Doctors use many tests to diagnose cancer and determine if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:

• Age and medical condition
• The type of cancer
• Severity of symptoms
• Previous test results

The following tests may be used to diagnose HCC:

Physical examination. If a person has symptoms of HCC, the doctor will feel the abdomen to check the liver, spleen, and other nearby organs for lumps, swelling, or other changes. The doctor will also look for an abnormal buildup of fluid in the abdomen and for signs of jaundice (yellowing of the skin and whites of the eyes).

Blood tests. At the same time as the physical examination, the doctor will most likely do a blood test to look for a substance called alpha-fetoprotein (AFP). In the United States, AFP is found in elevated levels in the blood of about 50% to 70% of people who have adult primary liver cancer. The doctor will also test for the presence of hepatitis B or C. Other blood tests can show how well the liver is working.

In addition, other tests are commonly needed to diagnose HCC and to determine the location of the tumor in the liver and if it has spread to other parts of the body. After the physical examination and blood tests, the doctor may order one or more of the following tests:

Imaging tests

Ultrasound. An ultrasound uses sound waves to create a picture of the internal organs. The sound waves bounce off the liver, other organs, and tumors. Each creates a different appearance on a computer monitor.

Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Usually a special dye is injected into the patient’s vein before the CT scan is done. The dye helps the liver and tumors show up more clearly.

Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. Sometimes an MRI can distinguish a benign (noncancerous) tumor from a malignant (cancerous) one.

Angiogram. An angiogram is an x-ray picture of the blood vessels. This test may be done in a hospital, and the person may be given a general anesthetic. A dye is injected into the bloodstream, so the blood vessels of the liver show up on an x-ray.

Surgery

Laparoscopy. A laparoscopy uses a thin, lighted tube to look at the liver and other internal organs. The tube is inserted through a small incision in the abdomen. The procedure is usually done under sedation and local anesthetic to numb the area; it doesn’t usually require a general anesthetic.

Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis (unless the AFP level is extremely high; see Blood Tests above). The sample removed is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluates cells, tissues, and organs to diagnose disease). The type of biopsy performed will depend on the location of the cancer. The biopsy can be taken during a laparoscopy, by fine needle aspiration (cells are removed using a thin needle inserted into the tumor), or by using a thick needle (a core biopsy). Most often it is done by a radiologist who follows the track of the needle using ultrasound to direct him or her to the particular part of the liver he or she wants to obtain the tissue from. The actual biopsy procedure usually lasts for less than one minute. It is typically not painful, and complications only arise in a very small number of cases. Your doctor will test your blood for its ability to clot before this procedure to decrease risk of bleeding after the procedure.

When the AFP test strongly indicates HCC, and the imaging and the clinical picture are typical of HCC, an increasing number of doctors are deciding that a biopsy may not be necessary. Also, if surgical removal of the tumor is being considered, most surgeons will recommend that a biopsy is done as part of the operation, rather than a separate procedure beforehand.

It is also important to note that, with newer imaging technology, very small masses are increasingly being found. However, it is not always possible to identify what these tumors are and determine if they represent a risk to the patient’s health. Under these circumstances, particularly when the mass is one centimeter or less in size, the doctor may recommend a "watch and wait" (also called active surveillance and watchful waiting) approach, repeating the scan in three to six months. If the later scan shows that the size hasn’t changed, the surveillance approach is continued. If it grows, however, the doctor will then do a biopsy.