.

T Stage

The T stage represents the extent of the primary tumor itself.

  • TX: Primary tumor cannot be assessed
  • T0: No evidence of primary tumor
  • T1: Solitary tumor without invasion of blood vessels in the liver (not including major branches of the portal of hepatic vein)
  • T2: Solitary tumor with invasion of blood vessels in the liver (not including major branches of the portal of hepatic vein) OR multiple tumors, none of which are >5 cm in size
  • T3a: Multiple tumors at least one of which is >5 cm in size, OR a tumor that involves a major branch of the portal or hepatic vein
  • T3b: At least one tumor that has grown into a major branch of the large veins of the liver (the portal and hepatic veins)
  • T4: Tumors that directly invade into adjacent organs (not including the gall bladder) OR a tumor that invades the lining of the abdomen

N Stage

The N stage represents the degree of the involvement of the lymph nodes.

  • NX: The regional lymph nodes cannot be assessed
  • N0: No evidence of spread to the lymph node
  • N1: Regional lymph nodes are involved with tumor

M Stage

The M stage represents whether or not there is spread of cancer to other parts of the body.

  • M0: No evidence of distant spread of the cancer
  • M1: Evidence of distant spread of the cancer including spread to non-regional lymph node chains

The “staging diagnosis” combines the T, N and M groups:

  • Stage I: T1, N0, M0: There is a single tumor (any size) that has not grown into any blood vessels. The cancer has not spread to nearby lymph nodes or distant sites.
  • Stage II: T2, N0, M0: Either a single tumor (any size) has grown into blood vessels; OR there are several tumors, and all are less than 5 cm (2 inches) in diameter. The cancer has not spread to nearby lymph nodes or distant sites.
  • Stage IIIA: T3a, N0, M0: There are several tumors, and at least one is larger than 5 cm (2 inches) across. The cancer has not spread to nearby lymph nodes or distant sites.
  • Stage IIIB: T3b, N0, M0: At least one tumor is growing into a branch of the major liver blood vessels (portal vein or hepatic vein). The cancer has not spread to nearby lymph nodes or distant sites.
  • Stage IIIC: T4, N0, M0: A tumor is growing into a nearby organ (other than the gallbladder); OR a tumor has grown into the outer covering of the liver. The cancer has not spread to nearby lymph nodes or distant sites.
  • Stage IVA: Any T, N1, M0: Tumors in the liver can be any size or number and they may have grown into blood vessels or nearby organs. The cancer has invaded nearby lymph nodes. The cancer has not spread to distant sites.
  • Stage IVB: Any T, Any N, M1: The cancer has spread to other parts of the body. (Tumors can be any size or number, and nearby lymph nodes may or may not be involved.)

Physicians at Penn often classify liver cancers by whether or not they can be entirely removed by surgery, or resectable. There are three ways physicians look at liver cancer:

  • Localized resectable cancers: Only a small number of patients with liver cancer have tumors that can be completely removed by surgery. This would include most stage I and some stage II cancers in the TNM system, in patients who do not have cirrhosis.
  • Localized unresectable cancers: Cancers that have not spread to the lymph nodes or distant organs, but cannot be completely removed by surgery are classified as localized unresectable. This would include some early stage cancers, as well as stage IIIA and IIIB cancers in the TNM system.
  • Advanced cancers: Cancers that have spread to lymph nodes or other organs are classified as advanced. These would include stage IIIC and stage IV cancers in the TNM system. Most advanced liver cancers cannot be treated with surgery.

Liver Cancer Treatment

Following the diagnosis and staging of liver cancer, cancer specialists at Penn's Abramson Cancer Center develop a personalized treatment plan. Penn's treatment options for liver cancer include:

  • Surgery
  • Radiation therapy
    • 3-D conformal radiation therapy
    • Intensity-modulated radiation therapy (IMRT)
    • Volumetric-modulated arc therapy (VMAT)
    • Proton therapy
    • Stereotactic body radiotherapy
  • Chemotherapy
    • Liver-directed therapies
      • Ethanol injection
      • Chemoembolization of the hepatic artery
  • Biologic therapies
  • Other treatments

Because navigating a cancer diagnosis and treatment options can be difficult, patients who wish to connect with a cancer specialist at Penn Medicine can speak with a cancer nurse, who can help them make an appointment with the right physician.

To connect with a cancer nurse at Penn Medicine, patients should call 800-789-PENN (7366).

Read more Liver Cancer Treatment

Liver Cancer Survivorship

There are more than 12 million cancer survivors living and thriving today as a result of advances in cancer treatment. However, cancer treatments can result in physical, emotional and financial complications long after the therapy is complete. Survivorship programs at Penn Medicine are a distinct phase of liver cancer care and are designed to help patients transition from their cancer treatment routine to a post-cancer care lifestyle.

Read more Liver Cancer Survivorship


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