Fatty Liver: Concerns About Liver Cancer Risks and Diagnosis

Fatty liver disease

Hello Dr.
Yang,
In March, I experienced occasional sharp pain and discomfort in my right upper abdomen.
Given my family history, where my uncle and his two sons passed away due to liver cancer, I was concerned about a hereditary risk for liver cancer.
Therefore, I underwent blood and urine tests in March, all of which returned normal results.
The details are as follows:
1.
Liver function tests were all normal (AST, ALT, Alk-P, Total Protein, Albumin, Globulin, A/G Ratio, T-Bilirubin, D-Bilirubin, TTT, ZTT, Mucoprotein, HBsAg (-), Anti-HBs (+), Anti-HAV (-), alpha-fetoprotein: 21, Anti-HAV (-)).

2.
Special tests (Alpha-fetoprotein: 8.16, CEA: 0.57, PSA: 1.05, Prolactin: 8.17, CA 19-9: 18.2, CA-125: 9.07, SCC: 0.14, ANA (-)).

At that time, it was believed that there were no issues.
However, this month I experienced similar problems, so I went to a large hospital for further examination, including an ultrasound.
Last week, the doctor mentioned, "You have fatty liver, but it is not evenly distributed.
Strangely, there is a localized circular area." Therefore, the doctor suggested testing for liver cancer markers and cholangiocarcinoma markers.
If any abnormalities are found, a CT scan or angiography will be performed immediately; if not, I will return for a follow-up in three months, as any abnormalities should show growth after March.
I have the following questions:
1.
Given that the sensitivity of alpha-fetoprotein for liver cancer is not high, with 1 in 3 individuals having small liver cancers while alpha-fetoprotein levels remain normal, can this be a reason to delay testing for three months? If it is not simply fatty liver, could this delay worsen my condition?
2.
What is the rate of misdiagnosis for fatty liver in ultrasound examinations? Is it clearly distinguishable as fatty liver or something else? Based on past cases, have there been instances of unevenly distributed fatty liver with localized circular areas?
3.
Based on the current information, what should my condition be considered?
4.
If the attending physician believes there is no issue, can I request further imaging such as a CT scan? Some medical literature suggests that if there are concerns, at least two of the following should be checked: CT scan, angiography, or ultrasound, to avoid missing a diagnosis and to facilitate early treatment.
I appreciate your help in addressing my concerns.
Thank you.

LL, 30~39 year old female. Ask Date: 2002/07/17

Dr. Yang Peizhen reply Gastroenterology and Hepatology

In response to the questions you raised, my answers are as follows: (1) Although alpha-fetoprotein (AFP) is considered a marker for liver cancer, it specifically pertains to hepatocellular carcinoma (HCC).
Approximately two-thirds of small HCC cases have AFP levels within the normal range, so it cannot be solely relied upon to rule out liver cancer.
Generally, aside from diffuse hepatocellular carcinoma, liver cancer typically presents with well-defined margins on abdominal ultrasound.
However, in cases of severe fatty liver disease, the peripheral margins may appear more indistinct.
Therefore, if a patient has fatty liver, we must be very cautious in verifying any suspicious areas, as no imaging study can achieve 100% accuracy.
If it is not merely fatty liver, the condition may change in three months, but the extent is uncertain.
(2) Based on your abdominal ultrasound description, the most common finding is uneven fat accumulation, which can sometimes lead to what is referred to as a "pseudotumor" appearance.
Localized areas may show round hypoechoic shadows, typically representing normal liver tissue without fat, most commonly near the gallbladder.
This occurs because fatty liver tissue appears brighter on ultrasound, while non-fatty liver tissue appears darker, creating the shadowing effect.
An experienced hepatobiliary specialist is unlikely to misinterpret fatty liver; however, even with normal tumor markers, the possibility of liver cancer cannot be completely excluded.
(3) In Taiwan, chronic hepatitis B and C are the primary causes of hepatocellular carcinoma, with alcohol abuse being another significant factor.
Since you do not have any of these three risk factors, the likelihood of liver cancer is considerably reduced, and your condition is more likely to be uneven fatty liver.
(4) Computed tomography (CT) is quite helpful in differentiating between fatty liver and malignant tumors, but due to its radiation exposure, we do not recommend its indiscriminate use unless necessary.
Furthermore, angiography is an invasive procedure that can be painful and has some side effects, but it plays a decisive role in distinguishing between malignant and benign liver tumors, so we reserve it for situations where absolutely necessary.
Since I have not seen the actual results of your imaging studies, I cannot provide you with specific recommendations.
If your physician is uncertain or has concerns, they should arrange for further testing.
I hope my response is satisfactory!

Reply Date: 2002/07/17

More Info

Understanding Fatty Liver: Concerns About Liver Cancer Risks and Diagnosis
Hello, thank you for your detailed inquiry regarding your health concerns related to fatty liver and the potential risks of liver cancer. It is understandable to be worried, especially given your family history of liver cancer. Let’s address your questions systematically.

1. Alpha-fetoprotein (AFP) Sensitivity and Timing of Follow-up: You are correct that AFP is not a perfect marker for liver cancer. While elevated levels can indicate the presence of hepatocellular carcinoma (HCC), many patients with small tumors may have normal AFP levels. The decision to wait three months for a follow-up is likely based on your current stable liver function tests and the absence of significant symptoms. However, if you are experiencing ongoing discomfort or have concerns about the potential for rapid changes, it is reasonable to discuss with your physician the possibility of earlier imaging studies, such as a CT scan, to rule out any malignancy.

2. Ultrasound Accuracy in Diagnosing Fatty Liver: Ultrasound is a commonly used tool for diagnosing fatty liver disease. It can typically distinguish between fatty liver and other liver conditions, but it is not infallible. The accuracy can vary based on the operator's experience and the patient's body habitus. In cases where fatty liver is present, it can sometimes appear heterogeneous, leading to confusion. There have been documented cases where focal lesions in a fatty liver were misinterpreted, which is why further imaging, such as a CT scan or MRI, might be warranted if there are atypical findings.

3. Current Health Status: Based on the information you provided, your liver function tests are normal, and your AFP levels are within the normal range. This is reassuring. However, the presence of fatty liver, especially if it is not uniformly distributed, warrants close monitoring. Fatty liver itself is generally not a direct cause of liver cancer, but it can progress to non-alcoholic steatohepatitis (NASH), which has a higher risk of developing into cirrhosis and subsequently liver cancer. Maintaining a healthy lifestyle, including a balanced diet and regular exercise, is crucial in managing fatty liver.

4. Requesting Further Imaging: If you feel that your concerns are not being adequately addressed, you absolutely have the right to request further imaging studies. It is important to advocate for your health. If your physician believes that the current findings do not warrant immediate further investigation, you can express your concerns and ask for a second opinion or a referral to a specialist in hepatology. Medical literature often supports the idea that when there is uncertainty, especially with a concerning family history, further investigation can be justified.

In conclusion, while fatty liver itself is a common condition and often manageable with lifestyle changes, your family history and current symptoms warrant careful monitoring. It is essential to maintain open communication with your healthcare provider, express your concerns, and advocate for your health. Regular follow-ups and appropriate imaging can help ensure that any potential issues are identified early, allowing for timely intervention if necessary. Thank you for your questions, and I hope this information helps clarify your concerns.

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