Tests before liver cancer treatment are the starting point for deciding whether local treatments such as radiofrequency ablation (RFA) or chemoembolization (TACE) are suitable, and which one fits best. The international BCLC 2022 staging system and the Japan Society of Hepatology guidelines both choose treatment by looking at three things together — the tumor (imaging), liver function (blood tests) and overall physical condition — and under BCLC 2022, very early and early stage (0 and A) liver cancer has an expected survival of more than five years.
Based on European and Japanese clinical guidelines, recommendations from the Society of Interventional Radiology (SIR) and patient information from UK NHS hospitals, this guide explains which tests are done and why, how to read the key numbers, and how to prepare in the days before the procedure.
About this guide · It summarizes tests and thresholds used in standard care in the US, Europe and Japan. Actual test lists and cut-offs vary by hospital and patient, and this article does not recommend any specific procedure.
Why the tests decide the treatment
Unlike many other cancers, liver cancer is not treated based on the tumor alone. Most patients also have chronic hepatitis or cirrhosis, so how well the remaining liver can tolerate treatment matters as much as tumor size. Pre-treatment testing is therefore designed to answer four questions.
- How many tumors are there, how large, and have they invaded blood vessels? → imaging
- How much liver function remains? → blood tests (Child-Pugh and ALBI scores)
- How active is the patient in daily life? → performance status (ECOG score)
- Is it safe to insert a needle or catheter? → clotting, platelets and current medicines
The first three set the stage and treatment direction; the fourth is a safety check for the day of the procedure. Each test is part of finding the treatment that fits you best. The basics of ablation and catheter treatments are explained in our RFA guide and IVR guide.
Imaging: size, number and location of tumors
The Japan Society of Hepatology recommends ultrasound every six months for high-risk people (cirrhosis, chronic hepatitis B or C), and every three to four months plus dynamic CT or MRI for the extremely high-risk group, such as cirrhosis caused by hepatitis B or C. Before a procedure, the following tests are usually done.
| Test | What it shows | Good to know |
|---|---|---|
| Ultrasound | Tumor location and the needle path | Ablation is often guided by ultrasound, so it matters whether the tumor is clearly visible |
| Dynamic CT | Multiple scans after contrast to see the tumor's blood-flow pattern | Liver cancer typically brightens in the arterial phase and fades later, which supports diagnosis |
| Dynamic MRI (including EOB-MRI) | Finds small tumors and counts them accurately | A liver-specific contrast agent (gadoxetic acid) helps detect small lesions |
| Chest CT, bone scans, etc. | Checks for spread outside the liver | Added when needed |
Based on the Japan Society of Hepatology guidelines (2019 update) and usual clinical practice.
Liver cancer can often be diagnosed without a biopsy when imaging shows the typical blood-flow pattern. When imaging is not conclusive, biopsy or contrast-enhanced ultrasound may be added. Tell your team in advance about contrast allergies or reduced kidney function so the imaging method can be adjusted.
Blood tests: liver function and tumor markers
The most important blood-test result is the liver function grade. The long-used Child-Pugh classification scores five items and groups patients into A (5–6 points), B (7–9) and C (10–15). Local treatments such as RFA and TACE are generally considered for class A or B patients.
| Child-Pugh item | How it is measured | What it means |
|---|---|---|
| Bilirubin | Blood test | The liver's ability to clear waste (high levels cause jaundice) |
| Albumin | Blood test | The liver's ability to make protein |
| PT-INR (clotting) | Blood test | The liver's ability to make clotting factors |
| Ascites | Examination, imaging | Fluid in the abdomen |
| Hepatic encephalopathy | Examination | Confusion or drowsiness |
The score is the sum of 1–3 points per item.
The BCLC 2022 update added the ALBI score (calculated from albumin and bilirubin) to distinguish patients more finely within Child-Pugh A. In Japan, the indocyanine green (ICG) 15-minute retention test is also widely used to assess liver reserve before surgery.
Tumor markers complement imaging. The Japan Society of Hepatology guidelines advise closer evaluation with dynamic CT or MRI when the following levels are exceeded.
| Tumor marker | Level prompting further imaging | Notes |
|---|---|---|
| AFP | 200 ng/mL or higher, or persistently rising | The longest-used liver cancer marker |
| PIVKA-II (DCP) | 40 mAU/mL or higher | Rises by a different pathway from AFP, so checking both improves accuracy |
| AFP-L3 | 15% or higher | The share of the AFP fraction most linked to liver cancer |
Kokudo N et al., Hepatology Research 2019 (Japan Society of Hepatology HCC guidelines).
Tumor markers are also used to follow progress. A pre-treatment value becomes the baseline for checking whether levels fall after treatment.
Staging (BCLC) and treatment choice
Once imaging and blood tests are in, the stage is set. Below is a summary of BCLC 2022 (Journal of Hepatology), widely used in Europe and the US.
| Stage | Tumor | Liver function and condition | Treatments considered first |
|---|---|---|---|
| 0 (very early) | Single tumor ≤2 cm | Preserved liver function, no symptoms | Radiofrequency or microwave ablation, or resection |
| A (early) | Single tumor, or up to 3 tumors ≤3 cm | Preserved liver function, ECOG 0 | Resection; ablation for ≤3 cm; transplant in selected cases |
| B (intermediate) | Multiple tumors beyond stage A, no vascular invasion | Preserved liver function, ECOG 0 | Chemoembolization (TACE); transplant or systemic therapy in selected cases |
| C (advanced) | Vascular invasion or spread outside the liver | Preserved liver function, ECOG ≤2 | Systemic therapy such as immunotherapy combinations |
| D | Any | Impaired liver function or ECOG >2 | Symptom relief and supportive care |
Reig M et al., Journal of Hepatology 2022. Actual treatment is decided case by case at a multidisciplinary meeting.
BCLC 2022 lists expected survival of more than five years for stages 0 and A and more than 2.5 years for stage B. The Japanese guidelines similarly recommend resection and RFA with equal weight for up to three tumors of 3 cm or less, resection first for tumors larger than 3 cm, and TACE first for four or more tumors. BCLC also uses the concept of "treatment stage migration": if one treatment is not feasible or not effective enough, the plan moves to the next option. The first choice is not the end of the road — it can be adjusted as things progress.
For specific procedures, see liver cancer RFA: steps and recovery, TACE plus RFA for intermediate liver cancer and Y-90 radioembolization for liver cancer.
Safety checks before the procedure: bleeding, medicines, fasting
Once the treatment is chosen, safety tests are done for the day of the procedure. The Society of Interventional Radiology (SIR) 2019 guidelines classify ablation and chemoembolization as procedures with moderate-to-high bleeding risk and recommend a clotting test (PT-INR) and blood count beforehand.
| Check | Typical threshold or advice | Basis |
|---|---|---|
| PT-INR | Corrected to 1.5–1.8 or lower before the procedure | SIR 2019 |
| Platelets | Consider platelet transfusion if below 50×10⁹/L | SIR 2019 |
| Warfarin | Example: stop 6 days before | Royal Devon (UK) leaflet |
| Aspirin, clopidogrel | Example: stop 7 days before (some hospitals continue low-dose aspirin) | Royal Devon and Cambridge University Hospitals leaflets |
| Rivaroxaban, apixaban, NSAIDs | Example: stop 2 days before | Royal Devon leaflet |
| Fasting | From 4 hours before (Royal Devon) to from midnight before (Cambridge, general anaesthetic) | Royal Devon and Cambridge leaflets |
Medicine stop times are hospital examples. Always follow your prescribing doctor and treating hospital, and never stop medicines on your own.
Low platelets or a high INR are common with cirrhosis. These numbers do not automatically rule out a procedure; in many cases the procedure goes ahead after transfusion or medicine adjustment to meet the thresholds. Also tell your team about diabetes medicines (to avoid low blood sugar while fasting) and any contrast or drug allergies. UK hospital leaflets advise arranging someone to take you home and stay with you for 24 hours.
Records to bring to an overseas consultation
When requesting a consultation at a hospital in Japan or another country, your test results are the basis of the medical assessment. Preparing the following speeds things up.
- Dynamic CT or MRI from the last three months (DICOM files on CD or USB) with radiology reports
- Recent blood results: bilirubin, albumin, PT-INR, platelets, creatinine, AFP, PIVKA-II
- Hepatitis B or C status and antiviral treatment history
- Previous treatments (surgery, procedures, medicines) with dates
- Current medicines (especially blood thinners) and allergies
Overseas hospitals may repeat some tests under their own protocols, but earlier scans let doctors compare how the tumor has changed over time, which is very helpful for planning. See also five questions to ask before an RFA consultation.
Questions to ask your care team
- What is my Child-Pugh score and ALBI grade?
- What is my BCLC stage, and which treatment do you recommend first?
- Is the tumor clearly visible on ultrasound, or will CT guidance or another approach be needed?
- Do my platelet and INR levels require any preparation before the procedure?
- Which of my medicines should be paused, and when can I restart them?
Frequently asked questions
Do I always need a biopsy before liver cancer treatment?
Not always. In patients with risk factors such as cirrhosis, liver cancer is often diagnosed by imaging alone when dynamic CT or MRI shows the typical blood-flow pattern. A biopsy is done when imaging is inconclusive or another tumor type must be ruled out.
Can I still have ablation if my platelet count is low?
A low count does not automatically rule it out. The SIR 2019 guidelines suggest considering platelet transfusion when platelets are below 50×10⁹/L, so the procedure can often proceed after correction. The treating hospital makes the final decision.
When should I stop blood thinners?
It depends on the medicine. Examples from the Royal Devon hospital leaflet are warfarin 6 days before, aspirin or clopidogrel 7 days before, and rivaroxaban or apixaban 2 days before. These medicines may protect your heart or blood vessels, so always agree the timing with the prescribing doctor.
If my AFP is normal, does that mean I don't have liver cancer?
Liver cancer can be present even with a normal AFP. That is why doctors look at PIVKA-II, AFP-L3 and imaging together. A pre-treatment value is also useful for tracking how well treatment works.
This article is general information summarizing overseas official sources and papers, not medical advice. Please discuss treatment choices with doctors who have examined you.
Sources (checked October 22, 2026)
- Reig M, Forner A, Rimola J, et al. BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update. Journal of Hepatology. 2022;76(3):681-693.
- Kokudo N, Takemura N, Hasegawa K, et al. Clinical practice guidelines for hepatocellular carcinoma: The Japan Society of Hepatology 2017 (4th JSH-HCC guidelines) 2019 update. Hepatology Research. 2019;49(10):1109-1113.
- Patel IJ, Rahim S, Davidson JC, et al. Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions—Part II. Journal of Vascular and Interventional Radiology. 2019;30(8):1168-1184.
- Royal Devon University Healthcare NHS Foundation Trust. Percutaneous ablation of a liver tumour (patient information)
- Cambridge University Hospitals NHS Foundation Trust. Liver ablation: a guide for patients