Information on liver cancer

Definition: What is liver cancer?

Representation of liver tumors

Hepatocellular carcinoma (HCC) is the most common form of malignant liver tumors. This form of liver cancer is one of the most common tumor diseases, affecting 6% of men and 3% of women.

Hepatocellular carcinoma (HCC, liver cell cancer) is caused by mutations in the liver's own cells, which lead to the affected cells multiplying uncontrollably. Risky diseases that are frequently associated with this type of cancer include hepatitis B (a viral infection of the liver), liver cirrhosis (shrunken liver) and hemochromatosis (iron storage disease).

The liver is the central metabolic organ of the human body. A failure of this organ is incompatible with life.

Liver cancer symptoms

The signs of liver tumors are very unspecific. Patients usually complain of:

Weakness
Loss of performance
Lack of appetite
Weight loss

Late signs of the disease are:

Feeling of pressure in the upper abdomen
Protrusions of the abdominal wall
Yellowing of the skin (jaundice)
5% of tumors only become apparent late due to tumor metastases (tumor spread to other organs).

How is liver cancer diagnosed?

The course of the disease usually progresses very quickly.

If liver cancer is suspected, a blood sample is taken first. The blood sample is then examined in the laboratory, with the analysis focusing in particular on liver-specific parameters that can provide information about the presence of hepatitis (inflammation of the liver) or liver cirrhosis (shrunken liver). In addition, the level of the alpha1-fetoprotein (AFP) parameter is often determined. This is used as a tumor marker in liver cell cancer screening in patients with hepatitis B and C and is used as a progression parameter in cases of already diagnosed liver cell cancer.

If risk factors for liver cell cancer are present, the diagnosis can be made by detecting a tumor with special contrast agent behavior in imaging. The tumor can be detected using ultrasound, computed tomography or magnetic resonance imaging.

If the tumor is detected, further imaging tests are often performed to determine the exact extent of the tumor and the presence of any tumor metastases. A CT or MRI of the abdomen, a CT of the chest and a skeletal scintigraphy (a nuclear medicine examination) are often used for this purpose.

In some cases, a biopsy of the tumor is also performed to confirm the diagnosis (removal of liver tissue through the abdominal wall using a special needle). However, a biopsy is not necessary in all cases and must be considered depending on the previous illnesses and the available findings.

What types of liver tumors are there?

In addition to hepatocellular carcinoma (HCC), which is the most common form of liver cancer, there is cholangiocellular carcinoma (bile duct carcinoma), hepatoblastoma, sarcoma or cystadenocarcinoma, all of which are rather rare.

Even more common than HCC (liver cell cancer) are liver metastases, i.e. tumor metastases in the liver that originate from a tumor that is primarily located in another, distant region of the body (malignant secondary tumors of the liver). These can be metastases from colon carcinoma (colon cancer) or breast cancer, for example. Since the liver is the main metabolic organ in humans and has a very high blood supply, it is also the organ that is most frequently affected by tumor metastases.

Benign liver tumors include liver cell adenomas, focal nodular hyperplasia (FNH), cavernous hemangiomas or liver cysts.

How is hepatocellular carcinoma treated?

The exact therapeutic procedure depends in particular on the stage of the cancer. In most cases, however, a so-called multimodal therapy concept is used, i.e. different types of therapy are combined with one another.

Therapy procedures in early stages with the aim of healing (curative intent):

The best survival rates for malignant liver tumors are achieved by complete surgical removal (resection) of the tumor by a specialist in liver surgery. However, this procedure is only possible if the liver function is sufficiently good.

If severe liver cirrhosis (shrunken liver) is also present, a liver transplant can also be considered. Since a waiting time of 6-18 months for a donor organ must usually be expected, so-called ablative (tumor-reducing) procedures are usually used in the meantime, which aim to reduce the size of the tumor or at least prevent further tumor growth.
Alternative treatment methods for tumor reduction (so-called ablative therapy methods):
The ablative, tumor-reducing therapy measures are usually carried out with palliative intent. However, they are sometimes also used with curative intent, i.e. in patients in whom a cure for the cancer is sought. For example, these measures can be used to bridge the waiting time until a liver transplant (see above).

If the tumor cannot be removed by surgery, it can be reduced using radiofrequency ablation (= RFA). Electrodes are inserted into the tumor tissue. A pulsed high-frequency current is then applied, which causes the tumor cells to die due to the heat generated. By reducing the tumor, a previously inoperable tumor can be "reduced" to an operable stage. Radiofrequency ablation is the standard method among ablative procedures in Germany.

If radiofrequency ablation cannot be used, a percutaneous ethanol injection (PEI) can be used to shrink the tumor. In this case, 95% alcohol is injected directly into the tumor tissue using a fine hollow needle, which leads to the death of the tumor cells.

In advanced stages of the disease, the tumor can also be reduced using selective internal radiotherapy (SIRT, radioembolization). Radioactive material is introduced directly into the tumor. This method reduces the size of the tumor and protects the surrounding tissue as best as possible.

Another option for reducing the tumor is the use of transarterial chemoembolization (TACE). In this case, a chemotherapeutic agent is injected directly into the cancerous tissue using a vascular catheter that is advanced to the tumor. These tumor-reducing measures can be bridging measures until liver transplantation, resection or palliative interventions.

A highly modern method for reducing tumors in liver cancer is HIFU therapy (ultrasound-guided high-intensity focused ultrasound). In this treatment approach, the tumor is "exposed" to ultrasound from the outside using high-energy ultrasound waves. This heats the tumor cells so much that they "boil" and the tumor is reduced in size. This method is still in its early stages, but numerous studies have already shown that HIFU therapy is a successful therapeutic approach for reducing tumors with only minimal side effects.

Radiation:
Thanks to the development of more precise radiotherapy methods, the importance of radiotherapy for liver cancer is increasing. Stereotactic radiosurgery, brachytherapy or proton therapy can achieve good results in controlling the disease, especially in advanced stages. The targeted use of radiation means that healthy tissue is largely spared. This enables many patients to survive for a long time and is generally well tolerated.
Palliative systemic therapy in advanced stages of cancer:
Palliative systemic therapy includes drug therapies that are used in advanced stages of the disease, affect the entire body and are intended to inhibit tumor growth.

Palliative systemic therapy methods are used in the following cases:

Surgical tumor removal is not possible
Liver transplantation is not possible
Progression of the cancer despite treatment with ablative (tumor-shrinking) methods

First-line therapy: In patients with preserved liver function, the combined administration of the drugs Atezolizumab and Bevacizumac (both antibodies) is recommended in first-line therapy. Alternatively, the tyrosine kinase inhibitors Sorafenib or Lenvatinib can also be administered.

Second-line therapy: If first-line therapy with Sorafenib fails and liver function is preserved, other drugs such as the tyrosine kinase inhibitors Regorafenib and Cabozantinib or the antibody Ramucirumab can be used.

Palliative symptom-oriented therapy:
Palliative symptom-oriented therapy is used when systemic therapy is not possible due to poor liver function and is intended in particular to alleviate symptoms and thus improve quality of life. Symptoms such as severe itching or excruciating pain are treated with medication. Psycho-oncological or pastoral treatment and care from a palliative care service are also part of the palliative therapy concept.

What are the chances of recovery from liver cancer?

Overall, the chances of recovery from hepatocellular carcinoma are rather poor. Patients with known liver cirrhosis (shrunken liver) should therefore be screened approximately every six months using ultrasound and laboratory tests (tumor marker AFP = alpha-fetoprotein).

What is the life expectancy of liver cancer?

If left untreated, the average survival time after a diagnosis of liver cancer (HCC) is around 4 months. After surgical resection, patients survive an average of 3 years, and 20-50% of patients are cured after partial liver resection (removal of all tumor tissue).
Bonn University Hospital doctors are specialists in the treatment of liver cancer.
Anyone suffering from liver cancer wants the best medical care for themselves. That is why the patient asks themselves, where can I find the best clinic for liver cancer treatment?

As this question cannot be answered objectively and a reputable doctor would never claim to be the best doctor, one can only rely on the experience of a doctor. The more patients with liver cancer a doctor treats, the more experienced he becomes in his specialty.

Liver cancer specialists are therefore specialists in gastroenterology, oncology, visceral surgery, radiology and nuclear medicine who have specialized in the treatment of liver tumors. Their experience makes them the right people to contact for planning, implementation or second opinions.