Liver Cancer

If you’ve been told you need a liver biopsy, you might have some questions. What will the liver biopsy reveal? Will the procedure hurt? How long will it take to recover? 

Read on to find the answers to these and eight other questions patients ask me about liver biopsies.

What is a liver biopsy?

A liver biopsy is a procedure in which a doctor extracts a small amount of tissue from that organ using a needle and sends it off for examination under a microscope. 

Why might I need a liver biopsy?

When an ultrasound, CT scan or MRI shows something unexpected in your liver that cannot be explained based on imaging alone, a biopsy can help us obtain an accurate diagnosis — whether that turns out to be liver cancer, a benign condition or something else entirely. 

If a radiologist sees something suspicious in your liver on imaging and your physician is unsure of the cause, they may order a liver biopsy to figure out what’s going on. In patients with known cancer, the biopsy of cancerous lesions in the liver may also help guide treatment by looking for certain mutations. 

Are there different kinds of liver biopsies?

Yes. At MD Anderson, our interventional radiologists perform about 140 image-guided liver biopsies per month. We use ultrasound, CT or MRI imaging during biopsy procedures to help us determine the best place to insert the needle and collect samples.

Most liver biopsies are performed targeting a specific lesion or abnormality. The rest are non-targeted, or not taken from any particular lesion within the liver. A fair number of liver biopsies are performed for reasons other than a cancer diagnosis. 

Aside from liver cancer, what else can a liver biopsy detect?

Here are some conditions that a liver biopsy may reveal:

• abscess: a pus-filled pocket often caused by infection
• autoimmune disorders: includes inflammatory conditions such as auto-immune hepatitis
• cholangitis: inflammation of the bile ducts, which can be due to infection or inflammatory conditions like primary sclerosing cholangitis (PSC)
• cirrhosis: scar tissue in the liver
• cyst: a fluid-filled sac
• fatty liver disease: a build-up of fat within liver tissue; often seen with excess body weight
• focal nodular hyperplasia (FNH): a benign, or non-cancerous, lesion
• hemangioma: an abnormal collection of blood vessels that can mimic cancer on imaging
• hepatic adenoma: another type of benign tumor; uncommon
• infection
• inflammation 

Keep in mind this isn’t an all-inclusive list; sometimes there are other things that a liver biopsy may reveal. 

We also perform liver biopsies on patients who are in active cancer treatment because some therapies — such as chemotherapy and immunotherapy — can affect the liver. We monitor those patients’ liver function with blood tests, so we can quickly address any problems.

How long does a liver biopsy take?

The procedure itself usually takes 20 to 30 minutes, but sometimes it can take an hour or more. Depending on the complexity of the procedure, it could take as long as 45 to 90 minutes.

What are the risks of a liver biopsy?

The main risk is bleeding. We do everything we can to mitigate that risk and ensure patients can safely tolerate the biopsy. We use small needles specifically designed for biopsies. We typically ask patients taking blood thinners to stop these medications before a procedure. We also obtain bloodwork before any liver biopsy to assess clotting function and confirm that minimum parameters are met to allow for a safe procedure. 

In most situations, bleeding due to a liver biopsy is minimal and resolves on its own. Rarely, additional procedures may be needed to stop the bleeding. 

Another risk is pain. We may need to pass the needle in between ribs to access the liver, and there are many nerves there. In addition, the liver surface can be sensitive and may be an additional source of pain. Soreness after a liver biopsy can last for a few days. Most people will not have too much pain, though, and it’s easily treatable with over-the-counter pain relievers, such as ibuprofen or acetaminophen.

Infection is an additional risk, though it’s very uncommon.

Will I have to be put to sleep for a liver biopsy?

Not usually. Most patients only need local anesthetic and intravenous sedation to stay comfortable and relaxed during the procedure. Some people might need slightly deeper sedation than others, but it’s uncommon to need general anesthesia for a liver biopsy. The sedation needed for a liver biopsy may be administered by the Interventional Radiology team or a dedicated anesthesia team.

How painful is a liver biopsy?

The combination of local anesthetic and sedation usually keeps the process of getting to the liver itself fairly painless. Some people report feeling a little pain as the needle goes into the liver.  That’s why a little soreness is common afterward. 

Severe pain is unusual, though, and it can be a sign of something more serious, such as internal bleeding. In the rare cases when someone has a lot of pain after a liver biopsy, we will do a thorough examination, which may include additional ultrasound or CT imaging, to make sure we are not missing anything. 

Is a liver biopsy considered a serious procedure?

Any procedure involving a major internal organ is serious by definition. The risk of any procedure is never zero. But liver biopsies are considered minimally invasive procedures that are safe with a relatively low rate of adverse events.

How long do you have to stay in the hospital after a liver biopsy?

The vast majority of liver biopsies are performed in outpatient facilities, and patients go home the same day. We usually monitor you afterward for at least three hours. You will be asked to stay in bed and not move around too much. This is usually not a problem, as most people are still tired from the sedation.

How long does it take to fully recover from a liver biopsy?

Patients can usually return to their desk jobs or those that don’t require any physical labor the next day. We advise patients to avoid heavy lifting for at least a couple of weeks. After that, they can return to their normal activities.

Zeyad Metwalli, M.D., is an interventional radiologist who specializes in minimally invasive, image-guided liver and vascular interventions.

Request an appointment at MD Anderson online or call 1-877-632-6789.

The liver is your body’s largest organ. It’s responsible for digestion, blood clotting and helping get rid of toxins. But unlike other organs, it has two blood sources. This makes the liver vulnerable to cancer cells moving through the bloodstream. The cancers that most commonly spread to the liver through the bloodstream are colorectal, breast and lung cancers.

When cancer starts in the liver, it’s called hepatocellular carcinoma. This type of liver cancer can start as a single tumor or as multiple spots on the liver caused by heavy drinking, obesity or a long-term hepatitis infection. These conditions cause scarring and permanent damage, known as cirrhosis of the liver.

To learn more about liver cancer symptoms, diagnosis and treatment, we spoke with Emma Holliday, M.D. Here’s what she had to say.

What are common symptoms of liver cancer?

Many patients don’t experience any symptoms in the early stages of liver cancer. When symptoms do develop, they may include abdominal pain or bloating, fatigue, nausea, vomiting, and yellowing of the skin or eyes, known as jaundice. Keep in mind that these symptoms vary from person to person.

Are some people more likely to develop liver cancer?

Hepatocellular carcinoma is more common in men than women, and the average age of diagnosis is 63.

Patients with cirrhosis of the liver are more likely to develop hepatocellular carcinoma, so it’s important to understand what can lead to cirrhosis:

• Alcohol consumption: Alcohol should be avoided. Talk with your doctor about what that means for you.
• Chronic hepatitis infection: Hepatitis B and C increase your risk, so it’s important to seek treatment if you have either of these infections. New antiviral medications can treat both types.
• Non-alcoholic fatty liver disease: This is caused by a buildup of fat in the liver. You can lower your risk by maintaining a healthy weight, eating a plant-based diet and staying active.
• Genetic conditions: Hemachromatosis, Wilson disease, Alpha 1-antitrypsin deficiency, porphyria and other rare conditions can lead to cirrhosis. If you have a family history of liver cancer, talk with your doctor about whether you should meet with a genetic counselor.

What are screening options are available for liver cancer?

National guidelines recommend routine screening liver cancer screening for patients with cirrhosis. This includes a blood test for a cancer marker called alphafetoprotein as well as an ultrasound looking for any suspicious liver masses. This screening regimen is typically done every six months. Your doctor can advise if this is right for you.

How is liver cancer diagnosed?

Talk to your doctor if you have any liver cancer symptoms. Your doctor may order a CT scan or an MRI along with an alphafenoprotein blood test to look for cancer. In some cases, CT scans or MRI results, along with blood test results, may be enough to make a diagnosis. But if the images aren’t clear, your doctor may remove a tissue sample for closer examination by doing a biopsy.

How is liver cancer treated?

The type of liver cancer treatment your doctor recommends will depend on the tumor’s size and location, whether you have cirrhosis, and your overall health.

If the cancer is early stage and your liver is healthy, surgery may be an option. If the tumors are small and haven’t spread to nearby blood vessels, your doctor may suggest a liver transplant.

Sometimes surgery isn’t an option, especially if the tumor is too large to be removed safely or is in a difficult location. In these cases, your doctors may recommend radiation therapy, which uses an external beam of X-rays or protons to destroy tumors. They may also suggest radiofrequency ablation, which uses a needle-thin probe to deliver electric currents directly to the tumor, heating it until it’s destroyed.

Another approach is to prevent blood flow from reaching tumors through a process called chemoembolization. A needle is inserted into an artery in the groin, and a tiny tube is threaded into the artery that leads to the liver to deliver drugs to the tumor. Afterward, the artery is blocked to prevent blood flow to the liver. In some cases, patients may instead undergo radioembolization, where the doctor injects liquid containing tiny radioactive spheres that treat the tumor. 

Chemotherapy and immunotherapy may also be options for some patients.

What’s next for liver cancer treatment? Tell us about promising research developments and clinical trials here at MD Anderson.

Unfortunately, liver cancer is one of the most rapidly increasing types of cancer in the U.S. But we’re hopeful for the future based on new research. At MD Anderson, we have several clinical trials exploring new liver cancer treatments.

One clinical trial is comparing chemotherapy with a type of radiation called stereotactic body radiotherapy, which delivers a high dose of radiation precisely to the tumor while limiting exposure to healthy cells.

Another clinical trial is comparing proton therapy with intensity-modulated radiotherapy, and others are looking at T-cell therapy for patients with advanced liver cancer. MD Anderson is also investigating using microscopic glass beads called TheraSpheres to target tumors with internal radiation in a treatment called radioembolization.

What advice do you have for liver cancer patients?

There are many liver cancer treatment options, but not all options are right for all patients. And weighing through these treatment options can be overwhelming, so make sure you find a team of doctors you trust who can answer your questions and help you choose the right treatment for you.  

Request an appointment at MD Anderson online or by calling 1-877-632-6789.

When Gordon Drygalski was diagnosed with early-stage liver cancer in December 2023, several friends told him to go to UT MD Anderson for treatment.

Today, he’s cancer-free and happy that he took that advice.

Incidental finding leads to liver cancer diagnosis

Gordon has a history of ulcers and pancreatitis, so he contacted his gastroenterologist when he began having symptoms in late 2023. He made Gordon an appointment at a local hospital for scans.

“I’ve had scans before, and normally they take 10 minutes. This one took 30 minutes,” he recalls.

The next day, Gordon’s doctor called and said they found a spot on his liver that needed to be evaluated.

“It took three weeks to get a biopsy scheduled,” he says. “And after I had the biopsy, it took another two weeks to get my diagnosis. I wasn’t happy about that. You don’t mess around if there’s a possibility you have cancer.”

Gordon was diagnosed with hepatocellular carcinoma, the most common type of liver cancer that starts in the liver.

“It’s a miracle because my gastroenterologist was looking for ulcers or other issues in my gastrointestinal system and incidentally found the tumor in my liver,” he says. “Once I told my friends I had liver cancer, they immediately told me to see Dr. Kaseb at UT MD Anderson.”

Immunotherapy clinical trial successfully treats liver cancer

Gordon’s first appointment was Dec. 14, 2023. He lived in the Houston area, so it was pretty convenient to get to UT MD Anderson’s Texas Medical Center Campus.

“The first three days, I was all over the place getting blood tests and full body scans,” he says. “I was amazed I was able to get all that done so quickly, especially when it took so long just to get a biopsy at the previous hospital. UT MD Anderson handled everything efficiently.”   

Gordon had another biopsy, which confirmed his liver cancer diagnosis. It was stage 1B.

He met with gastrointestinal medical oncologist Ahmed Kaseb, M.D., to go over his treatment plan.

Since the cancer was caught early, it was still treatable.

“Dr. Kaseb told me, ‘I’m not here to treat you; I’m going to cure you,’” Gordon recalls. “After hearing I had liver cancer, all of my research said I was going to die. And he tells me he’s going to cure me. That felt amazing.”

Kaseb told Gordon about an immunotherapy clinical trial he was leading for patients with liver cancer that could be removed by surgery. During the trial, Gordon would be given combination immunotherapy and targeted therapy drugs – atezolizumab and bevacizumab – before surgery. The trial’s goal was to keep the cancer from growing and spreading and to help prevent the cancer from coming back.

UT MD Anderson’s previous work in this area led to the first-ever report of complete pathologic responses in liver cancer patients after neoadjuvant immunotherapy. After learning more about the trial and hearing that immunotherapy had been working well for other patients, Gordon decided to enroll.

The drugs were delivered intravenously, and he received treatment every three weeks. He received a total of three treatments.  

Gastrointestinal surgical oncologist Hop Tran Cao, M.D., spoke with Gordon about his health ahead of surgery.

“Dr. Tran Cao has the best bedside manner,” says Gordon. “He said the cause of my liver cancer was likely from me having diabetes, fatty liver disease and being overweight. He recommended I lose 30 pounds.”

A standard open surgery would have required a big incision and a longer recovery time. Instead, on April 1, 2024, Tran Cao performed a robotic-assisted partial hepatectomy to remove the cancerous growth.

Since the surgery, Gordon’s scans have shown no evidence of disease. He’s now on active surveillance; he comes to UT MD Anderson every six months for follow-ups and scans.

What makes UT MD Anderson special

Since completing treatment, Gordon has regained his strength. He’s still on a mission to lose 30 pounds, as Tran Cao suggested, and he stays active by playing softball and pickleball.

He’s thankful he chose UT MD Anderson and says every staff member is phenomenal.

“My care team is amazing, especially Dr. Kaseb’s physician assistant, Kristen Carter,” he says. “She’s got a child who plays baseball, and I play baseball, so we always chat about her son and how he’s doing during our appointments. I love it.”

He says the positive demeanor of everyone he meets here makes UT MD Anderson stand out from other hospitals.

He appreciates the smiling faces of the staff members at check-in on the gastrointestinal floor. And he often shares a laugh with the nurses when giving blood.

“I’ll joke and say, ‘By the size of these vials, I’m not going to have any blood left when we’re done.’ We always end up laughing,” he says. “Even though they’re treating patients with something as serious as cancer, every staff member at UT MD Anderson is always smiling and helpful. That really makes you feel comfortable.”

Request an appointment at UT MD Anderson online or call 1-877-632-6789.

Elastography is an imaging test to check the elasticity of tissue in your body. Stiffness in your tissue is often a sign of disease. Elastography is often used to check for disease in the liver.

Here, I’ll explain more about elastography, including the different types, how it helps detect liver disease and what happens during the procedure. 

What is elastography?

Elastography is a non-invasive test that measures tissue stiffness and elasticity in your body’s organs and structures. It is most often used to assess the liver, a test that is sometimes called liver elastography. If you have increased tissue stiffness in your liver, it may be a sign of disease.

Elastography can also be used to help diagnose:

• Thyroid nodules
• Breast lesions
• Conditions in the tendons

How does elastography help diagnose liver disease?

If elastography detects a lot of stiffness in your liver, it is usually a sign of liver fibrosis. Liver fibrosis is a buildup of scar tissue that, if left untreated, can progress to chronic liver disease like cirrhosis. Cirrhosis of the liver is the leading cause of hepatocellular carcinoma, the most common type of liver cancer.

Common causes of liver fibrosis include:

• Hepatitis B and Hepatitis C: Hepatitis B is a virus that spreads through infected blood, semen and other bodily fluids. Hepatitis C is a virus that spreads through infected blood.
• Alcoholic-associated liver disease (ALD): This develops from long-term, heavy alcohol use. ALD causes a buildup of fat in your liver, which leads to inflammation.
• Fatty liver disease: This condition, also known as metabolic dysfunction-associated steatotic liver disease (MASLD), is a buildup of fat in the liver. It is more common in people who have obesity, type 2 diabetes, high cholesterol levels in the blood and metabolic syndrome. It is not caused by drinking alcohol. Elastography does not detect fatty liver disease, per se, but when combined with an ultrasound or MRI, it does provide an overall assessment of the liver. So, both ultrasound and MRI are able to measure fat deposits and fibrosis. 

Your doctor might order an ultrasound or MRI elastography if you have abnormal liver function tests that suggest underlying liver disease. Or your doctor may want to see the extent of liver disease. For instance, if you have a fatty liver, they may want to see if you have fibrosis as well. This can help guide your treatment.  

What are the types of elastography?

There are two main types of elastography.

Ultrasound elastography

This type combines elastography with an ultrasound. Your radiologist may use different techniques to perform ultrasound elastography.

Point shear wave elastography: This technique measures the stiffness of your liver tissue in a specific location. The technology is built into the ultrasound machine, which delivers pulses into your tissue that create shear waves. The faster the shear waves travel through the tissue, the stiffer the tissue.

2D shear wave elastography: This technique works like point shear wave elastography. The difference is that instead of a single location, 2D shear wave elastography can measure stiffness across a larger area of tissue by creating a detailed 2D image.

Transient elastography (FibroScan®): Your doctor uses a handheld device called a transducer on your skin to send vibrations to your liver. The faster the vibrations move through the tissue, the stiffer the tissue.  

Magnetic Resonance Elastography (MRE)

This type of elastography is a test that is often combined with a standard MRI to measure how stiff your liver is.

During this test, your radiologist will place a little paddle on your skin covering your liver. This will create gentle vibrations that travel through the liver. The MRI will use magnets and radio waves to take detailed images and produce an elastogram that tracks how the waves move through your tissue. If the waves don’t move easily, the tissue is stiff.

Which test is right for me? 

Your healthcare provider will determine which type of elastography is right for you based on several factors, such as your weight, overall health, whether you’ve had previous surgeries and your personal preference.

How should I prepare for elastography?

Usually, you will need to fast for at least four to six hours before the test. This is because eating foods – especially those high in fat or sugar – can increase the stiffness in your liver tissue. This can affect the results of your elastography.

Let your doctor know if you have any medical devices, such as a pacemaker, or any metal in your body. These can affect MRE results, so your provider may recommend a different type of elastography for you.  

Your radiologist will provide detailed instructions on how to prepare for elastography.

Is elastography painful?

No. Elastography is a non-invasive test that is well tolerated by patients. There are no needles involved, and you should not feel any pain or discomfort.

How long does elastography take?

The time it takes to complete an elastography depends on the type of test you get.

In general, ultrasound elastography takes about 20 minutes. An MRE by itself takes about 15 to 20 minutes, but if you get one with an MRI, it could take an additional 15 to 30 minutes. Keep in mind, times may vary depending on the doctor or hospital that performs yours. In some cases, it may take longer.

What do my elastography results mean?

Your radiologist will read the shear wave elastography images or the MR elastogram, which are visual maps of your tissue stiffness, with results reported in terms of velocity in m/s or kilopascals for ultrasound elastography, and kilopascals for MREs.

The good news is you won’t have to worry about these specific metrics. The radiologist will analyze the test results and share a report with your doctor who ordered the elastography. Then, your doctor will go over the results with you. Your results will typically include your liver’s stiffness level and a fibrosis score – which measures how much scarring is present in your liver.

Here are possible results of a fibrosis score:

• F0 to F1: Your liver is normal, with minimal or no scarring.
• F2: There is moderate scarring in your liver.
• F3: There is severe scarring in your liver.
• F4: The scarring in your liver is very severe, which indicates cirrhosis.

If you have ultrasound elastography, your results will also include whether there is suspicion of compensated advanced chronic liver disease (cACLD). This is a stage of severe liver fibrosis or cirrhosis that may not have any symptoms.

Results may be:

• Normal or high probability of normal: You likely don’t have compensated advanced chronic liver disease.
• Suggestive of cACLD: There is a suspicion of compensated advanced chronic liver disease, but you may need other tests like a liver biopsy to confirm.
• Highly suggestive of cACLD: It is highly likely that you have advanced fibrosis or cirrhosis and need further evaluation.

It’s important for doctors to catch compensated advanced chronic liver disease early before it progresses to decompensated advanced chronic liver disease (DACLD). This is an irreversible stage when cirrhosis becomes life-threatening. Symptoms can include ascites, gastrointestinal bleeding, jaundice and brain dysfunction.

Diagnosing cACLD can allow the doctor to intervene and treat the liver disease, so that it regresses back into the normal range. 

How accurate is liver elastography?

Liver elastography is an accurate non-invasive way to measure the stiffness of tissue in your liver. This can be done to diagnose liver fibrosis. Your doctor also may order a liver elastography to assess whether the fibrosis gets better after treatment, or if the disease progresses.

Some things may affect the results of your liver elastography. These include:

• Eating foods high in fat or sugar before the test
• Having obesity
• Inflammation in the liver
• Having a lot of iron in your liver or metal from prior surgeries, such as cholecystectomy clips

In some cases, other diagnostic tests, such as a liver biopsy, may be recommended.

What are my treatment options after an elastography?

Chronic liver disease is treatable in its early stages and can often be reversed.

Treatment often depends on the cause of liver disease. If you have hepatitis, doctors can prescribe antiviral medications to decrease the viral load on your liver. Diet and lifestyle changes are often recommended to treat fatty liver disease. These changes may include getting more exercise and eating a healthy diet with less fats. If you have alcohol-associated liver disease, eliminating alcohol removes the toxin that is damaging your liver. 

Once the fibrosis in your liver is severe (cirrhosis), the scarring cannot be undone. Your doctor will discuss treatment options to stop or slow further damage to the liver.

Tests like elastography are important to help doctors find liver disease early. They’re able to reverse the damage to the liver and cure the disease.      

Leonardo Marcal, M.D., is an abdominal imaging specialist at UT MD Anderson.

Request an appointment at UT MD Anderson online or call 1-877-632-6789.