Liver cancer

In its early stages, liver cancer does not usually cause any problems. A tumor in the liver is often discovered by accident. This article explains when liver cancer can be cured, and what treatment options there are in the advanced stage of the disease. 

At a glance

  • The most common type of liver cancer is hepatocellular carcinoma. 
  • Apart from that, there is also bile duct cancer of the liver. 
  • In its early stages, liver cancer does not usually cause any problems. 
  • The main risk factor of hepatocellular carcinoma is chronic liver damage, known as cirrhosis of the liver.  
  • Men suffer from malignant liver tumors more frequently than women. 
  • The treatment depends on the stage of the disease. 

Note: The information in this article cannot and should not replace a medical consultation and must not be used for self-diagnosis or treatment.

Liver cancer: doctor standing in front of an anatomical model of the human body. She has removed the liver from the model and is holding it in both hands.

What is liver cancer?

Liver cancer is a malignant tumor occurring in the liver. Medical practitioners refer to it as primary liver cancer.  

Ein Arzt sitzt gegenüber von einem Patienten. In der Hand hält er ein Modell der Leber. Mit einem Kugelschreiber zeigt er auf das Modell.

The majority of all liver cancers are hepatocellular carcinomas (HCC), which originate in liver cells. The primary liver tumors also include tumors in the bile ducts inside the liver (intrahepatic bile duct carcinomas) and more uncommon liver cancers such as sarcomas. Around 9,000 people get liver cancer every year in Germany.  

Die Illustration zeigt die Lage der Gallenblase und den Verlauf der Gallengänge im Körper. Dargestellt sind, von links nach rechts: Leber, Gallenblase, Gallengänge und Bauchspeicheldrüse.

Die Tumoren in den Gallengängen benennen Fachleute entsprechend ihrer Lage.

Important: Liver metastases are far more common, but they are not primary liver tumors. These are spreadings of a tumor that originally formed in another organ. Specialists refer to metastases in the liver as secondary liver cancer.

The difference between a primary tumor and a metastasis

The video below explains the difference between a primary tumor and a metastasis.

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Which symptoms can occur with liver cancer?

Often there are no symptoms indicating liver cancer to begin with. When someone has a complaint, it tends to be general: 

  • pain and a sense of pressure in the upper stomach 
  • general reduction in performance 
  • loss of appetite 
  • involuntary weight loss 

Sufferers usually get the liver cancer diagnosis at a late stage in the illness: a yellowing of the skin and eyes (jaundice), a much-enlarged liver (hepatomegalia), or a buildup of fluid in the abdomen (ascites) may then indicate a tumor in the liver.  

Bile duct cancer in the liver (also known as cholangiocarcinoma or biliary tract cancer) similarly only produces symptoms at a late stage. As well as the complaints already mentioned, dark urine, white-colored stools, and severe itching may also occur.   

General symptoms such as loss of appetite and general reduction in performance do not only occur in cases of cancer, but also often with benign illnesses. If these symptoms persist, a visit to the doctor is recommended. General Practitioners can already narrow down what is causing the symptoms and, if necessary, initiate further diagnostic steps with specialists.

What are the causes and risk factors for liver cancer?

The main risk factor for hepatocellular carcinoma is chronic liver damage, known as cirrhosis of the liver. In Germany it is most commonly linked to a chronic infection with the hepatitis C virus or high alcohol consumption.

Other risk factors include:

The risk factors for bile duct carcinomas in the liver are largely the same as those for hepatocellular carcinoma. There are also additional risk factors, such as chronic inflammation of the bile ducts, protruding (cystic) enlargements of the bile duct outside of the liver or bile duct stones in the bile ducts of the liver.

Häufigkeiten von Leberkrebs: Frauen (2015) 2880 Neuerkrankungen, Männer (2015) 6110 Neuerkrankungen.

In der Regel erhalten betroffene die Diagnose Leberkrebs in einem fortgeschrittenen Erkrankungsstadium. Männer sind zudem häufiger von Tumoren in der Leber betroffen als Frauen.

Are there any measures to prevent liver cancer?

In general, experts recommend a healthy lifestyle with a balanced diet and sufficient movement. These can help prevent liver disease.

By abstaining from alcohol and maintaining a healthy body weight, liver cancer in particular may be prevented.

Other preventive measures include:

  • a hepatitis B vaccination in compliance with the guidelines issued by the Standing Committee on Vaccination (STIKO) at the Robert Koch Institute 
  • treating those suffering from chronic infections with the hepatitis B or hepatitis C viruses
  • giving up smoking
  • drinking coffee

Is liver cancer screening available?

In its early stage, liver cancer does not usually cause complaints that point to a tumor in the liver. There is no statutory liver cancer screening program for the healthy population.

High-risk patients

Some people have a higher risk of getting liver cancer. These include patients with cirrhosis of the liver or hepatitis, caused by a chronic hepatitis B or hepatitis C infection or a fatty liver. Experts recommend that these patients get regular ultrasound checks on their liver and, if necessary, have blood tests. Determining the fibrosis stage also helps to better assess the risk of liver cancer for some high-risk patients. It indicates the extent to which the structures of the liver tissue have already changed.

How is liver cancer diagnosed?

Various methods are available to doctors to diagnose liver cancer.

An initial idea can be gained from an ultrasound scan (sonography) of the abdomen. To further clarify any suspect structure in the liver, doctors use imaging tests. To do this, they first inject a contrast agent into the patient’s vein. Images are then captured at specific time intervals. If liver cancer is present, doctors can usually identify the fact from the resulting sectional images.

The main contrast agent-enhanced imaging method for diagnosing liver cancer is magnetic resonance imaging (MRI). Other possible methods using contrast agents are computed tomography (CT) and sonography.

If the initial images fail to provide a definite diagnosis, the way forward depends on the size of the suspect area.

If imaging methods fail to provide a definite diagnosis twice in a row, the doctor will take tissue from the tumor (biopsy). This intervention is done from outside, through the abdominal wall. Patients are given a local anesthetic for this. The tissue removed is then examined under the microscope in the laboratory. This will secure the diagnosis.

Biopsies are a particular option if the liver lesions are small or if lesions are found in a cirrhosis-free liver.

Molecular pathology-based tests may also be useful in some cases, as they allow doctors to determine the properties of the tumor cells. This may help with planning future treatment.

Diagnosing bile duct carcinoma in the liver

The methods described above are used to diagnose bile duct carcinoma in the liver. Additional tests may also be required, such as:

  • a three-dimensional image of the bile ducts using magnetic resonance imaging (MRI) and contrast agents
  • an endoscopic method for showing bile ducts and possibly pancreatic ducts – this is called endoscopic-retrograde cholangio(pancreato)graphy, ERC(P)
  • percutaneous transhepatic cholangiography (PTC), in which the bile ducts in the liver, guided by imaging, are punctured with a thin needle and shown using contrast agents
  • an endoscopy of the abdominal cavity (laparoscopy) and removal of tissue samples

If it is not clear whether the issue is a primary liver or bile duct tumor or liver metastases, an endoscopy of the stomach and bowel may also be needed. This can be used to exclude a primary tumor that has come from those organs.

There is detailed information about the procedures and possible risks involved in imaging and surgical methods of diagnosing cancer on the website of the Cancer Information Service of the German Cancer Research Center (in German).

How is liver cancer treated?

Which therapy is best for hepatocellular carcinoma depends on the stage of the disease. Doctors use a special system they call the Barcelona Clinic for Liver Cancer (BCLC) staging system to determine the stage. Key criteria in this system are:

  • the number and size of tumors in the liver.
  • the spread and location of the tumor: is the tumor restricted to the liver, locally advanced or are there metastases?
  • the patient’s health: does the patient have chronic liver disease (cirrhosis of the liver) and how serious is it?
  • the patient’s liver function.

Patients should also receive psycho-oncological support to accompany their cancer treatment and should be informed about palliative care regardless of the stage of their disease. If a patient has a late-stage tumor, experts generally recommend palliative care.

If patients with hepatocellular carcinoma (HCC) also have a chronic hepatitis B or C viral infection, experts recommend that this be treated also.

Liver cell carcinoma – when a cure is possible

At an early stage of the disease, a cure is possible if doctors are able to completely remove the liver cancer. A liver transplant, surgery to remove part of the liver or local procedures are options in this case.

In the period until a liver becomes available for a transplant, the patient often has to be tided over with other treatments. This is known as bridging.

A patient sometimes also receives treatment before surgery to reduce the size of the tumor. This is known as downstaging.

As an alternative to surgery – in particular if the location of the tumor is unfavorable – doctors may instead destroy the tumor locally using various methods. These include, in particular, thermal (heat-based) treatments such as radiofrequency ablation (RFA) and microwave ablation (MWA).

Liver cell carcinoma – when no cure is possible

If a cure is no longer possible there are therapeutic methods that can alleviate the patient’s discomforts. Specialists call this palliative therapy. These therapies can slow down the growth of the tumor and improve the quality of life.

If the liver cancer is between the early and advanced stages, less invasive, localized treatments that target the tumor directly are considered. For example, chemotherapy drugs (TACE) or radioactive particles (SIRT) can be injected directly into the arteries that supply blood to the tumor. While they cannot cure the cancer, they slow down its growth. Prerequisites are good patient health, good liver function, and no metastases.

Is the disease already advanced, has it spread to the surrounding tissue or dispersed to other organs? If so, a (systemic) treatment acting on the entire body makes more sense – in this case, the effects should be monitored every 6 to 12 weeks with an imaging scan. In the case of systemic treatments, doctors use, for example, immunotherapy with immune checkpoint inhibitors or targeted therapy drugs. Targeted therapy drugs attack, in a targeted way, the biological properties of tumor cells that are important for the cancer’s progression.

In the final stage of the disease, and when they have discomfort, patients receive a supportive treatment. The aim of this supportive therapy is to alleviate tumor-related symptoms and improve the sufferer’s quality of life. This means that the measures taken are aimed at the patient’s symptoms.

Bile duct carcinomas in the liver

In early stages doctors remove bile duct tumors in the liver by operating, along with parts of the liver. Which part of the liver the surgeon removes depends on the vessels and bile ducts affected. The neighboring lymph nodes are usually taken out, too. Experts do not recommend a liver transplant outside of studies.

A supportive treatment may follow on after the operation. It is intended to lower the risk of the cancer returning. Doctors tend to favor chemotherapy in these cases. Specialists call this treatment phase “adjuvant therapy”.

Patients with tumors that cannot be surgically removed may receive localized treatments to destroy the tumor following consultation with their medical team.

If the disease is already well advanced, the treatment is based on the patient’s general condition. The aim of this palliative therapy is not to cure, but to check the disease and maintain the quality of life:

  • When a tumor is well advanced or metastasized, medication is an option. Doctors usually then favor chemotherapy.
  • To alleviate discomfort, a patient can also be given in situ therapies that destroy the tumor.
  • Depending on the individual situation, targeted therapies are also an option.
  • A supportive treatment can alleviate the sufferer’s onerous symptoms.

Liver cell carcinoma or bile duct carcinoma – what happens if the tumor comes back?

If a tumor grows back again following successful treatment, medical practitioners refer to this as a relapse. Another operation may be possible, provided that the tumor is limited to the liver. Otherwise, localized or systemic treatments will be considered.

What should be considered when it comes to operations? What are the procedures for chemotherapy and targeted therapies and what side effects do they have? There is detailed additional information on the website of the Cancer Information Service of the German Cancer Research Center (in German).

After liver cancer therapy: rehabilitation

Medical rehabilitation (rehab) after a cancer therapy is aimed at helping patients deal with the consequences of their illness and treatment as well as possible. A medical rehab program thus focuses on the personal medical history and existing limitations. 

A medical rehab program after liver cancer therapy may include: 

  • psychological support 
  • nutritional advice 
  • re-integration into working and social life 

The website of the Cancer Information Service of the German Cancer Research Center has the addresses of cancer advisory services and psycho-oncologists who provide outpatient psychotherapy. There is also a list of the main contacts for any questions relating to social law. 

What happens after the treatment? Liver cancer aftercare

Aftercare examinations help to quickly identify, and treat, any relapse or complications arising from the treatment.  

When a tumor has been completely removed, patients are regularly examined, first at short, then at longer intervals. Aftercare monitoring can stretch over a period of 5 years.  

If the cancer is incurable, regular follow-up checks will help to identify and treat any adverse symptoms at an early stage. For example, a doctor can prescribe medication for nausea, vomiting and fatigue. 

What are suitable points of contact for information about liver cancer?

Doctors with different specializations work closely together to treat liver cancer. Hospitals that are particularly experienced in treating patients with liver cancer can get certification to prove this. The German Cancer Society (DKG) regularly checks their compliance with certain professional requirements.  

You can find the addresses of the certified liver cancer centers on the OncoMAP website.

In relation to the quality of the surgical clinic/department, the German Society for General and Visceral Surgery (Deutsche Gesellschaft für Viszeralchirurgie) maintains a list of certified centers for surgical liver diseases.

Do you have further questions about dealing with the condition in everyday life and additional support options? You can find information about this on the website of the Cancer Information Service of the German Cancer Research Center (in German).

You can also contact the Cancer Information Service directly on freephone 0800 420 30 40 or by e-mail at krebsinformationsdienst@dkfz. 

In cooperation with the Cancer Information Service of the German Cancer Research Center (Krebsinformationsdienst des Deutschen Krebsforschungszentrums).

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