On average, men are affected by liver cancer two to four times more often than women. The incidence increases with age and is highest in people over 70. Learn more here about why liver cancer often causes symptoms late in life, what risk factors exist, and how technological advances in modern medicine have led to a significant improvement in the situation for many patients.
At ERCM, the individual options for your treatment are always discussed and decided in partnership with you and an interdisciplinary treatment team.
We will clarify for you whether a precision radiosurgical treatment can be carried out successfully in our practice or whether another therapy might be appropriate for you.
The terms are closely related in both German and English: Leber & das Leben – liver & to live . In fact, we could only survive for hours, at most days, without a liver. Weighing approximately 1,500 grams, the organ lies well protected by the lower ribs in the right upper abdomen. Around 1.5 liters of blood flow per minute through fine supply channels. This means that in 24 hours, approximately 2,000 liters of blood pass through our liver.
As the largest metabolic organ, the liver performs numerous vital functions, including energy metabolism and the production of important enzymes. Stresses, such as those resulting from lifestyle, are not easily absorbed: The liver often suffers silently without symptoms. This is one reason why many liver diseases are diagnosed late.
Liver cancer is relatively rare in Germany, with just under 10,000 new cases annually [1, 2] . Yet, hepatocellular carcinoma (HCC) is the most common primary liver cancer in adults, accounting for approximately 90% of cases. Other primary liver tumors include cholangiocarcinoma, in which the bile ducts are also affected by tumor cells, and angiosarcoma.
The most important risk factor for liver cancer is liver cirrhosis [2, 3]. This term describes a progressive change in the typical lobular architecture of the liver. This results in a diffuse process with increasing damage to healthy tissue [4].
Robot-guided CyberKnife therapy can be a good treatment alternative for primary liver tumors – and especially metastases in the liver – for selected situations. The innovative and state-of-the-art radiosurgical technology enables you as a patient to receive extremely precise, effective, painless and comfortable treatment.
Modern tracking technology, for example, ensures that natural, breathing-related movements of the liver are precisely tracked during your treatment, and the therapy dose is automatically adjusted to each movement [5]. This allows the tumor to be targeted with a precise accuracy of less than 1 mm, while simultaneously minimizing damage to surrounding healthy tissue.
Therapy procedures using the CyberKnife precision robot also represent a new bridging option for patients with hepatocellular carcinoma on the liver transplantation waiting list [6].
In the case of liver tumors, a distinction must be made between primary liver tumors and metastases – i.e. metastases of a cancer outside the liver.
Primary hepatocellular carcinomas (HCC) are rare. They arise when liver cells themselves degenerate (primary tumor). Malignant tumors can develop, for example, as a result of chronic liver inflammation or, particularly, liver cirrhosis.
Liver metastases occur much more frequently than primary hepatocellular carcinoma. These metastases are metastases from other cancers, referred to as primary tumors. These include, primarily, the colon, stomach, breast, lung, or pancreas [7].
The symptoms of metastases in the liver are initially rather unspecific, including discomfort in the right upper abdomen or weight loss.
The most important risk factor for the development of primary liver cancer is liver cirrhosis.
Liver cancer often causes symptoms late and is therefore often detected late.
Possible signs may include:
As the liver disease progresses, jaundice (jaundice) can occur as the disease progresses.
A cirrhotic liver is associated with chronic inflammatory processes. Since liver cirrhosis is also the most important risk factor for primary hepatocellular carcinoma, affected patients should undergo a contrast-enhanced ultrasound approximately every 6 months as part of a systematic screening [3].
Chronic hepatitis C virus infections and excessive alcohol consumption are among the most common causes of liver cirrhosis in Germany. Chronic hepatitis B virus infection is another risk factor for liver cancer, even without liver cirrhosis [2].
Smoking also increases the likelihood of developing liver cancer [2].
Imaging techniques play a key role in the diagnosis. Various blood tests can also indicate liver cancer.
Imaging techniques
Contrast-enhanced ultrasound is a simple yet sensitive method for an initial assessment of the liver. If abnormalities are found, further cross-sectional imaging techniques may be used. Depending on the individual situation, these may include magnetic resonance imaging (MRI) or spiral computed tomography (spiral CT).
The aim of these examinations is to further specify the diagnosis and, in particular, to better assess the location and extent of the tumor for an individual therapy decision.
Modern cross-sectional imaging techniques have the great advantage of enabling three-dimensional treatment planning, which is particularly important for larger or anatomically more complex tumor formations [8].
While this may sound complicated, the medical community has been replacing the familiar term "non-alcoholic fatty liver disease" since 2023 to define the disease more precisely and free of stigma. In a healthy liver, only up to 5% of the cells contain fat droplets (fat vacuoles). Any fatty degeneration of the liver tissue beyond this level is referred to as fatty liver.
MASLD can also increase the risk of liver cancer. Metabolic dysfunction-associated steatotic liver disease is becoming increasingly common in Germany. It can be a consequence of lifestyle factors or diabetes, for example [2].
Only 15% of primary liver tumors are amenable to curative surgery. In medicine, we define "curative" as any measure aimed at completely restoring your health. In liver cancer, however, such curative options are reserved for very early (BCLC 0) and early (BCLC A) tumor stages with adequate liver function [3].
Liver surgery is now one of the standard procedures in tumor therapy. When integrated into multimodal treatment concepts that combine multiple therapeutic approaches, surgical intervention can significantly improve patient survival [8, 9].
Established treatment methods for primary liver cancer include:
Methods of targeted tissue damage through local ablative therapies include:
Advanced liver cancer
In advanced stages of the disease, various systemic treatment options are available, and their capabilities have evolved enormously in recent years. Although intermediate stage B liver cancer (BCLC) is still confined to the liver, it can no longer be treated surgically or with local ablative therapy because the disease already has multiple and/or very large tumor foci.
In such situations, studies have investigated, among other things, a treatment regimen combining transarterial chemoembolization (TACE) followed by robot-guided CyberKnife therapy. This combination demonstrated optimal efficacy and improved long-term patient survival compared to the use of these methods alone [10].
Multimodal therapy of metastases
The treatment of metastases is also often multimodal, combining different approaches in a patient-specific modular approach [9]. To ensure treatment decisions that best benefit you as a patient, a multidisciplinary team works closely together [8, 9]. This includes, for example, visceral surgeons, oncologists, radiosurgeons, interventional radiologists, and radiation medicine experts.
Surgery (resection) is also the treatment of choice for metastases, but in many cases, such an intervention is not feasible. For example, individual factors often significantly limit microsurgical options [8, 9]. These include age, other pre-existing conditions, the risk of postoperative liver failure, and extensive prior liver treatments, such as chemotherapy or previous surgeries.
Conventional radiation therapy is also subject to certain limitations due to the radiosensitivity of the surrounding healthy liver tissue, as well as the liver's mobility due to natural respiration. In these cases, robot-guided CyberKnife therapy can offer a good alternative, as it offers, among other things, the possibility of precise respiratory tracking.
Radiosurgical treatments using the image- and robot-guided CyberKnife system are an effective method for treating malignant diseases [6, 11]. They represent an effective tool for local tumor control in patients in selected situations, including primary hepatocellular carcinoma or liver metastases [5, 6].
Furthermore, radiosurgical therapy offers a promising regimen as a bridging measure before a planned liver transplantation [6].
Robot-guided, usually single-treatment CyberKnife therapy enables highly precise tumor treatment with high photon doses. This means cancer cells are targeted and destroyed with extreme precision, while protecting healthy surrounding tissue as best as possible.
Various scientific studies demonstrate the efficacy and safety of radiosurgical treatment in patients with primary hepatocellular carcinoma [6, 11]. Response rates of 60 to 90% are achieved.
The innovative CyberKnife therapy can also be used in combination with surgery.
Studies prove the effectiveness of modern radiosurgery
For liver metastases, local control rates of up to 100% have been reported two years after radiosurgical treatment [9]. Since CyberKnife therapy optimally protects surrounding tissue, treatment-related liver dysfunction and late complications are rare.
Compared to other procedures, radiosurgery is more comfortable for patients because it is painless and can be performed on an outpatient basis. Nausea may occur briefly after the treatment.
In summary, therapy with the CyberKnife precision robot represents an effective treatment method for liver metastases with a maximum tumor size of 6 cm each and a maximum of 5 metastases present (liver oligometastases), when surgery is not an option or desired for these patients [5, 12].
Other individual factors relevant for a treatment decision include general health and adequate liver function [5].
Overall, high-precision technology in radiosurgery (e.g., CyberKnife, ZAP-X) can expand the possibilities of multidisciplinary oncological treatment concepts by providing a safe, effective, and gentle treatment method for selected situations [12].
The increasing complexity of treatment options means that the decision regarding treatment should always be made with your individual life situation in mind. It is important to us that you, as well as your family and loved ones who support and accompany you, are able to fully understand and assess all aspects of your illness and its treatment options.
Together with our medical partners, we will accompany you on this journey and, together with our team, will ensure that you feel well looked after at ERCM right from the start.
For treatment inquiries, please use the contact form. You can also reach us by phone during our opening hours or via our social media channels.
Your request will be processed individually and promptly.
Most commonly, those affected complain of a deterioration in their general condition, loss of appetite and weight, and sometimes uncharacteristic upper abdominal pain. If the tumor is located in the central bile duct system, it can disrupt bile flow, resulting in jaundice (icterus).
An elevated concentration of white blood cells, a high erythrocyte sedimentation rate, and substances in the blood that are often produced in liver cancer (tumor markers) can indicate liver cancer. The tumor marker alpha-1-fetoprotein (AFP) plays a particularly important role here.
Liver cancer is a malignant tumor in the liver. Malignant tumor cells proliferate uncontrollably, invade surrounding tissue, and displace and damage it.
What's particularly insidious is that symptoms only appear at a late stage of the disease. Furthermore, nonspecific complaints are often initially attributed to other, less serious illnesses. This can sometimes lead to valuable time being lost before an accurate diagnosis is made. Symptoms of liver cancer include persistent abdominal pain in the right or upper middle abdomen.
In recent years, careful patient selection, technical advances in modern medicine, and the use of risk scores for individual prognosis assessment have led to a significant improvement in the situation for many affected patients \[9\]. Scientific studies confirm that the best treatment outcomes are achieved through multidisciplinary and multimodal therapy concepts based on a combination of different treatments.
If liver cancer is detected early, there is a chance of cure. In advanced stages or when liver function is severely impaired, liver cancer is no longer curable, and the prognosis for those affected is poor. However, treating physicians can slow tumor growth and alleviate cancer-related symptoms.
Individual cancer cells can also reach distant organs via lymphatic vessels and bloodstreams. There, they can settle and multiply again, forming secondary tumors (metastases). In liver cancer, these metastases can occur in the lungs, adrenal bones, or brain, for example.
[1] Zentrum für Krebsregisterdaten am Robert Koch-Institut, Berlin; Stand 07.12.2023: https://www.krebsdaten.de/Krebs/DE/Content/Krebsarten/Leberkrebs/leberkrebs_node.html#:~:text=Leberkrebs%20ist%20zwar%20relativ%20selten,und%20M%C3%A4nnern%20um%2017%20Prozent. [letzter Zugriff: 01.12.2024]
https://www.krebsdaten.de/Krebs/DE/Content/Krebsarten/Leberkrebs/leberkrebs_node.html
[2] Robert Koch-Institut (Hrsg.) und die Gesellschaft der epidemiologischen Krebsregister in Deutschland e.V. (Hrsg.), Krebs in Deutschland für 2019/2020 (14. Ausgabe). Berlin 2023; ISBN 978-3-89606-323-6.
https://www.krebsdaten.de/Krebs/DE/Content/Publikationen/Krebs_in_Deutschland/krebs_in_deutschland_node.html
[3] Gairing, S. J., Müller, L., Penzkofer, L., Stoehr, F., Michel, M. et al., Diagnostik und Therapie des primären Leberzellkarzinoms, Gastroenterologie 2022;17:403-412.
https://doi.org/10.1007/s11377-022-00636-5
[4] Schreiner, P., Pfisterer, D., Krögerxis, A., Continuing Medical Education: Neu diagnostizierte Leberzirrhose, Teil 1, Hogrefe Praxis 2016;105(8):429-434.
https://doi.org/10.1024/1661-8157/a002317
[5] Ihnát, P., Skácelíková, E., Tesař, M., Penka, I., Stereotactic body radiotherapy using the Cyberknife system in the treatment of patients with liver metastases: state of the art, Onco Targets Ther. 2018;11:4685-4691.
https://doi.org/10.2147/OTT.S165878
[6] Rentsch, M., Runge, M., Thomas, M., Drefs, M., Andrassy, J., et al., Cyberknife Radiochirurgie als potenzielle Bridging-Strategie zur Lebertransplantation für Patienten mit hepatozellulärem Karzinom und Leberzirrhose, Z Gastroenterol. 2014;52:KC076.
https://doi.org/10.1055/s-0034-1386378
[7] Drebber, U., Dries, V., Dienes, H. P., Kasper, H. U., Lebermetastasen. Inzidenz und Verteilung. Eine Untersuchung aus dem Leber-Register der Universität zu Köln, Z Gastroenterol. 2005;43:P377.
https://doi.org/10.1055/s-2005-920160
[8] Kniepeiss, D., Talakić, E., Schemmer, P., Interventionelle und chirurgische Therapie non-kolorektaler Lebermetastasen, Tumor Diagn u Ther. 2021;42:585-597.
https://doi.org/10.1055/a-1557-7043
[9] Stintzing, S., von Einem, J., Fueweger, C., Haidenberger, A., Fedorov, M., Muacevic, A., Long-term Survival in Patients Treated with a Robotic Radiosurgical Device for Liver Metastases, Cancer Res Treat. 2018;51(1):187-193.
https://doi.org/10.4143/crt.2017.594
[10] Jiang, C., Jing, S., Zhou, H., Li, A., Qiu, X., et al., Efficacy and Prognostic Factors of Trans-Arterial Chemoembolization Combined With Stereotactic Body Radiation Therapy for BCLC Stage B Hepatocellular Carcinoma, Front. Oncol. 2021;11:640461.
https://doi.org/10.3389/fonc.2021.640461
[11] Schoenberg, M., Khandoga, A., Stintzing, S., Trumm, C., Schiergens, T. S., et al., Cyberknife Radiosurgery – Value as an Adjunct to Surgical Treatment of HCC? Cureus. 2016;8(4):e591.
https://doi.org/10.7759/cureus.591
[12] Stintzing, S., Hoffmann, R. T., Heinemann, V., Kufeld, M., Rentsch, M., Muacevic, A., Radiosurgery of liver tumors: value of robotic radiosurgical device to treat liver tumors, Ann Surg Oncol. 2010;17(11):2877-2883.
https://doi.org/10.1245/s10434-010-1187-9