How is Liver Cancer Diagnosed?

This is the sixth page in the Understanding Liver Cancer Guide. This guide was developed by the HealthTree Education Team and was last updated and reviewed on June 20, 2026.

If your doctor suspects you may have liver cancer, or if surveillance testing has found an abnormal area in your liver, there are several tests and procedures that can confirm a diagnosis. Some tests are used to confirm whether cancer is present. Others are used to learn more about the cancer, how far it has spread, and how well your liver is functioning, which is important for planning treatment. You may not need all of the tests listed here.

Physical examination and medical history

Your doctor will begin with a thorough medical history and a physical examination. They will ask about your symptoms, your history of liver disease, hepatitis infections, alcohol use, and other risk factors. During the physical exam, your doctor will feel your abdomen to check for an enlarged liver, a hard mass, or other abnormalities. They will also look for signs of liver disease such as jaundice, swelling in the legs, and changes in the skin.

Blood tests

Several blood tests help evaluate your liver health and check for signs of liver cancer:

• Liver function tests. These tests measure enzymes, proteins, and substances in the blood that reflect how well the liver is working. Abnormal results can indicate liver damage or reduced liver function.
• Alpha-fetoprotein. Alpha-fetoprotein, often called AFP, is a protein that is produced in large amounts during fetal development. In adults, high levels of AFP in the blood can be a sign of hepatocellular carcinoma. However, AFP is not always elevated in liver cancer, and elevated AFP can also occur with other liver conditions, so it is not used alone to diagnose liver cancer.
• Complete blood count and metabolic panel. These tests check for anemia, bleeding problems, and kidney function, all of which are important when planning treatment.
• Hepatitis B and hepatitis C testing. If not already known, your doctor will check whether you have hepatitis B or hepatitis C, which are important risk factors for liver cancer and affect treatment decisions.
• Clotting tests. The liver makes proteins that help blood clot. Clotting tests help assess liver function and are important before any surgery or invasive procedure.

Imaging tests

Imaging tests are central to the diagnosis of liver cancer. Unlike many other cancers, liver cancer can often be diagnosed with imaging alone, without a biopsy, if the imaging findings are typical.

• Ultrasound. An ultrasound uses sound waves to create images of the liver. It is painless and does not use radiation. Ultrasound is the main surveillance test used for people at high risk for liver cancer. When a suspicious lesion is found, additional imaging is needed for further evaluation.
• CT scan. A computed tomography scan takes detailed cross-sectional X-ray images of the abdomen and can show the size, location, and number of liver tumors. A specific pattern of blood flow seen on a contrast-enhanced CT scan is often enough to diagnose hepatocellular carcinoma without a biopsy.
• MRI scan. Magnetic resonance imaging creates detailed images using magnetic fields and radio waves. MRI is often more sensitive than CT for detecting liver tumors, especially small ones. Like CT, MRI with contrast can show the pattern of blood flow that is typical of hepatocellular carcinoma. MRI is often the preferred imaging test for liver cancer diagnosis and planning.
• PET-CT scan. A positron emission tomography scan combined with a CT scan can help detect cancer in lymph nodes and distant sites. It is less commonly used for primary liver cancer than for other cancers because hepatocellular carcinoma does not always show up well on PET scans.
• Bone scan. If there is concern that cancer has spread to the bones, a bone scan can be used to check for this.

Biopsy

A biopsy removes a small sample of tissue from the liver to be examined under a microscope by a pathologist. In many cases of hepatocellular carcinoma, a typical appearance on CT or MRI in a person with cirrhosis or hepatitis B is sufficient to make the diagnosis without a biopsy. A biopsy is more often needed when the imaging findings are not typical, when the diagnosis is uncertain, or when the cancer type is other than hepatocellular carcinoma.

• Needle biopsy. A thin needle is inserted through the skin and into the liver to remove a small sample of tissue. This is usually done under ultrasound or CT guidance to make sure the needle reaches the right area. The main risk of a needle biopsy is bleeding, which is a greater concern when liver function is reduced.
• Surgical biopsy. In some cases, a biopsy is taken during surgery or laparoscopy.

Assessing liver function

Because most people with liver cancer also have underlying liver disease, assessing how well the liver is working is just as important as diagnosing the cancer itself. The Child-Pugh score and the MELD score are two systems commonly used to evaluate liver function and help determine which treatments are safe and likely to be effective. These scores take into account factors such as bilirubin levels, clotting ability, the presence of fluid in the abdomen, and mental status.

Biomarker and molecular testing

Biomarker testing is becoming a standard part of liver cancer care. It is especially important for patients being considered for targeted therapy and immunotherapy:

• PD-L1 testing. Measures a protein on tumor cells that may predict response to immunotherapy drugs such as atezolizumab and pembrolizumab.
• Mismatch repair and microsatellite instability testing. Checks for defects in the DNA repair system. Cancers that are mismatch repair deficient or microsatellite instability-high may respond to certain immunotherapy drugs.
• Next-generation sequencing. A broad test that looks for mutations in many cancer-related genes at once. It can identify specific targets that may be treatable with targeted therapies.
• FGFR2 testing. Relevant for intrahepatic cholangiocarcinoma, where FGFR2 fusions are common and can be targeted with specific drugs.
• IDH1 and IDH2 testing. Mutations in these genes occur in some intrahepatic cholangiocarcinomas and can be targeted with approved drugs.