Hepatobiliary/Liver Cancer

Home » Hepatobiliary/Liver Cancer » Diagnosis, Staging

Questions to Ask Your Doctor About Your Cancer
(Free Handout)

Diagnosis

Common symptoms include abdominal pain, weight loss, weakness, loss of appetite, vomiting, and jaundice (yellowing of the skin and eyes). Physical signs include abdominal distention caused by enlargement of the liver (hepatomegaly), ascites (water in the abdominal cavity), enlargement of the spleen (splenomegaly); and wasting and fever.

In addition, paraneoplastic syndromes (changes in tissues, remote from the primary tumor, which are indirectly caused by the presence of disease) may develop. Such syndromes may include low blood sugars, elevated cholesterol levels and red blood cell counts, and sexual changes.

Laboratory tests performed include the following:

• measurements of the serum markers alpha feto-protein and PIVKA-II (protein induced by the absence of vitamin K)
• hepatitis serology tests
• liver function tests
• complete blood counts (CBC)
• coagulation profile

Imaging studies, such as magnetic resonance imaging (MRI scan), or computed tomography (CT scan) with angiophotography may then be performed. CT scans use a highly sensitive x-ray beam focused on a specific plane of the body. As this beam passes through the body, it is picked up by a detector, which transmits the information into a computer. The computer analyzes the information on the basis of tissue density and displays the results on a monitor, producing a picture of the cross-section of the body.

The images may be enhanced by using angiography, a procedure in which a very thin tube called a catheter is threaded into an artery; a contrast agent or dye is injected through the catheter into the bloodstream. The enhanced images enable the physician to see blood vessels in the liver and tumors more clearly. Angiography can help determine whether the tumor is primary or metastatic cancer.

Diagnosis is confirmed by either needle or open biopsy. Biopsy is the removal and microscopic examination of tissue for diagnosis of disease. In a needle biopsy, a long hollow needle is inserted directly through the skin and into an organ or tissue to secure the tissue sample. An open biopsy involves opening the body surgically to obtain the tissue sample.

Once the presence of cancer cells is confirmed, assessment of possible metastatic sites with CT scans of the head and chest, and a bone scan can be performed. After the results have been reviewed, the cancer can be staged and discussions regarding treatment options and the prognosis can take place.

Staging

The stage of a cancer is determined by the size and location in the body of the primary tumor, and whether it has spread to other areas of the body.

Staging involves using the letters T, N, and M to assess tumors:

• size of the primary tumor (T);
• degree to which regional lymph nodes (N) are involved. Lymph nodes are small organs located along the channels of the body's lymphatic system which store special cells that fight infection and other diseases); and
• absence or presence of distant metastases (M) - cancer that has spread from the original (primary) tumor to distant organs or distant lymph nodes.

Each of these categories is further classified with a number. Thus a T1-N1-M0 cancer would describe a T1 tumor, N1 lymph node involvement, and no metastases.

Once the T, N, and M components are determined, a "stage" of I, II, III or IV is assigned:

• Stage I cancers are small, localized and usually curable.
• Stage II and III cancers typically are locally advanced and/or have spread to local lymph nodes.
• Stage IV cancers usually are metastatic (have spread to distant parts of the body) and generally are considered inoperable.

TNM Staging System (hepatocellular carcinoma)

Primary Tumor
TX:	Primary tumor cannot be assessed.
T0:	No evidence of primary tumor.
T1:	Solitary tumor 2 cm or less in greatest dimension without vascular invasion.
T2:	Solitary tumor 2 cm or less in greatest dimension with vascular invasion, OR multiple tumors limited to one lobe, none greater than 2 cm and without vascular invasion, OR a solitary tumor more than 2 cm in greatest dimension without vascular invasion.
T3:	Solitary tumor more than 2 cm in greatest dimension with vascular invasion, OR multiple tumors limited to one lobe, none more than 2 cm with vascular invasion, OR multiple tumors limited to one lobe, any more than 2 cm in greatest dimension, with or without vascular invasion.
T4:	Multiple tumors in more than one lobe or tumor(s) involve(s) a major branch of the portal or hepatic vein.

Regional Lymph Node
NX: Regional lymph nodes cannot be assessed.
N0: No regional lymph node metastasis present.
N1: Regional lymph node metastasis present.

Distant Metastasis
MX: Presence of distant metastasis cannot be assessed.
M0: No distant metastasis present.
M1: Distant metastasis present.

Stage Groupings
Stage I: T1 N0 M0
Stage II: T2 N0 M0
Stage III: T1 N1 M0; T2 N1 M0; T3 N0 M0; T3 N1 M0
Stage IV A: T4 any N M0
Stage IV B: any T any N M1

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