Can Liver Cancer Be Definitively Ruled Out?

[BobWest]

I had a kidney stone (6.5 mm) removed via ureteroscopy/laser lithotripsy on 11/18/05 because it became lodged at the ureto-vesicular junction after 12 days of excruciating right flank pain (6-8 hrs. per day) as it passed all the way down the right ureter.  The day after the surgery, I experienced a different pain in the RUQ of the abdomen extending under and into the rib cage, back, and right shoulder area.  I had a contrast helical(spiral) CT scan done on 11/21/05, and everything was normal except for sclerotic lesions found on my 4th and 7th left ribs (opposite side of the pain), which were believed to be bone islands by the radiologist. I had a bone scan done on 12/6/05, which showed two "hot spots" on my 10th left rib, which I later found out via a complete skeletal survey and a second reading of the CT scan (as they were not found on the initial read) to be two small sclerotic lesions on the 10th left rib (in addition to two small sclerotic lesions on the 7th left rib, one sclerotic lesion on the 4th left rib, and one sclerotic lesion on the right distal femur).  The nuclear medicine physician's report simply stated that the findings were "suggestive of a benign process". I had an abdominal ultrasound done on 12/21/05, and the liver, pancreas, and gall bladder were seen as normal, except that a gallstone was found (without ductal dilatation, w/o widening of gall bladder walls, etc. and thus, was adjudged not to be a potential source of my RUQ adominbal/right rib cage pain).  As shown below, lab tests were done before surgery (on 11/17/05), on 12/5/05, on 12/19/05, and, finally, on 1/10/06.  The reason for the gap between the last two tests was to allow time for the liver enzymes to normalize, as multiple physical exams, CT scan, and abdominal ultrasound seemed to rule out liver, pancreatic, gall bladder, or kidney cancer, and the source of the elevated liver enzymes was hypothesized to be medicine (which was discontinued on 11/25/05).  A colonoscopy was done on 11/28/05, and an upper endoscopy was done on 1/4/06, both of which were perfectly normal.  Further, the cystoscopy done in conjunction with the ureteroscopy on 11/17/05 seemed to rule out bladder cancer.  My PSA level is about 0.8 (ref. range 0-4), and thus, seems to rule out prostate cancer (along with a DRE done by my urologist).  My main problem is that I am still experiencing no diminution of my RUQ abdominal/right rib cage/right upper shoulder pain (after almost 2 months), and my liver enzymes became significantly elevated between 11/17/05 and 12/19/05, although they seem to have come down significantly between 12/19/05 and 1/10/06, as seen below (AST down from 53 to 32 (ref. range 3-50 U/L) (ALT down from 209 to 77 (ref. range 3/60 U/L).

My principal QUESTION is, in light of the above facts, and the below lab results, can I definitively rule out liver cancer?  In this connection, would a liver tumor too small to be detected by CT scan and ultrasound cause the AST and ALT levels to rise significantly from well within normal limits the day before the surgery to well outside of normal limits (at least with respect to the ALT)about a month later (i.e., from 11/17/05 to 12/19/05), with a significant rise between 11/17/05 and 12/05/05?  Would a liver tumor cause the AST and ALT levels to rise as they did in a one month period, and then fall (although the ALT is still mildly elevated) in the next one month period, when they were perfectly normal just prior to the first one month period?  Would a liver tumor cause pain before a rise were seen in the AST and ALT levels? Would a liver tumor cause pain without being detectable via ultrasound and helical CT scan?  Based on my below lab results, can you provide any explanation as to what may have caused my abnormal LFTs? What recommendations do you have regarding further lab tests, imaging studies, etc.? (BTW:  The medications I was given post-surgery were Cipro (2 tablets per day for 6 days, oxycodone 3 5 mg tablets per day for 7 days, and phenazopyridine (2 200mg tablets per day for 3 days).  After a severe hypertensive episode on 12/5/05 (180/112 blood pressure), I was prescribed and have been taking ever since, Amlodipine (Norvasc) (1 5 mg tablet per day) and Ramipril (Altace) (1 2.5 mg capsule per day).  A CT-Angiogram was also performed on 12/8/05 to rule out renovascular hypertension as the cause of my blood pressure.  The findings were normal. Also, several blood and urine tests have been taken to rule out pheochromocytoma, multiple myeloma, and carcinoid tumors.  All those tests were negative.  

11/17/05:  ALT: 32 (reference range 3-60 U/L)  AST: 16 (reference range 3-50 U/L) (this was taken one day prior to ureteroscopy/laser lithotripsy to remove impacted kidney stone) Alkaline Phosphatase: 82 (ref. range 20-125 U/L)LDH: 171 (100-250 U/L) GGT: 59 (ref. range 3-80 U/L)Cholesterol: 162 (ref. range <200 MG/DL) Triglycerides: 82 (ref. range <150 MG/DL) HDL Cholesterol: 50 (ref. range > 39 MG/DL) LDL Cholesterol: 96 (ref. range 0-100 MG/DL) VLDL Cholesterol: 16 (ref. range 8-40 MG/DL) (CBC, Sodium, Potassium, Chloride, and Iron all within normal ranges)
12/5/05:  ALT: 104 (see ref. range above)  AST:  36 (see ref. range above)
12/19/05: ALT: 209 (see ref. range above)  AST: 53 (see ref. range above) Glucose: 104 (ref. range 65-99 MG/DL) Urea Nitrogen: 12 (ref. range 7-25 MG/DL) Creatinine: 1.1 (ref. range 0.5-1.6 MG/DL) Albumin: 4.8 (ref. range 3.5-4.9 G/DL) Bilirubin, Total: 0.5 (ref. range 0.2-1.5 MG/DL) Alkaline Phosphatase: 103 (ref. range 20-125 U/L) Globulin, Calculated: 2.6 (ref. range 2.2-4.2 G/DL)Iron, Potassium, Chloride, and Sodium: all within normal range
1/10/06:  ALT: 77 (see ref. range above) AST: 32 (see ref. range above)CRP: 2 (ref. range <8 mg/L); ESR: 1 (ref. range 0-15 MM/HR) CK, Total: 184 (ref. range 0-200 IU/L)Urea Nitrogen: 12 (ref. range 7-25 MG/DL) Glucose: 102 (ref. range 65-99)Creatinine: 1.0 (ref. range 0.5-1.6 MG/DL) Bilirubin, Total: 0.9 (0.2-1.5 MG/DL)Alkaline Phosphatase: 88 (ref. range 20-125 U/L)LDH: 159 (ref. range 100-250 U/L) GGT: 64 (ref. range 3-80 U/L)Albumin: 4.7 (ref. range 3.5-4.9 G/DL)  Globulin, Calculated: 2.6 (ref. range 2.2-4.2 G/DL) Cholesterol: 198 (ref. range <200 MG/DL) Triglycerides: 67(ref. range <150 MG/DL) HDL Cholesterol: 50 (ref. range > 39 MG/DL) LDL Cholesterol: 128 (ref. range 0-100 MG/DL) VLDL Cholesterol: 13 (ref. range 8-40 MG/DL) (CBC, Sodium, Potassium, Chloride, and Iron all within normal ranges)

[hannieboo]

My father has liver mets from ocular melanoma.

His last test results came back as this:

LFT:
Urea 6.4
Sodium 140
Potassium: 4.8
Clor: 105
CO2: 26
Gluc: 7
Creat: 81
LD: 1479
AST: 115
ALT: 48
ALP: 465
Amylase: 88
Tot BilirubinL 9
INorg Phos: .87
Cal 2.28
Album: 30


I thought the Creatinine and Bilirubin were very important, but they are fine. It is the LD, AST, ALT and ALP numbers that re frightening.

Any comments?

S

[BobWest]

Would a liver tumor cause the AST and ALT levels to rise as they did in a one month period, and then fall (although the ALT is still mildly elevated) in the next one month period, when they were perfectly normal just prior to the first one month period? Would a liver tumor cause pain before a rise were seen in the AST and ALT levels? Would a liver tumor cause pain without being detectable via ultrasound and helical CT scan?

[Kevin Pho, MD]

With the normal imaging tests thus far, this would make liver cancer unlikely.

You can pursue further imaging tests, including an MRI of the liver, or an MRCP to evaluate the biliary ducts if cancer in the RUQ area is of concern.  

Although not used for screening, the alpha-fetoprotein level in the blood correlates with liver tumor size and extent.  This blood test is used in those who have had a previous diagnosis of cancer.  

It is unclear as to what is leading to the fluctuations in the liver function tests.  If the enzymes continue to rise, you can consider a liver biopsy for further evaluation.

These options can be discussed with your personal physician.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
kevinmd_b