What are the Symptoms of Liver Cancer

Liver cancer

Liver cancer is a malignant tumor in the liver that usually metastasizes to the lungs and bones. A distinction is made between

  • secondary liver cancer, i.e. daughter tumors (metastases) of other types of cancer
  • primary liver cancer that develops directly from cells in the liver

Definition: What is Liver Cancer?

The liver (Greek: hepar) is the largest gland in the human body and so that central organ of the entire metabolism. Your most significant tasks are

  • Production of important proteins
  • Utilization of food components
  • Production of the bile fluid
  • Breakdown and excretion of metabolic products, pharmaceuticals and toxins.

If malignant neoplasms develop in the cells of the liver, it is called liver cancer. A distinction must be made between primary liver cancer and secondary liver cancer. If malignant tumors develop directly from the cells of the liver, the term is used primary liver cancer. If the malignant tumor forms in the liver, but not from its cells, but from cells of other tissues that continue to grow in the liver, this is called daughter tumors of other organs (liver metastasis) secondary liver cancer.

The location of the liver © Sebastian Kaulitzki / Fotolia

Secondary liver cancer

Metastases from various types of tumors can form daughter tumors in the liver. Colon cancer, stomach cancer and breast cancer, among others, are types of cancer that spread to the liver via the bloodstream and cause liver cancer. The basic disease is then in one advanced stage. In some cases it is not possible to determine which underlying disease caused the metastasis. Then this is called cancer of unknown primary (CUP syndrome, cancer of unclear origin).

Primary liver cancer

Primary liver cancer is divided into hepatocellular carcinoma (HCC) and cholangiocellular carcinoma (CCC), the latter starting from the bile ducts and invading the liver.

Primary liver cancer metastasizes mostly in the lungs and bones. Liver cell carcinoma (HCC) is the fifth most common malignant tumor worldwide. Nevertheless, compared to other types of cancer (e.g. prostate cancer, breast cancer), HCC is one of the more rare types of cancer. Around 600,000 people fall ill worldwide every year. In comparison, 6,000 people fall ill in Germany every year. The incidence has doubled over the past 20 years. This is associated with the higher rate of new hepatitis C cases.

Men are 3 times more likely to be affected than women. Cholangiocellular carcinoma is even rarer.

Causes of Liver Cancer

Primary liver cancer is usually due to liver cirrhosis or molecular-genetic causes.

Cirrhosis of the liver

Liver cirrhosis (end-stage chronic liver disease) is considered to be Main factor for the development of malignant liver cancer. The chronic decline of healthy liver tissue and the subsequent regeneration result in a disturbed tissue architecture with nodular changes. In addition, an enormous amount of connective tissue (fibrosis) is formed. Due to these scarred areas, which can take up more than 50 percent of the entire tissue of a cirrhotic liver, the blood flow to the liver is disturbed and the blood in the area of ​​the portal vein accumulates in front of the liver. One speaks of portal hypertension.

Chronic Alcohol abuse and chronic Viral infections (Hepatitis B and Hepatitis C) are the main causes of cirrhosis. In liver cirrhosis with underlying hemochromatosis (congenital disorder of the iron metabolism), the risk of the disease is increased several times. In addition, the Aspergillus flavus mold forms aflatoxins (B1), which have a carcinogenic effect on the liver. Avoid contaminated foods such as nuts and certain grains.

The hereditary congenital alpha1-antitrypsin deficiency leads to liver cirrhosis due to the deficiency of protease inhibitors. If the body is permanently exposed to carbon tetrachloride, liver cancer can develop. Carbon tetrachloride is a solvent for fats and oils and plays a role in the manufacture of pesticides.

Molecular Genetic Causes

Molecular genetic causes are also under discussion as a cause of primary liver cancer. The FHIT tumor suppressor gene is disrupted in around 60 percent of tumor patients. The gene disorder inhibits the production of a large number of proteins and thus leads to uncontrolled cell growth. Long-term androgen abuse (for example by bodybuilders) can also promote the development of HCC.

The causes of cholangiocellular carcinoma are also not fully understood. The risk factors include

  • Bile duct stones (choledocholithiasis)
  • rare chronic inflammation of the biliary tract (primary sclerosing cholangitis)
  • Adenomas (benign growths) of the biliary tract, which can degenerate
  • Cysts in the bile duct (common bile duct cysts)
  • chronic parasitic liver diseases (for example liver fluke), which occur mainly in Asia

Liver cancer symptoms

Unspecific symptoms like

  • unwanted weight loss,
  • Loss of appetite,
  • Performance kink,
  • Upper abdominal pain,
  • Fever and
  • Night sweats

can be the first signs of a malignant tumor disease of the liver.

Other symptoms occur later and are usually the result of increased growth of the tumor.

  • Jaundice (jaundice): yellowing of the eyes, later also of the skin
  • itching
  • Tension pain in the right upper abdomen (capsular pain in the liver)
  • Ascites: Disturbance in the protein balance leads to an excessive accumulation of fluid in the free abdominal cavity and thus to an increase in circumference
  • Palpable tumor in the right upper abdomen as a sign of an advanced disease
  • Dark urine and light, discolored stools

If any of these symptoms occur, a doctor should be consulted.

Diagnosis of liver cancer

The diagnosis begins with the anamnesis (medical history). ask for

  • a profession in the medical field,
  • a trip or activity abroad,
  • frequently changing sexual partners without the necessary protection from sexually transmitted diseases as well
  • possibly previously diagnosed cirrhosis of the liver

are particularly important.

The physical examination follows the anamnesis. By palpating (touching) and percussion (tapping) the abdomen, the size and condition of the liver surface as well as any ascites can be clarified.

Blood collection

A blood sample with all important values, including the blood count and coagulation, for determination

  • possible anemia (anemia)
  • a disturbance in the synthesis capacity of the liver and increased cholestasis values ​​(disturbance of the formation of bile in the liver or its drainage through the biliary tract) and
  • a decrease in the tumor markers AFP and Ca 19-9, which are also increased in liver cancer, among other things,

can provide initial clues about the disease.


Then the doctor can perform a sonography (ultrasound). A large liver tumor can usually be shown well in the ultrasound examination. Also an existing cholestasis, free fluid in the abdomen and the assessment of the other upper abdominal organs can be done in slim patients problem-free and painless be assessed. Random diagnoses during an ultrasound examination are not uncommon in the context of other diseases.

Further research to diagnose liver cancer

If there is a well-founded suspicion of liver cancer, further examinations should be carried out:

  • Computed tomography (CT) and / or magnetic resonance tomography (MRT) of the abdomen with contrast agent administration to assess the extent of the tumor and any enlargement of the lymph nodes
  • Chest x-ray to rule out daughter tumors
  • Bone scintigram to exclude daughter tumors
  • Biopsy of the tumor (ultrasound or CT-assisted) to obtain tissue samples and differentiate the type of tumor (primary or secondary liver cancer)
  • If necessary, angiography (representation of the blood vessel system) in preparation for surgery or if the diagnosis is unclear

© zlikovec # 67501905 / Fotolia

Only by obtaining a tissue sample - this can be done by biopsy via puncture or by laparoscopy (laparoscopy) - the final diagnosis of liver cancer can be made. In rare cases, the actual primary disease (origin of the tumor colonization in the liver) cannot be clarified. Then further investigations are necessary to clarify the origin.

For further diagnosis of suspected metastases, a Gastroscopy (Gastroscopy) and one Colonoscopy (Colonoscopy), as stomach cancer, colon cancer or cancer of the pancreas first spread to the liver. But other types of cancer can also form metastases in the liver. Therefore, an extensive search for the origin of the disease is important. In very rare cases, however, this can remain unexplained even after an extensive search (CUP syndrome).

If cholangiocellular carcinoma is suspected, an initial ultrasound examination of the upper gastrointestinal tract (endosonography) and a subsequent mirroring of the biliary tract (endoscopic retrograde cholangiography: ERCP) is advisable for the diagnosis.

Treatment of liver cancer

The therapy for liver cancer depends on the size, extent and location of the tumor. In addition, the general condition of the patient plays a major role. The is a scale for evaluating the symptom-related limitation of activity, self-sufficiency and self-determination in patients with malignant tumors Karnofsky Index (Karnofsky performance status scale). At 100 percent there are no restrictions; the greater the restrictions, the more the percentage of the Karnofsky index is reduced. This scale can be used to clarify which therapy is most suitable for the respective patient. In order to make a therapy decision, it is important in which state the liver is, whether there is cirrhosis or the synthesis performance or detoxification are restricted.

A therapy decision specially tailored to the patient should always be made in a interdisciplinary tumor conference be felled. In these conferences, surgeons, gastroenterologists, oncologists and radiation therapists discuss the individual case in the smallest detail and then make a joint decision on the best possible, individual therapy for the patient, taking all aspects into account.

Operate on liver cancer

Whether surgery is an option depends on the function of the liver, the size, number and location of the tumor. If the liver is still functioning well, it is Operation the method of choice. However, the tumor must be easily accessible surgically. It must also be clarified whether it is one or more metastases from another tumor or whether there is primary liver cancer. If there are metastases, the origin of the metastases must also be treated and any chemotherapy and / or radiation therapy carried out to reduce the size of the metastases.

Small tumors can be operated on well and thus improve the prognosis. The surgeon then removes the part of the liver in which the tumor is located (liver segment resection) with a safety margin so that the removal takes place in the healthy and the treatment result can be viewed as curative (healing). If the liver cancer is more extensive but limited to the right or left lobes of the liver, the whole can also be right or left lobe of the liver (Hemihepatectomy). The pathologist examines the submitted specimen under a microscope to determine what type of liver cancer it is, what the tumor stage is and whether any residual cancer cells have remained in the body. If the liver is completely metastasized, an operation is not promising.

Liver transplant for liver cancer

If the liver has extensive cirrhosis, transplantation is more promising for treating liver cancer than simply removing the tumor. This can only be carried out if the general condition is good and without serious concomitant illnesses. After the hepatectomy (complete removal of the liver) a Donor liver used.

After the transplant, immunosuppressive drugs must be taken for a long time to avoid rejection of the organ.

Chemotherapy for liver cancer

In Germany, chemotherapy is not one of the standard treatments for primary liver cancer because it does no life-prolonging effect shows.

If there are metastases, the type of chemotherapy depends on the type of primary tumor. In principle, the doctors use cell poisons, which mainly act on the faster dividing tumor tissue and thus become one Inhibition of tumor growth and Death of vital tumor cells to lead. The drug sorafenib, which is primarily used for advanced renal cell carcinoma, has also been approved for liver cell cancer since 2007.

This is taken as a tablet and can then be used if the liver cancer cannot be operated on.

Internal radiotherapy for liver cancer

As part of internal radiotherapy, the liver is used irradiated from the inside. Small radioactively marked substances are introduced directly into the vessels supplying the liver. This is also known as selective internal radiotherapy.

Thermal ablation in liver cancer

Laser light or radio frequency waves are induced directly into the tumor via a probe and so on the tissue is heated. This leads to necrosis (death of the cells) of the tumor tissue.

Cold probes can also achieve similar results. The tumor tissue is also obliterated by freezing with nitrogen.

Percutaneous ethanol injection / transarterial chemoembolization

Concentrated alcohol or acetic acid is injected through the abdominal wall into the area of ​​the liver where the tumor is located (percutaneous ethanol injection).

Alternatively, the doctor can puncture the great inguinal artery (iliac artery) and insert a cannula directly up to the liver artery supplying the tumor. He then injects the drug through this cannula. This method is called transarterial chemoembolization.

This procedure can also be used to shrink liver cancer prior to surgery.

Palliative therapy for liver cancer

Palliative treatment means that healing is no longer possible at this stage. At this stage the Quality of life of the person concerned secured and possibly improved. Symptomatic, supportive therapies are available to combat the increasing pain and other symptoms caused by liver cancer (such as nausea, vomiting, ascites and other weight loss). The decision about palliative therapy should always be made individually, taking into account the general condition in an interdisciplinary tumor conference

Prospects for healing

In general, the earlier you detect liver cancer, the better the chances of recovery. Life expectancy is immediate linked to the following factors:

  • number
  • size
  • location
  • Spread of the tumor

If an operation is possible for primary liver cancer, the life expectancy of every second person operated on is more than 5 years. In the case of metastases, the prognosis depends on the stage and treatment option of the underlying disease.

In seven out of ten patients, however, the diagnosis comes too late and the liver cancer is already so advanced that only palliative therapy comes into consideration. The mean survival time is then between 6 to 12 months. Daughter tumors of primary liver cancer worsen the prognosis even further.

Follow-up care and prevention

Every 6 months, a determination of tumor markers, a physical examination and medical history, and an ultrasound to detect a recurrence (recurrence of the tumor) should be performed. Further examinations can then be carried out if there is justified suspicion.

A vaccination against hepatitis B, especially in small children and at-risk adults (medical professionals, drug addicts, etc.), reduces the likelihood of hepatitis. You can reduce the risk of developing cirrhosis of the liver, which is one of the main causes of liver cancer, by using alcohol responsibly.

People who already have cirrhosis of the liver should also have it checked every 6 months.

Congenital hematochromatosis should be treated.

Conclusion on liver cancer

  • Early detection of the tumor improves the prognosis through rapid initiation of diagnostics and therapy
  • Continuous follow-up care for the early detection of a relapse and adaptation of the appropriate therapy
  • Regular check-ups to identify and treat consequences of the surgery and local procedures in good time
  • Pain therapy and supportive therapy in the palliative stage
  • Physical, psychological and social support for the patient during and after the illness

Prof. Dr. med. Matthias Pross
Dr. med. Maik Sahm
Dr. med. Katharina Rubach