Hepatocellular carcinoma is the term used to describe cancer arising from liver cells (so-called hepatocytes).

Primary liver cancer is a rare disease in Europe; secondary liver tumours, such as liver metastases from other cancers, are much more common in the liver. In Germany, an average of 5 people per 100,000 inhabitants are diagnosed each year, with men being affected three times as often as women. The peak age is between 60 and 70 years.

The main cause of liver cancer is liver cirrhosis, i.e. the final stage of chronic liver disease. Patients with liver cirrhosis due to chronic hepatitis B infection or hepatitis C infection and patients with liver cirrhosis due to chronic harmful use of alcohol or other liver diseases have the highest risk of developing liver cancer.

There are no characteristic signs of liver cancer. They may include pressure pain in the right upper abdomen, weight loss, abdominal fluid formation, a worsening of pre-existing liver cirrhosis and fever.

If cancer of the liver is suspected, a number of examinations are required to make a diagnosis, which are briefly described below.

Medical history and physical examination

During a detailed consultation, you will tell the doctor about all your symptoms and previous illnesses. A thorough physical examination will then be carried out.

Laboratory tests

A series of blood tests will be carried out on you to provide information about your general condition and certain organ functions. Common changes in liver cancer concern the liver values, the blood count and the coagulation function. The AFP tumour marker known for liver cancer has a poor sensitivity and is therefore becoming less and less important.

Ultrasound examination (sonography)

Due to its inexpensive availability and the absence of side effects or radiation exposure, ultrasound is now the first and most important examination for suspected liver cancer. Combined with ultrasound contrast agents, a high level of informative value can be achieved. The position of the liver, air overlay or the presence of a lot of abdominal fluid can make the assessment more difficult, so that further imaging procedures are used.

Computer tomography (CT)

Computed tomography is a painless, special X-ray examination (with a contrast agent administered into the vein) that illuminates the body layer by layer. This allows the location and size of the tumour, its exact spread and any metastases to be determined.

Magnetic resonance imaging (MRI)

Magnetic resonance imaging is not an X-ray examination, but is based on the effects of magnetic fields. It is very important in the diagnosis of liver cancer in order to visualise the liver cancer as well as the location and size of the tumour and its exact spread.

In order to determine the most suitable therapy, the exact extent to which the tumour has spread, i.e. the tumour stage, must be determined using the diagnostics described above before starting therapy. The TNM classification (see table below) is used for this purpose. In the TNM classification, T stands for the size and extent of the primary tumour, N stands for the number of affected lymph nodes and M stands for the occurrence and localisation of distant metastases (tumour metastases).

TNM classification UICC 2010

The treatment options depend on the stage of the tumour and the liver function. In general, the earlier the liver cancer is detected and the better the liver function is, the more favourable the treatment options are. Curative treatment options include not only surgery or liver transplantation, but in certain stages also so-called locoregional procedures, which treat liver cancer directly on site in various ways (see below).

Curative (curative) surgery

For patients at a very early stage with preserved liver function and favourably located tumour nodules, curative surgery is the treatment of first choice. In rare cases, surgical removal of tumour nodules (without cure) can also be used to bridge the gap until a possible liver transplant.

Liver transplantation

A curative measure for a small number of patients who must fulfil special criteria. The advantage of liver transplantation is that it cures both liver cancer and liver cirrhosis as a risk factor for the development of liver cancer, but it is also a treatment option with many complications and is costly.

Locoregional treatment methods

Well suited for patients who are not suitable for surgical treatment due to the severity of the underlying liver disease or due to an advanced stage of liver cancer. Various locoregional procedures are available (the most frequently used are listed below):

• Percutaneous ethanol injection therapy (PEI), in which alcohol is injected into the tumour through the skin in several sessions under imaging guidance.
• Radiofrequency ablation (RFA) or microwave ablation, in which heat is generated in the tumour under imaging control, causing heat destruction of the liver cancer.
• Transarterial chemoembolisation (TACE), in which an oily contrast agent and a chemotherapeutic agent are injected through the artery into the liver cancer in patients with no chance of cure.

Drug therapy

Neither "classic" chemotherapies nor hormonal therapies have been able to show convincing efficacy against liver cancer to date. The standard drug therapy for advanced liver cancer is currently the administration of sorafenib (Nexavar®) in tablet form. This is an active substance that inhibits the growth of liver cancer cells in various ways. However, this therapy is not possible with poor liver function

The course of the disease depends very much on the treatment options for the tumour, which depend in particular on the location of the tumour nodules, but also on the function of the remaining liver.