What blood work is recommended for patients suspected of having liver cancer?

Blood Work for Suspected Liver Cancer

For patients with suspected liver cancer, a comprehensive blood work panel should include liver function tests (ALT, AST, ALP, GGT, bilirubin, albumin, PT/INR), complete blood count, hepatitis panel, and alpha-fetoprotein (AFP) measurement. 1

Core Laboratory Tests for Suspected Hepatocellular Carcinoma (HCC)

Essential Blood Tests

1. Liver Function Tests

   • Alanine aminotransferase (ALT)
   • Aspartate aminotransferase (AST)
   • Alkaline phosphatase (ALP)
   • Gamma-glutamyl transpeptidase (GGT)
   • Total and direct bilirubin
   • Albumin
   • Prothrombin time/International Normalized Ratio (PT/INR)

2. Tumor Markers

   • Alpha-fetoprotein (AFP)
     • While elevated in only 50-75% of HCC cases, levels >400 ng/mL have high positive predictive value when combined with imaging findings 1
     • Important caveat: AFP can be elevated in other conditions including pregnancy, intrahepatic cholangiocarcinoma, some colon cancer metastases, lymphoma, and germ cell tumors 1

3. Hepatitis Panel

   • Hepatitis B surface antigen (HBsAg)
   • Hepatitis B surface antibody
   • Hepatitis B core antibody (HBcAb)
   • HBcAb IgM (for suspected acute viral hepatitis)
   • Hepatitis C antibodies 1

4. Additional Tests

   • Complete blood count (CBC)
   • Blood urea nitrogen (BUN)
   • Creatinine
   • Platelet count (surrogate marker for portal hypertension) 1, 2

Interpretation and Follow-up

When to Suspect HCC Based on Laboratory Results

• AFP >400 ng/mL with a focal hypervascular liver lesion >2 cm on imaging is highly suggestive of HCC 1
• Abnormal liver enzymes (ALT, AST, ALP, GGT) are present in approximately 90% of HCC cases 3
• Declining albumin and prolonged PT/INR may indicate impaired liver synthetic function 2

Viral Load Assessment

• For patients who test positive for HBsAg, HBcAb IgG, or HCV antibodies, viral load confirmation is essential
• Patients with positive viral load should be evaluated by a hepatologist for antiviral therapy consideration 1

Special Considerations

Patients with Abnormal Baseline Liver Tests

• Baseline ALT elevations are common in oncology patients (31% in those with liver metastases)
• Baseline total bilirubin elevations are less common (5% in patients with liver metastases) 1
• For patients with abnormal baseline values, monitoring trends is more important than absolute values 1, 2

Risk Factors That Should Prompt Testing

• Chronic hepatitis B or C infection increases HCC risk by approximately 7-fold and 4-fold, respectively 4
• Liver cirrhosis (3-year cumulative HCC risk of 12.5% vs. 3.8% for chronic hepatitis) 4
• Elevated baseline AFP, even without imaging findings 4

Common Pitfalls to Avoid

• Relying solely on AFP for diagnosis (normal in up to 30% of HCC cases) 1
• Failing to interpret liver tests as a panel rather than individual tests 2
• Overlooking the need for hepatitis testing in all suspected HCC cases 1
• Assuming all LFT abnormalities indicate primary liver cancer rather than metastatic disease or non-malignant conditions 2

Remember that while blood work is essential for evaluation, imaging studies (ultrasound, CT, or MRI) remain crucial for definitive diagnosis of HCC, with biopsy reserved for cases where imaging is inconclusive 1.