Treatment of Liver Metastases in Germany

Secondary liver cancer, or liver metastases, develops when the oncological process spreads to the liver from other areas of the body. In most cases, liver metastases indicate advanced cancer, i.e. stage IV cancer. Primary tumors of the kidneys, stomach and pancreas, rectum and colon, uterus and appendages, breasts, and lungs are most likely to cause secondary liver cancer. Given the variety of possible primary tumors, the treatment of liver metastases is usually a medical challenge. However, liver cancer treatment in Germany offers many modern medicines and treatments, so remission is possible for some patients.

Content

1. Diagnosing liver metastases
2. Surgical interventions in patients with liver metastases
3. Treatment of liver metastases with alcohol ablation
4. Treatment of liver metastases with radiofrequency ablation
5. Treatment of liver metastases with percutaneous embolization
6. Treatment of liver metastases with radiation therapy
7. Systemic treatments for liver metastases
8. Leading German hospitals and cost of treatment
9. Treatment of liver cancer in Germany with Booking Health

Diagnosing liver metastases

Making an accurate diagnosis of secondary liver cancer is extremely important in planning the subsequent liver cancer treatment. In fact, it is necessary to examine all body organs to find the primary neoplasm and secondary malignant loci. Laboratory examination is also conducted to assess a patient’s health status.

The diagnostics begins with the collection of anamnesis. This includes discussion of the history of oncological and gastroenterological disorders in the patient or his family members. The doctor may also need information about exposure to radiation or chemicals, working conditions, etc. After collecting an anamnesis, a physical examination, instrumental procedures and laboratory analyses are performed.

Diagnostics of liver cancer in Germany includes the following laboratory and instrumental procedures:

• Blood tests for the liver function assessment
• Abdominal ultrasound scan 
• Abdominal CT scan and / or MRI
• Abdominal angiogram (if required)
• Diagnostic laparoscopy with biopsy

Laparoscopy allows doctors to take a liver tissue sample. The sample of suspicious liver tissue is examined in the laboratory. Immunohistochemical and histological laboratory tests are aimed at determining the type of tumor, presence of genetic mutations, sensitivity to medicines, etc.

Depending on the results of the initial examination, surgery, radiofrequency or alcohol ablation, embolization with chemotherapeutic or radioactive drugs, as well as systemic liver cancer treatment may be used.

Surgical interventions in patients with liver metastases

Surgery is indicated to the selected group of patients with liver cancer. Efficacy of the surgical treatment depends on few criteria:

1. The size and number of metastatic loci in the liver.
2. The primary tumor localization. For example, in patients with bowel cancer, liver metastases are often treated with surgery.
3. The degree of the primary tumor medical control. Surgery is performed at the stage of remission and not in the case of tumor’s active progression.
4. The spread of the malignant process outside the liver, the presence of secondary lesions in other organs.

Surgery for the treatment of liver cancer is called hepatectomy or liver resection. Hepatectomy may include removing a part of the liver or the entire organ (total hepatectomy). When a part of the liver is removed, the rest of the organ regenerates and maintains normal liver function.

The process of regeneration takes few months. To facilitate it, surgeons may block a corresponding branch of the portal vein for several weeks before performing the procedure. When the entire liver is destroyed and there are no healthy hepatocytes left for regeneration, a liver transplant is performed.

Treatment of liver metastases with alcohol ablation

Alcohol ablation for liver cancer treatment is an image-guided interventional medical procedure. It has demonstrated efficacy in the therapy of liver malignancies under 5 cm in size, including primary liver tumors and liver metastases. In most cases, these are patients in whom breast cancer, colorectal cancer, or endocrine tumors have spread to the liver. Alcohol ablation therapy candidates must meet such requirements:

1. Presence of no more than 3 malignant loci, both primary and secondary ones
2. Clear margins of each locus, a fibrous capsule around them
3. Localization of each neoplasm deep inside the liver

Alcohol ablation is carried out under visual control. A surgeon uses ultrasound to guide the introduction of medical equipment precisely. When anesthesia is performed, the doctor introduces a thin needle into the target locus in the liver. Once the long needle is in the target region, a concentrated solution of alcohol is injected through it. The injected solution causes necrosis of the nearby tissues. To achieve the desired result of liver cancer treatment, the patient may have several repeated therapeutic interventions.

Alcohol ablation is also suitable for patients with liver cirrhosis of different etiology. Moreover, if the healthy hepatocytes have signs of cirrhosis, then they are more stable to the damaging action of concentrated alcohol.

This treatment option is not suitable for patients with acute or chronic liver failure, as patients with impaired liver function do not tolerate it well.

Treatment of liver metastases with radiofrequency ablation

Liver cancer treatment with radiofrequency ablation destroys malignant foci directly, but without invasive surgery. When compared to the conventional open surgery, radiofrequency ablation is less likely to cure the disease completely. However, it has been proved that the intervention results in better quality of life and survival of patients.

Few types of physical ablation are used for liver cancer treatment.In Germany, the following techniques are used:

1. Radiofrequency ablation. High energy radio waves are used for controlled medical destruction of malignant loci in the liver.
2. Cryoablation (cryotherapy). Cryoablation uses low temperatures for freezing and destroying malignant cells.
3. Microwave ablation. Microwave ablation, on the other hand, uses the energy of electromagnetic waves for controlled and targeted heating of liver lesions.

Regardless of the ablation type, this type of liver cancer treatment in Germany involves inserting a needle-like probe or needle directly into the malignant liver locus. To make the procedure more safe and convenient for the patient, reliable anesthesia is applied. High procedure accuracy is ensured by visual control of computed tomography or ultrasound.

When a needle-like probe or needle is inside the tumor, electromagnetic waves, cold gases, or radio waves pass via it. After treatment completion, the patient stays in the general ward. Usually, a procedure is tolerated well, and a patient may leave a hospital the same day.

Treatment of liver metastases with percutaneous embolization

The medical procedure "embolization" refers to the manipulations on the hepatic artery. As the large blood vessel, the hepatic artery feeds the liver and all neoplasms inside it. Selective embolization leads to reduced blood supply of liver metastases; lack of nutrients and oxygen causes metastasis suppression or even disappearance. Combined therapeutic procedures are also used for liver cancer treatment in Germany, with additional introduction of radioactive or chemotherapeutic substances:

1. Radioembolization (selective internal radiation therapy, SIRT).
2. Drug-eluting bead chemoembolization (DEB-TACE).
3. Trans-arterial chemoembolization (TACE).

Transarterial embolization (TAE) begins with a small skin cut in the groin. A catheter is inserted into the femoral artery through it. Gradually, the catheter is directed closer to the liver; it reaches the blood vessel feeding the malignant neoplasm. Once the medical device enters the target artery, foam or oily liquid is injected through it. The introduced substances cut-off the vessel from the systemic circulation, while sparing blood supply to the healthy parts of the liver.

When performing DEB-TACE and TACE, the embolization is complemented by injection of a chemotherapy drug into the blocked vessel. A high local concentration of the chemotherapy drug is achieved without damaging healthy liver. However, treatment should be selected individually, as in liver metastases from NETs, TAE is even superior to TACE. In such patients TAE has slightly better tolerability and comparable antitumor effect.

Treatment of liver metastases with radiation therapy

In Germany, radiation therapy is not a first-line liver cancer treatment because a healthy liver is very sensitive to radiation. If a patient has liver cirrhosis or hepatitis, he is also not a candidate for radiation therapy. Thus, the possible risks and benefits are assessed individually before starting treatment. For most patients, radiation therapy is only part of a combination regimen for liver cancer.

Radiation therapy is performed in three different modes:

1. Selective internal radiation therapy (SIRT) is also called radioembolization. It is performed as a routine embolization. Unlike a routine embolization, SIRT involves the injection of radioactive microspheres before the hepatic artery is blocked. In SIRT, healthy hepatocytes remain safe.
2. External beam radiation therapy (EBRT) uses radiation sources outside the patient's body. EBRT resembles an X-ray examination, but higher radiation doses are used. This type of treatment usually takes few weeks, because the patient receives small doses of radiation daily.
3. Stereotactic body radiation therapy (SBRT) reduces radiation damage to healthy liver tissues. In SBRT, beams of radiation are precisely focused on the malignant liver area. Compared to EBRT, SBRT has a shorter course, because higher radiation doses are used daily.

Systemic treatments for liver metastases

Systemic treatment is carried out orally or intravenously. The term "systemic" means that the medical agent is present in the systemic circulation and is able to reach metastases not only in the liver, but also in all organs. Depending on the type of the medical agent, systemic treatment methods include:

• Chemotherapy. The most effective approach is to use a combination of chemotherapy drugs. In patients with liver metastases, the response to any chemotherapy regimen is usually poor.
• Immunotherapy. These medical agents affect proteins that are important for recognizing malignant cells and attacking tumors. Thus, a patient's own immunity is boosted.
• Hormone therapy. When the primary neoplasm is hormone-sensitive (for example, in patients with breast cancer or prostate cancer), hormone therapy is also effective for the treatment of liver metastases.
• Targeted medicines. These include PARP inhibitors, monoclonal antibodies, angiogenesis and cancer growth blockers. Targeted medicines act against particular tumor antigens or conditions that are required for tumor survival and spreading.

Leading German hospitals and cost of treatment

Liver cancer clinics must have modern equipment for accurate diagnostics, access to novel drugs and treatments, and highly qualified personnel. These hospitals are the most well-known regarding liver cancer treatment in Germany:

1. University Hospital Heidelberg
2. University Hospital Bonn
3. University Hospital Carl Gustav Carus Dresden
4. Charite University Hospital Berlin
5. University Hospital Ulm

The cost of treatment depends on the procedure chosen. The approximate cost of treatment with surgery, ablation, radiation therapies, and systemic drugs are listed below:

1. Price for diagnostics – from 1,686 EUR
2. Price for radiofrequency or alcohol ablation – from 4,727 EUR
3. Price for surgery – from 20,865 EUR
4. Price for percutaneous embolization or chemoembolization – from 4,756 EUR

Once treatment in Germany is completed, a patient may return to his native country and stay under remote supervision of his attending physician. If necessary, a patient may come to Germany again, for the control examination, repeated treatment course or rehabilitation.

Treatment of liver cancer in Germany with Booking Health

After being diagnosed with liver metastases, a patient can receive modern treatment in any country and any hospital. The international provider of medical tourism Booking Health helps with this. Booking Health takes into account all the features of the treatment of liver metastases and offers assistance in:

• Choosing the healthcare facility according to the specialization in liver cancer treatment and success rates
• Making appointment or booking date of hospital admission
• Skipping long waiting lists
• Explaining procedures included in the medical program
• Excluding unnecessary medical procedures
• Providing fair cost of treatment, without fees for foreign patients (saving up to 50%)
• Help in buying necessary medicines
• Communicating with clinic and physician after the program completion
• Cost of treatment control and return of unspent funds
• Arranging additional medical procedures, if necessary

In addition, Booking Health offers non-medical services of the highest level. These are transfer, booking accommodation and tickets, interpreting services, etc.

Start planning cancer treatment in Germany from leaving the request on the Booking Health website. After receiving and examining the request, a medical advisor or patient case manager will contact you for further guidance.

Authors: Dr. Nadezhda Ivanisova, Dr. Sergey Pashchenko