Liver Metastases: Stage 4 Secondary Liver Cancer Treatment in Germany

What Are Liver Metastases?

Metastatic liver cancer (also called secondary liver cancer) is cancer cells that have spread (metastasized) to the liver from another part of the body.^[1] The original tumor might be in the colon, breast, pancreas, or another organ. While the primary tumor is located elsewhere, cancer cells travel through the blood or lymphatic system and settle in the liver, where they start to grow and form new tumors.^[2]

Liver lesions usually mean the cancer is stage IV, which is serious and often not curable.^[3] However, that does not automatically imply “nothing can be done”. Here, we explore the details of diagnosis and treatment for liver metastases in Germany. Additionally, you can find specifications and features related to this condition in Germany. The exact outlook depends on the type of original cancer, the number of metastases, and the person’s overall health.

Difference Between Primary & Secondary Tumors

When a scan shows a tumour in the liver, German oncologists and hepatobiliary surgeons first ask a key question: did this cancer start in the liver itself, or did it come from somewhere else?^[4][5] Patients at he same time hearing the diagnosis are checking “what is metastatic liver cancer” and if my therapy should be different from a typical liver tumor.

Understand Primary Liver Tumor

If the cancer develops within the liver cells, it is referred to as primary liver cancer.^[6] The most common type is hepatocellular carcinoma (HCC).^[7] Primary liver cancers are usually managed following their own specific guidelines, and the approach can be different from the treatment of liver metastases.^[8][9]

What is Secondary Liver Cancer

Liver metastasis, meaning, by contrast, is secondary liver cancer.^[1] The original tumour is in another organ, but once cancer cells have spread to the liver, they form new tumours there. Even if the most enormous masses are now in the liver, doctors still name and treat the disease according to the place where it began, such as metastatic colorectal cancer with hepatic mts. or metastatic breast cancer. This distinction is crucial for treatment decisions.^[1][4]

Get consultation

Which Cancers Commonly Spread to the Liver?

The liver is one of the most common places for cancer to spread.^[10] Medical reviews estimate that the liver is involved in about one quarter of all metastatic cancers.^[11] Roughly 5% of all people with cancer already had liver spots at the time their cancer was first diagnosed.^[11][13]

Almost any solid tumour can spread to the liver, but some do so much more frequently.^[10][14] Check the most frequent cancers that spread to the liver below.

The Most Common Sources

• Colon & Rectal Cancers. Colorectal cancer is by far the most common source of metastatic liver cancer. National cancer registry data show that colon and rectal cancer are among the three most frequent cancers in both men and women.^[17] Studies from Germany and other European countries suggest that around 25% to 50% of colorectal cancer patients will develop progression at some point.^[10][15][16]
• Breast Cancer. Malignant breast tumor is also a frequent source of liver metastases in advanced stages.^[10][15] Many women with metastatic breast cancer will at some stage have liver involvement, often alongside bone or lung metastases.^[18]
• Pancreatic, stomach, bile duct & other gastrointestinal cancers. These primary locations also have a strong tendency to spread to the liver because the blood from the digestive organs flows directly through the portal vein into the liver.^[19][20][21]

Centres like University Hospital Würzburg explicitly list pancreatic, gastric, neuroendocrine tumours (NETs), gastrointestinal stromal tumours (GISTs), and melanoma among the malignancies that frequently metastasize to the liver.^[22]

Less Common Origin

Several other cancers can also give rise to metastatic liver cancer, even if this is less common. Prostate cancer, for example, usually spreads first to the bone. Still, liver involvement is seen in a minority of men with very advanced, castration-resistant disease.^[12][23][24]

Next, head & neck cancers, soft-tissue sarcomas, aggressive thyroid cancers, bladder and testicular tumours, and certain skin cancers can all occasionally seed the liver, typically as part of widespread stage-IV disease.^[25][26][27]

In addition, lung, kidney, and some gynaecological cancers may involve the liver in later stages, when circulating cancer cells spread via the bloodstream to multiple organs.^[28][29] For patients and families, the key message is that almost any solid tumour can, in principle, reach the liver, so new liver findings in advanced or recurrent cancer should always be evaluated carefully.

Let us help

Liver Metastases Symptoms: When to See a Doctor

One of the challenges with metastatic liver cancer is that, at first, many people feel almost nothing unusual.^[30] In Germany, they are often discovered during routine follow-up scans after initial cancer treatment or when doctors investigate abnormal liver blood tests.^[31]

Signs of Liver Metastases Progression

When we have disease advancement, symptoms of secondary liver cancer may slowly appear. People often describe a dull, pulling, or pressing sensation in the upper right quadrant of the abdomen, where the liver is located.^[1][32] They may feel more tired than usual, lose their appetite, or notice that small meals already make them feel full.^[1][33] Over the course of weeks or months, this can lead to unintended weight loss.

Late-Stage Disease Picture

Suppose metastases or liver damage are more advanced, or it’s already not only liver-only metastases. In that case, the abdomen can swell due to fluid accumulation (ascites), the skin and eyes can turn yellow (jaundice), urine can become dark, stools can become pale, and some patients can develop generalized itching.^[33][3][30]

Note that none of these signs is specific to secondary liver cancer symptoms. They can just as well come from non-cancerous liver diseases, gallstones, or other digestive problems.^[34]

Tell us about your case

Why Germany for Liver Metastases Treatment?

For patients with stage 4 secondary liver cancer, Germany offers a mix of high case numbers, strong cancer centres, advanced technology, and strict quality control.^[35] Around 500,000 people are newly diagnosed with cancer in Germany every year, and more than 50% of these cases are tumours that often lead to metastatic liver cancer.^[36][37] This means that German oncology teams deal with complex metastatic cases, including liver involvement, on a daily basis.

Strong Oncology Centers

Cancer care in Germany is highly centralised in certified oncology and organ-specific centres.^[35] The healthcare system here has specialized, narrowly focused units for almost every disease, aiming to deliver high-end care. Examples include the Liver Tumor Board & Liver Diseases Centre at University Hospital Rechts der Isar, Munich.^[38][39]

Multidisciplinary Tumor Boards

A key feature of German cancer care is the multidisciplinary tumor board. These panels are not an optional extra – they are a standard requirement for certified centres and are regularly audited.^[40] In a German study of a gastrointestinal tumor board, 732 cases were discussed in a single year, and 57% were stage-IV patients.^[42] Each week, specialists from surgery, medical oncology, radiology, nuclear medicine, radiotherapy, pathology, and psycho-oncology meet to review imaging and laboratory results, guideline recommendations, and agree on a plan.

This team approach is not just a formality. Analyses from Germany and other countries show that patients whose cases are handled in a board approach are more likely to receive guideline-compliant therapy and to be offered potentially curative options when appropriate.^[42][43] For someone with metastatic liver cancer, this increases the likelihood that all relevant options are weighed and considered in a coordinated manner, rather than in isolation.^[44]

High-Tech Diagnostics

When the liver metastases diagnosis is made, high-quality imaging and hospital infrastructure make a real difference.^[45] Here, Germany is well above the European average:

• The country has about 7.7 hospital beds per 1,000 inhabitants, compared with an OECD average of 4.2 – a sign of high inpatient capacity.^[46][47]
• There are 74 CT scanners, MRI units, and PET scanners per million people, compared to an OECD average of 51, providing broad access to cross-sectional imaging and PET-CT staging.^[46][47]
• Germany performs more MRI scans than any other EU country, with approximately 13 million MRI examinations per year, significantly ahead of France, Spain, and Italy. This is crucial for on-site availability for MRI of the liver.^[48]
• PET imaging for oncology has expanded rapidly: in 2021, approximately 154,000 PET exams were performed in Germany, corresponding to 1,857 scans per million inhabitants, and PET volume increased by 48% between 2017 and 2021. About 76% of these examinations were for re-staging cancer.^[49]

Patients seeking secondary liver cancer treatment in Germany benefit from rapid access to a simple CT scan for liver lesions, advanced imaging, or biopsy for liver lesions.^[46][50] Therefore, small liver lesions can be detected and tracked more precisely, which helps determine whether a particular treatment for liver metastases in Germany is a viable option.^[51]

German Treatment Experience & Access

For liver metastasis, Germany offers both broad access to modern procedures and a very high level of real-world experience. For instance, an analysis of colorectal liver spreading in Germany found that, overall, about 26% of affected patients underwent liver resection; however, in specialized liver centers, the operation rate rose to 46.6%, indicating that complex surgery is more widely used in centers with concentrated expertise. ^[52]

Precise data showing the advantage coming from the numbers. Nationwide hospital data indicate around 18,000 liver procedures per year, underscoring Germany’s role as a high-volume environment for liver surgery.^[53]

From another perspective, here patients can find a wide range of treatment options for liver metastases in Germany. The offerings are going beyond conventional operation or chemotherpay. Here, doctors can propose advanced techniques that are not readily available elsewhere.^[54]

Evidence-Based Protocols

Germany’s liver cancer care is tightly linked to national, evidence-based guidelines. Diagnostic and treatment recommendations are formalised in German Oncology Guidelines (S3 guidelines) of the German medical societies and in the Onkopedia system of the German Society of Hematology and Oncology. These documents are regularly updated and form the backbone of decision-making in tumor boards.^[55]

The impact can be measured. In the study of a German gastrointestinal tumor board mentioned earlier, 76% of all board recommendations were fully aligned with national guidelines, and most of the remaining deviations were not “errors” but deliberate decisions – for example, inclusion in a clinical trial or adjustments due to contraindications.^[40] Surgical recommendations were followed closely, with approximately 86% of proposed operations performed exactly as recommended.^[42]

Beyond single centres, large registry projects, such as WiZen, demonstrate that patients treated in certified cancer centres in Germany have significantly better long-term survival rates than those treated in non-certified hospitals.^[41] This suggests that adherence to evidence-based protocols, mandatory tumor boards, and quality audits is not merely bureaucratic; it translates into consistent care and better outcomes.

Individual Solution for Advanced Cases

Crucially, treatment plans are no longer “one size fits all”. Multidisciplinary liver cancer boards in Germany routinely consider tumor biology, the number and location of liver lesions, previous therapies, age, and overall health to design an individualized treatment plan for each patient.^[42][56] For some, this may mean an intensive systemic regimen with targeted or biological drugs; for others, a combination of chemotherapy with limited, minimally invasive liver surgery, image-guided ablation, or other local techniques.

German Statistical Data

Even with the best system, stage 4 liver metastases remain serious. Still, current German data show that long-term outcomes for many patients have improved markedly. In metastatic colorectal cancer – one of the leading groups with liver involvement – historical 5-year survival used to be below 10%.^[57] More recent analyses report a 35–40% range in some series, thanks to better systemic therapies and more aggressive use of liver operations, or targeted therapy when feasible.^[58]

Real-world data from 3,800 patients with metastatic colorectal cancer treated in Germany reveal a similar trend: survival times in routine care now exceed 30 months, approaching those in clinical trials.^[59] Another study shows that, among selected patients who can undergo surgery with curative intent, 5-year survival rates of 20–60% and 10-year survival rates above 25% have been documented.^[57]

Key Practical German Facts & Benefits

The choice of country for liver metastasis treatment is not just about reputation. Below are hard numbers showing Germany's performance in the field.

Request a second opinion

Treatment for Liver Metastases in Germany

​​Nowadays, the range of treatment options is vast and varies depending on each patient's specific situation. Here, we explore available treatments for liver metastases in Germany and highlight key findings from the country’s data.

Liver Metastases Surgery

Surgery is still among the primary treatments for metastatic liver cancer that can offer a real chance of long-term remission or cure for some people with liver lesions.^[60] Not everyone is a candidate, but when tumors can be removed entirely, survival rates improve dramatically compared with alternatives.^[58]

Liver Resection or Lobectomy

In a classic liver resection, the surgeon removes the part of the liver containing the metastases.^[71] A lobectomy is just a larger version of this, removing an entire lobe of the liver.^[72] The goal is simple: take out all visible cancer with a margin of healthy tissue, while leaving enough liver behind to work usually.

Because the liver can regenerate, many people can safely lose 50–70% of their liver volume in expert hands.^[58] International series show that after curative resection of colorectal liver deposits, 5-year survival is often 25–60%, and 10-year survival is 25–40% in selected patients.^[73][74] It's a significant improvement from the <10% survival seen in the old "chemotherapy only" era.^[58] Ten years after such surgery, reaching this milestone is considered a functional "cure" in almost all patients.^[73]

Germany is a leader in this field: a nationwide analysis found that 110,332 liver procedures were performed between 2010 and 2015, with colorectal liver spread being among the most common indications.^[53] German liver surgeons also make broad use of minimally invasive (laparoscopic or robotic) hepatobiliary surgery techniques.^[75]

Two-Stage Liver Surgery

Sometimes the cancer spots are too widespread to be removed safely in one operation, for example, when both lobes are packed with tumours. In these cases, liver surgeons may plan a two-stage hepatectomy:

• First operation. Remove or treat tumours on one side and block blood flow to the other side so the future remnant liver can regrow;^[76]
• Second surgery. Remove the remaining diseased liver part once the “good” side has enlarged.^[79]

The aim is to turn an “unresectable” situation into a safe, stepwise curative attempt. In one well-known study, patients who underwent a planned two-stage resection had a 5-year survival rate of approximately 51%, compared with 15% in similar patients treated with chemotherapy alone.^[77]

German centres are very active in this area, not only performing two-stage hepatectomies but also leading research on ways to grow the future liver remnant more quickly and safely. For example, combined portal and hepatic vein embolisation was studied in the multinational DRAGON collaborations with key German participation.^[76][78]

ALPPS Procedure

An even more aggressive version of two-stage liver surgery is Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS).^[80] In this procedure, the liver is partially divided and the blood flow is rerouted in the first surgery, which triggers very rapid liver growth within days.^[81] German surgeons were among the pioneers of ALPPS and remain heavily represented in the International ALPPS Registry, which now includes hundreds of patients with metastases and primary liver tumors.^[82]

Registry analyses show that, in experienced hands and with careful patient selection, ALPPS and other staged procedures can convert a substantial proportion of previously inoperable cases into candidates for complete tumour removal.^[83][84] For patients, this is one of the reasons why complex, “borderline” cases are often referred to German liver centres for a second opinion.

Liver Transplant

Liver transplantation for metastases is not a standard option. Still, Germany has played a significant historical and current role in this field. The basic idea is straightforward: if the metastases are confined to the liver and cannot be removed safely, replacing the entire liver with a donor organ may offer the best chance of long-term control or even cure.^[86]

The clearest experience is with neuroendocrine liver metastases. German transplant surgeons in Essen and Hannover were among the first to report a series of liver transplant candidates with diffuse, otherwise untreatable neuroendocrine metastases who underwent total hepatectomy and liver transplantation.^[85]

Local Ablation Procedures

Local ablation means destroying liver tumors from the inside using heat, cold, or special energy, instead of surgically removing them. A thin needle or probe is guided into the metastasis (usually under CT or MRI control), and the tumour is “burned”, “frozen,” or disrupted. At the same time, most of the healthy liver stays intact.

In Germany, these procedures are now routine, everyday work in interventional radiology. An extensive nationwide analysis presented via the European Society of Radiology showed that oncologic ablations are performed across Germany with very low complication rates.^[87] German centres have been publishing on liver ablation for more than two decades and now report 3–5-year survival of 30–40% after thermal ablation in patients whose metastases cannot be removed surgically – a considerable step forward compared with “best supportive care” alone.^[88]

Below is an overview of the primary ablation methods used for secondary cancer in the liver, highlighting treatment in Germany and national statistics.

Radiofrequency Ablation (RFA)

In radiofrequency ablation, the doctor places a thin needle electrode directly into the liver metastasis.^[89] An alternating electric current then flows through the tip. It heats the tumour to around 60–100 °C, literally cooking the cancer cells.^[90] Hence, they die, while the surrounding liver is spared as much as possible. Most procedures are performed through the skin (percutaneously) under CT or ultrasound guidance, resulting in a short hospital stay.^[89][90]

German groups were among the first in Europe to use RFA for the liver.^[91] In a classic series of patients with liver malignancies from various primary tumors, the mean overall survival after RFA-based treatment was approximately 41 months.^[92]

For a patient, this means that RFA in a German centre is not an experimental last resort but a well-established, guideline-supported option when surgery is not possible or a minimally invasive approach is required.^[93]

Microwave Ablation (MWA)

Microwave ablation is similar in concept to RFA, but instead of radiofrequency current, it uses microwave energy. A small antenna is inserted into the tumour. It produces an electromagnetic field that causes water molecules in the tissue to vibrate, generating heat and forming a hot “ball” of destroyed tumor.^[94]

German radiologists are very active in microwave ablation research. An extensive review led by University Hospital Frankfurt reported 1-, 3-, and 5-year survival rates after MWA of 89–94%, 54–74%, and 43–60%, respectively, with local control rates exceeding 90% for small liver metastases (≤4 cm).^[94]

Germany is also advancing technology: the MR-MIGHTY trial, listed in the German Clinical Trials Register, is specifically testing MRI-guided MWA for liver tumors to avoid radiation and visualize the ablation zone in real time.^[70] This means access not only to standard MWA but also to cutting-edge variants in the hands of experienced professionals.

Laser-Induced Thermotherapy (LITT Ablation)

Laser-induced thermotherapy (LITT) uses laser light delivered through a skinny fibre inserted into the tumour.^[95] The laser energy is converted into heat in the tissue, again raising the temperature high enough to kill the cancer cells.^[96] In Germany, LITT is often combined with MRI guidance, allowing doctors to monitor the temperature and the exact size of the ablation zone in real-time.^[95][97]

LITT can be an excellent option for secondary liver cancer treatment in Germany as the country pioneers the approach. Prof. Dr. med. Tho­mas Vogl from Frankfurt has published extensively on LITT for the liver, describing it as a “promising method of tumour ablation” mainly used for hepatic metastases.^[95] LITT ablation for liver metastases is particularly valued in Germany for difficult locations and for patients who cannot tolerate major surgery, giving another minimally invasive option beyond RFA and MWA.

Cryoablation

Cryoablation takes the opposite approach: instead of heat, it uses extreme cold.^[98] A special probe is inserted into the hepatic metastasis, and the rapidly expanding gas cools the tip to very low temperatures (often below –40 °C).^[99] This forms an “ice ball” that freezes and destroys the cancer cells. On imaging, the ice ball is clearly visible, allowing the doctor to precisely target the tumor.^[100]

Cryoablation is less common than RFA or MWA. Still, it is gaining a foothold in German centres, especially for tumours near sensitive structures. A recent German study on centrally located liver tumors, including hepatocellular carcinoma and metastases, showed that percutaneous cryoablation with special bile-duct protection was technically feasible and could be performed without an increased risk of bile duct injury or local tumor recurrence in the early follow-up period.^[101]

Irreversible Electroporation - NanoKnife (IRE)

Irreversible electroporation (IRE), often known by the brand name NanoKnife, is a non-thermal ablation.^[102] Several thin electrodes are placed around the tumour. Very short, high-voltage electrical pulses (typically exceeding 1,000 V) are then delivered between the needles.^[103] These pulses create tiny permanent pores in the cell membranes, causing the cancer cells to die. At the same time, the basic structure of blood vessels and bile ducts is largely preserved.^[103]

Germany has been at the forefront of IRE research. A well-known German study followed 71 patients with 103 inoperable liver tumours (both primary cancers and metastases) that were not suitable for heat ablation.^[104] All were treated percutaneously with IRE (NanoKnife). As a result, complete ablation was achieved in over 92% of tumours at six weeks.^[105]

High-Intensity Focused Ultrasound (HIFU)

High-intensity focused ultrasound (HIFU) is a non-invasive procedure that requires no incisions or needles.^[106] Powerful ultrasound waves are focused from outside the body onto a small point inside the liver. At that focal point, the energy builds up. It heats the tissue until the malignant cells die, while the skin and surrounding tissue stay mostly unharmed. Everything is typically monitored in real-time using ultrasound or MRI.^[106][107]

Germany is one of the countries where HIFU is actively used and evaluated.^[108] Early clinical work on HIFU for colorectal liver lesions showed that it was feasible, safe, and able to ablate areas of liver that were scheduled for resection, paving the way for trials in “difficult” metastases not suitable for surgery or classic ablation.^[109][110]

For individuals who are poor surgical candidates or are reluctant to undergo needle-based ablation, HIFU in a German centre can be an attractive “no-incision” option, especially within clinical trials.^[106][111]

Intra-Arterial Therapies

Intra-arterial therapies utilize a simple anatomical principle: liver lesions are primarily supplied by the hepatic artery, whereas healthy liver tissue receives most of its blood from the portal vein.^[112] By threading a thin catheter into the hepatic artery, doctors in Germany can deliver chemotherapy or tiny radioactive beads right into the tumour’s blood supply, bathing the metastases in treatment. At the same time, the rest of the body is exposed to much lower doses.

Transarterial Chemoembolization (TACE)

TACE combines local chemotherapy with tumour blood supply blockade in a single procedure.^[113] Through a tiny catheter placed in the groin or wrist, the interventional oncology doctor navigates to the hepatic artery branch that feeds the metastases. Then a high concentration of chemotherapy is injected, followed by microscopic particles that plug these vessels. The metastasis is hit by a drug “bath” and, at the same time, slowly starved of oxygen.^[114][115]

In Germany, TACE is standard not only for primary liver cancer but also for liver-dominant metastases from colorectal, neuroendocrine, and other tumours when surgery or simple ablation are not enough.^[116] An extensive German analysis reported nearly 50,000 TACE procedures between 2010 and 2019.^[61] Studies from Frankfurt and other centers demonstrate that regional arterial chemotherapy (including TACE) can induce tumor shrinkage in a substantial proportion of patients, extending median survival to several months to several years, depending on the tumor type and the timing of its use.^[116]

Selective Internal Radiotherapy (SIRT)

SIRT, also known as “transarterial radioembolisation”, works like highly targeted internal radiotherapy. Instead of chemotherapy, the catheter delivers millions of microscopic beads loaded with a radioactive substance, usually yttrium-90 or holmium-166 microspheres.^[54] These microspheres lodge in the tiny arteries within the metastases and emit radiation over days to weeks, directly within the tumour while sparing most of the surrounding liver.^[119]

Germany is one of the most active SIRT countries in Europe. A nationwide study found over 11,000 SIRT procedures performed between 2012 and 2019, and another analysis reported more than 14,000 procedures between 2006 and 2019.^[120][54] In both datasets, liver spots were the single most common indication.

For patients with chemotherapy-resistant colorectal liver metastases, German and European studies show that SIRT can add extra survival compared with best supportive care alone.^[119][121] The treatment often provides reasonable local control of liver disease, which is crucial for alleviating liver metastasis symptoms and improving quality of life.

Hepatic Artery Infusion Chemotherapy

Hepatic artery infusion (HAI) chemotherapy goes beyond a one-off TACE session. Instead of giving a single dose, doctors implant a small pump or catheter system that delivers chemotherapy directly and repeatedly into the hepatic artery, so that drug concentrations in the liver are many times higher than what could safely be given through a standard IV line.^[117]

This approach is exciting when metastases are almost entirely confined to the liver. International studies, many involving European teams, show that combining HAI with modern systemic chemotherapy can achieve response rates up to 70–90%.^[122]

Radiation-Based Solutions

When surgery or ablation aren’t possible, modern radiation can step in as a precise, organ-sparing option for liver metastases. Instead of bathing the whole body in treatment, these methods deliver a very high dose directly to the tumour while protecting as much healthy liver as possible.

Stereotactic Body Radiotherapy (SBRT)

Stereotactic radiotherapy is sometimes described as “radiation surgery without a scalpel.”^[123] Instead of multiple small radiation sessions over several weeks, SBRT uses a few (e.g., 3–5) precise treatments.^[63] Robotic machines or modern linear accelerators track the liver as it moves with breathing, and deliver a high dose directly into the metastasis, while quickly dropping the dose outside the target.^[125]

In Germany, liver SBRT is now a well-established treatment method, rather than a niche experiment.^[126] The German Society for Radiation Oncology runs a dedicated SBRT database. One of its key projects collected data on 474 patients with 623 liver oligometastases from 17 centres in Germany, Austria, and Switzerland. The results indicate that local control of the treated liver lesion is approximately 77% at 1 year and 64% at 2 years.^[63] Colorectal and breast cancer metastases were the most frequent, but many other primary tumours were included as well.

A more recent German single-centre study from the Technical University Clinic of Munich followed 115 patients treated with high-precision liver radiotherapy. Median survival was 20.4 months; at 2 years, approximately 45% of patients were still alive. The local control rate for the treated metastases was approximately 35 months, with only about 18% of local failures occurring within one year.^[127]

Proton Therapy

Proton therapy is a more precise form of radiation that uses protons instead of X-rays. The key advantage is the Bragg peak: protons release most of their energy right inside the tumour and then stop, so healthy liver tissue in front of and behind the metastasis gets far less dose.^[128] In simple terms, it lets doctors hit the cancer harder while sparing more of the liver.

Germany is one of the European countries with several clinical proton (and particle) therapy centres. The Heidelberg Ion Beam Therapy Center was the first European ion-beam centre, offering proton and carbon-ion treatments since 2009, and remains one of only a few facilities worldwide with heavy-ion capability.^[118][129] Other particle centres in Germany include Dresden, Essen, Marburg, and additional sites; together, they form around 5 operational particle therapy centres, according to recent overviews.^[130]

Systemic Treatments

Even when the main problem seems to be “just in the liver”, treatment almost always has to work through the whole bloodstream. Systemic therapies are the backbone of liver cancer final stages metastases treatment in Germany, as they reach cancer cells in the liver, at the primary tumor, and in tiny deposits that may not yet be visible.^[124][131] Here, most patients with liver lesions are treated in outpatient oncology practices that follow international guidelines.

Modern Chemotherapy Regimens

"Chemotherapy" is no longer just a single drip every few weeks. For liver disease, especially from colorectal, breast, pancreatic, and some other cancers, Germany routinely uses combination regimens that are much more effective than the old single-drug protocols.^[51][59]

For metastatic liver cancer treatment, going from colorectal tumor is standard combinations such as FOLFOX, FOLFIRI, and FOLFOXIRI.^[51] It's often combined with targeted drugs (like anti-VEGF or anti-EGFR antibodies when the tumor's genes allow it), which have pushed survival much further.^[124] Modern European and German series now report median overall survival around 30–40 months for many patients receiving contemporary first-line and second-line regimens, compared with less than 12 months in the 1990s "5-FU only" era.^[132]

Additional tumor biology (e.g., RAS, BRAF, or HER2 status), patient age, and fitness are considered to determine a regimen that balances efficacy with side effects.^[51][133] These decisions are regularly revisited as the situation evolves.

Immunotherapy

Immunotherapy, especially immune checkpoint inhibitors, has changed the outlook for some patient groups. These targeted therapies don’t attack the tumour directly; instead, they take the brakes off the immune system so that T-cells can recognise and attack cancer cells more effectively.^[134]

The effect can be dramatic in specific biological subtypes. For metastatic colorectal cancer with microsatellite instability (MSI-high) or DNA mismatch-repair deficiency (dMMR), international studies have demonstrated that PD-1 inhibitors can produce long-lasting responses and significantly prolong progression-free survival.^[135][51]

Outside colorectal cancer, many tumours that frequently cause progression to the liver are also immunotherapy-sensitive:

• Non-Small Cell Lung Cancer. Adding PD-1/PD-L1 inhibitors to chemotherapy has improved median overall survival by several months.^[136]
• Melanoma & Renal Cell Carcinoma. Combination immunotherapy (e.g., PD-1 plus CTLA-4 blockade) has led to long-term survival in a significant minority of patients, even in the presence of liver metastases.^[137][138]
• Breast Cancers. Especially triple-negative disease with PD-L1 expression, combining immunotherapy with chemotherapy has also become part of European and German treatment recommendations.^[139]

German cancer centres are deeply involved in these immunotherapy trials and routinely offer molecular testing (MSI/MMR, PD-L1, tumour mutational burden, and other tumor markers) to see whether a patient might benefit.^[140] Check Airomedical ranking regarding the top 5 specialized immunotherapy clinics, which might be relevant for patients seeking immunotherapy for liver metastases in Germany.

Alternative Treatment Options for Liver Metastases in Germany

Alongside standard treatments, Germany also offers a range of complementary approaches. These are typically provided in integrative or private clinics, rather than as first-line therapy in university hospitals.

It’s essential to view them as add-ons, not replacements, for evidence-based oncology. They should always be discussed with your oncology team to ensure that standard treatment is not compromised.

Hyperthermia

Hyperthermia refers to the process of warming tumors to approximately 39–43 °C using external applicators or specialized devices.^[141] The idea is simple: cancer cells are more sensitive to heat than normal tissue. Heating a malignant area can enhance the effectiveness of chemotherapy and radiotherapy, improve blood flow, and stimulate local immune responses.^[142]

Germany has a long tradition in regional deep hyperthermia, and its experts helped draft international quality-assurance guidelines for its safe and reproducible delivery.^[143] Hyperthermia is primarily used in integrative and specialized centers as a supportive treatment – for example, whole-body or regional hyperthermia alongside systemic therapy.

Dendritic Cells (DC) Vaccine

Dendritic cells are a type of “teacher” immune cell: they show fragments of tumour to T-cells and help the immune system recognise cancer.^[144] Dendritic-cell (DC) vaccines take this idea into the clinic. Doctors collect immune cells from a patient’s blood, prepare them in the lab with tumour antigens, and then reinfuse them as a personalised vaccine to try to trigger a stronger anti-tumour immune response.^[145]

For most solid tumors and metastatic progression, dendritic cell therapy remains an experimental treatment. Germany, however, is one of the countries where DC vaccines are actively offered.^[145] Dendritic-cell therapy is available only at a small number of licensed clinics. It is usually not part of standard care. Therefore, this approach can be classified as truly innovative metastatic liver therapy in Germany.

One of the clearest trials comes from patients with colon cancer and completely resected liver metastases. In this phase II study, everyone had standard treatment first: chemotherapy, then liver surgery, then more chemo. Afterwards, 15 patients undergoing liver resections were randomly assigned: half received routine follow-up. In contrast, the other half received a series of personalised DC vaccines. ^[146]After several years of follow-up, the median time to cancer recurrence was approximately 25.3 months in the vaccine group, compared with 9.5 months in the observation group. It was more than double the disease-free period.

Biological Infusion Therapy

Under the label “biological infusion therapy”, German integrative clinics often group high-dose vitamin infusions, herbal extracts, trace elements, amino acids, and other “natural” agents. The goals are usually to support overall condition, reduce treatment-related side effects, and, in some cases, directly target tumour cells via oxidative or immune mechanisms.

Supportive & Palliative Care

When cancer has spread to the liver, treatment is no longer just about shrinking tumours. It’s also about how you feel every single day – the pain, the tiredness, the nausea, the worry about what comes next.

Studies in advanced cancer and advanced liver disease show that 50–70% of patients live with significant pain, and most have several symptoms at the same time. In end-stage liver disease, fatigue affects more than 80%, pain affects around two-thirds, and loss of appetite affects over half of patients at the first palliative assessment.^[148]

Pain Control & Symptom Management

German palliative-care guidelines emphasise a few things that are especially important when advanced liver cancer is involved:^[147]

• Regular Pain Assessment. Not just “does it hurt?”, but where, when, how bad, and what makes it better or worse. Opioids are used without fear, but doses and intervals are adjusted carefully because damaged livers process medicines more slowly.^[149]
• Treating Liver Complications. Draining tense ascites, adjusting diuretics, treating constipation and nausea, correcting high calcium levels, managing itching and jaundice, and monitoring for hepatic encephalopathy – all of these can reduce pain and distress, even if they don’t directly target the tumour.^[147][150]
• Early Palliative Care. Randomised trials in advanced cancer show that patients who receive early, integrated palliative care have better quality of life, less depression, and often live as long or longer than those who only get standard oncology.^[151]

A structured approach, including specialist palliative wards in university hospitals in Germany, outpatient palliative teams, and a legal framework for specialized outpatient palliative care, supports this. The idea is not to “give up”, but to protect comfort and independence. At the same time, tumour-directed treatments continue, and to shift gently towards pure comfort when those treatments no longer help.

Nutrition, Psychological & Social Support

Advanced cancer treatment almost always affects eating and weight. Between 40% and 80% of people with advanced cancer develop cancer-related weight loss and muscle wasting (cachexia), and this is particularly common when the liver is heavily involved.^[152] Guidelines from ESPEN and ESMO recommend that every patient with advanced cancer be screened early for malnutrition and offered structured nutritional support, initially through counseling and energy-rich foods, then through oral supplements, and, in select cases, through tube feeding or intravenous nutrition.^[153][154]

In practice, this means that in German cancer hospitals and many outpatient practices, a dietitian becomes part of the team as soon as weight loss, poor appetite, or swallowing problems are observed. For a patient with liver metastases, the goal is often modest but realistic: to slow down weight loss, maintain strength for as long as possible, and adjust meals so that eating is not a daily battle. Small, frequent, protein-rich portions, careful management of nausea and taste changes, and realistic expectations (the aim is stability, not body-building) are the key messages.

On the emotional side, the numbers are just as precise. Studies show that up to half of all cancer patients experience clinically relevant psychological distress, and about one third develop a diagnosable anxiety or depressive disorder at some point. In Germany, the S3 Psycho-Oncology guideline therefore recommends that all oncology patients be screened for distress using brief questionnaires, and that those who “flag positive” be proactively offered psycho-oncological counseling.^[155][156]

Find care

Best Clinics in Germany for Liver Metastases

Choosing a clinic for liver metastases is less about a shiny building and more about how often they really treat complex liver cases and how many tools they can combine. Below is a brief overview of the liver cancer metastases treatment clinics in Germany, focusing on our main point and highlighting their key features.

University & Comprehensive Cancer Centers

Here we mention liver cancer-oriented centers of the top level within university facilities. It combined high-level academic achievements with rapid innovation in daily care.

University Hospital Frankfurt of Goethe University

Frankfurt is one of the best-known destinations in Europe for minimally invasive treatment of liver metastases. The Institute for Diagnostic and Interventional Radiology, headed by Prof. Thomas J. Vogl, has been publishing on TACE, radiofrequency, and microwave ablation, as well as other interventional methods, for decades.^[94][95][96] This specialized interventional radiology department emphasizes that TACE is performed “regularly” for liver lesions and is tailored to each patient, rather than rigidly prescribed by a protocol.

For patients with inoperable or liver-dominant metastases who are specifically seeking TACE, RFA, MWA, or SIRT at a single location, University Hospital Frankfurt is often considered a reference center.

University Hospital Rechts der Isar of Technical University Munich

Rechts der Isar is a powerful center for complex liver surgery. The Department of Surgery, led by Prof. Dr. Helmut Michael Friess, lists it among the top German clinics for extensive liver resection, with dedicated hepatobiliary surgery programmes.^[157] The surgical unit is actively involved in liver research (for example, work on how gut bacteria influence liver repair after injury), which informs modern peri-operative care for patients who require major resections or two-stage procedures.

For someone who clearly needs big liver surgery or a delicate hepatic intervention, University Hospital Rechts der Isar in Munich is one of the leading university options.

University Hospital Heidelberg

Heidelberg combines a very high volume of liver surgery with full access to interventional and systemic therapies. The Liver Cancer Center Heidelberg is explicitly described as “one of the most experienced and largest liver surgery units in Europe”, and the liver transplantation centre was the most comprehensive in Germany in 2013.^[158] The unit has been certified as a Liver Cancer Center by the German Cancer Society since 2024, which means regular audits of structures, outcomes, and multidisciplinary tumour boards. Together with the National Center for Tumor Diseases in Heidelberg, it can offer the full spectrum: high-end liver surgery, transplantation (for selected indications), interventional oncology, and state-of-the-art systemic therapies, all on one campus.^[159]

Due to this mix, University Hospital Heidelberg is often regarded as one of the strongest all-round options for patients exploring metastatic liver cancer treatment, particularly when surgical, radiological, and interventional procedures are considered.

Specialized Liver Cancer Clinics

Among the top clinics for liver metastases treatment in Germany, private facilities take an essential role. Frequently, private specialized hospitals can offer unique and limited therapies not widely available elsewhere. Additionally, for patients requiring extra comfort, this is a go-to option.

Helios Hospital Berlin-Buch

Within the private network, Helios Berlin-Buch stands out for advanced liver surgery, including ALPPS and two-stage procedures. In 2024, the hospital reported a successful ALPPS operation on a 44-year-old woman with multiple liver spots; all metastases were removed over two stages, and the case was presented as a new flagship approach for the clinic.^[160] The liver programme is led by Prof. Roger Wahba, a renowned hepatobiliary surgeon who now heads the Department of General, Visceral, and Oncologic Surgery, focusing on major liver resections and complex metastasis surgery.

Helios Hospital Berlin-Buch also operates a comprehensive oncology centre, featuring modern techniques such as regional chemotherapy, intraoperative electron beam therapy, and thermal tumour destruction. For patients seeking cutting-edge liver surgery in a high-tech private setting, especially for ALPPS or multi-stage resections, this clinic is often at the top of the short list.

Oncological Medias Clinic Burghausen

Medias Klinikum is a private oncology hospital in Burghausen that has specialised in regional chemotherapy for over 40 years.^[161] Precisely the targeted arterial infusions and chemoembolisation that are crucial when metastases are primarily confined to the liver.^[162] Many patients arrive there “weitgehend als austherapiert” – essentially outside of standard options.^[163] They are then offered regional treatment options, such as isolated liver perfusion, arterial infusion, and chemoembolization, for liver tumors.

For someone who has already undergone conventional systemic therapy and is now seeking regional treatment options (for example, repeated intra-arterial chemotherapy to the liver), Medias is one of the best-known specialized clinics in Germany.

Choose a clinic

Costs of Liver Metastasis Treatment in Germany

When planning stage-4 liver metastasis treatment in Germany, two key factors matter: medical options and their actual costs. Below is a rough price map for the main treatments of liver metastases.

Comparison Cost Table

Real costs vary by clinic & doctor, disease complexity, and length of stay, so consider them as an orientation, not a final quote.

Get personal cost

FAQ

References

1. Cancer Research UK. (2023, July 24). What is secondary liver cancer?. Retrieved November 2025.
2. Bundesministerium für Gesundheit. (2023, December 8). Liver cancer: risk factors, diagnosis, therapy. Retrieved October 2025.
3. Cancer Council Australia. (2024, July). Understanding Secondary Liver Cancer. Retrieved November 2025.
4. Cancer Council NSW. (n.d.). What is Secondary Liver Cancer?. Retrieved November 2025.
5. Boston Scientific Corporation. (2023). Understanding Liver Cancer: A guide to help you learn more about hepatocellular carcinoma (HCC) and treatment options. Retrieved October 2025.
6. Suddle, A., Reeves, H., Hubner, R., et al. (2024, July 11). British Society of Gastroenterology guidelines for the management of hepatocellular carcinoma in adults. Gut, 73(8), 1235–1268. https://doi.org/10.1136/gutjnl-2023-331695. Retrieved October 2025.
7. Amin, N., Anwar, J., Sulaiman, A., Naumova, N. N., & Anwar, N. (2025). Hepatocellular Carcinoma: A Comprehensive Review. Diseases, 13(7), 207. https://doi.org/10.3390/diseases13070207. Retrieved November 2025.
8. Voesch, S., Bitzer, M., Albert, J., et al. (2022). S3-Leitlinie: Diagnostik und Therapie des hepatozellulären Karzinoms (Langversion 2.0 – Juni 2021, AWMF-Registernummer: 032-053OL). Zeitschrift für Gastroenterologie, 60(1), e56–e130. https://doi.org/10.1055/a-1589-7568. Retrieved November 2025.
9. Pereira, P. L., Vogl, T. J., & Helmberger, T. (2022, February 18). Radiologische Aspekte der neuen deutschen S3-Leitlinie zum hepatozellulären Karzinom und biliären Karzinomen im internationalen Vergleich. Der Radiologe, 62, 253–262. https://doi.org/10.1007/s00117-022-00968-x. Retrieved October 2025.
10. de Ridder, J., de Wilt, J. H. W., Simmer, F., Overbeek, L., Lemmens, V., & Nagtegaal, I. (2016, July 13). Incidence and origin of histologically confirmed liver metastases: an explorative case-study of 23,154 patients. Oncotarget, 7(34), 55368–55376. https://doi.org/10.18632/oncotarget.10552. Retrieved November 2025.
11. Gosztonyi, B., Pestalozzi, B., Kenkel, D., Engel-Bicik, I., Kaufmann, P. A., Treyer, V., & Siebenhüner, A. R. (2022, December). A descriptive analysis of the characteristics, treatment response and prognosis of hepatic dominant solid tumors undergoing selective internal radiation therapy (SIRT). Journal of Gastrointestinal Oncology, 13(6), 3240–3253. https://doi.org/10.21037/jgo-22-122. Retrieved November 2025.
12. Thobe, M. N., Clark, R. J., Bainer, R. O., Prasad, S. M., & Rinker-Schaeffer, C. W. (2011, January 27). From Prostate to Bone: Key Players in Prostate Cancer Bone Metastasis. Cancers, 3(1), 478–493. https://doi.org/10.3390/cancers3010478. Retrieved November 2025.
13. Ebrahim, N. A. A., Farghaly, T. A., El-Sherif, A. A., Fahmy, A. M., Othman, M. O. O., Tahoun, N. S., Korany, O. M., Arafat, A., Oreaba, R., & Soliman, S. M. A. (2025). Clinicopathological insights and management of liver metastases: Current advances and future perspectives. World Journal of Hepatology, 17(10), 110026. https://doi.org/10.4254/wjh.v17.i10.110026. Retrieved November 2025.
14. Deutsches Krebsforschungszentrum (DKFZ), Krebsinformationsdienst. (2020). Lebermetastasen bei Krebs – Entstehung, Diagnose und Behandlung. Retrieved November 2025.
15. Universitätsklinikum Heidelberg. Lebermetastasen. Retrieved November 2025.
16. Universitätsklinikum Würzburg, Medizinische Klinik II – Hepatologie. Lebermetastasen. Retrieved November 2025.
17. Deutsche Krebsgesellschaft, Onko-Internetportal. Definition und Häufigkeit von Darmkrebs. Retrieved November 2025.
18. Living Beyond Breast Cancer (LBBC). (2022, July 9). Liver metastases. Retrieved November 2025.
19. Wu, L., Zhu, L., Xu, K., Zhou, S., Zhou, Y., Zhang, T., Hang, J., & Zee, B. C.-Y. (2021, January 18). Clinical significance of site-specific metastases in pancreatic cancer: a study based on both clinical trial and real-world data. Journal of Cancer, 12(6), 1715–1721. https://doi.org/10.7150/jca.50317. Retrieved October 2025.
20. Dong, Q., Huang, M., & Lai, X. (2024, October 29). Metastasis patterns and prognosis in patients with gastric cancer: a Surveillance, Epidemiology, and End Results-based analysis. Journal of Gastrointestinal Oncology, 15(5), 2079–2087. https://doi.org/10.21037/jgo-24-738. Retrieved November 2025.
21. Dong, D., Gao, Y., Fan, G., Jiang, N., & Jiang, X. (2024, August 6). Cellular and molecular mechanisms of gastrointestinal cancer liver metastases and drug resistance. Drug Resistance Updates, 77, 101125. https://doi.org/10.1016/j.drup.2024.101125. Retrieved November 2025.
22. Universitätsklinikum Würzburg, Leberzentrum. Lebermetastasen. Retrieved November 2025.
23. Gandaglia, G., Abdollah, F., Schiffmann, J., Trudeau, V., Shariat, S. F., Kim, S. P., et al. Distribution of metastatic sites in patients with prostate cancer: A population-based analysis. (2014). Prostate, 74(2), 210–216. Retrieved November 2025.
24. Verry, C., Vincendeau, S., Massetti, M., Blachier, M., Vimont, A., Bazil, M.-L., et al. (2022, July 16). Pattern of clinical progression until metastatic castration-resistant prostate cancer: An epidemiological study from the European Prostate Cancer Registry. Targeted Oncology, 17(4), 441–451. Retrieved November 2025.
25. Solis-Pazmino, D., et al. (2025, July). Liver metastases from oropharyngeal squamous cell carcinoma. Journal of Surgical Case Reports, 2025(7), rjaf417. Retrieved November 2025.
26. Xu, M.-L., Wang, Y.-Y., Xie, L.-P., Ding, N., & Hui, J.-J. (2025, July 25). Liver metastases in thyroid cancer: epidemiology, risk stratification and survival outcomes in the immunotherapy era. Frontiers in Immunology, 16, 1624181. Retrieved November 2025.
27. Sundararajan, S., Thida, A. M., Yadlapati, S., Mukkamalla, S. K. R., & Koya, S. (2024). Metastatic Melanoma. In StatPearls [Internet]. StatPearls Publishing. Retrieved November 2025.
28. American Lung Association. (2025, September 5). Liver Metastasis from Lung Cancer. Retrieved November 2025.
29. McKay, R. R., Kroeger, N., Xie, W., Lee, J.-L., Knox, J. J., Bjarnason, G. A., et al. (2014, March). Impact of bone and liver metastases on patients with renal cell carcinoma treated with targeted therapy. European Urology, 65(3), 577–584. Retrieved November 2025.
30. Canadian Cancer Society. Liver metastases. Retrieved November 2025.
31. Krebsinformationsdienst, Deutsches Krebsforschungszentrum (DKFZ). (2020, July 7). Lebermetastasen: Symptome und Diagnose. Retrieved November 2025.
32. The Christie NHS Foundation Trust. Secondary liver cancer. Retrieved November 2025.
33. Cancer Council NSW. Secondary Liver Cancer Symptoms. Retrieved November 2025.
34. Guts UK Charity. Liver Cancer | Symptoms, Causes, Treatment and Support. Retrieved November 2025.
35. Deutsche Krebshilfe. Onkologische Spitzenzentren. Retrieved November 2025.
36. Zentrum für Krebsregisterdaten, Robert Koch-Institut. (2018). Krebsdiagnosen im Lebensverlauf. Retrieved November 2025.
37. Universität Duisburg-Essen. (2023, August 8). New at UDE/UK Essen: Barbara T. Grünwald. Retrieved November 2025.
38. Deutsche Krebsgesellschaft. (2025). Zertifizierung von Krebszentren. Retrieved November 2025.
39. Comprehensive Cancer Center München TUM. Leberboard / Lebertumore. Retrieved November 2025.
40. Krause, A., Stocker, G., Gockel, I., Seehofer, D., Hoffmeister, A., Bläker, H., Denecke, T., Kluge, R., Lordick, F., & Knödler, M. (2023). Guideline adherence and implementation of tumor board therapy recommendations for patients with gastrointestinal cancer. Journal of Cancer Research and Clinical Oncology, 149(3), 1231–1240. https://doi.org/10.10
41. Völkel, V., Gerken, M., Kleihues-van Tol, K., Schoffer, O., Bierbaum, V., Bobeth, C., Roessler, M., Reissfelder, C., Fürst, A., Benz, S., Rau, B. M., Piso, P., Distler, M., Günster, C., Hansinger, J., Schmitt, J., & Klinkhammer-Schalke, M. (2023, September 15). Treatment of Colorectal Cancer in Certified Centers: Results of a Large German Registry Study Focusing on Long-Term Survival. Cancers, 15(18), 4568. https://doi.org/10.3390/cancers15184568. Retrieved November 2025.
42. Krause, A., Stocker, G., Gockel, I., Seehofer, D., Hoffmann, A., Bläker, H., Denecke, T., Kluge, R., Lordick, F., & Knoedler, M. (2022, January 11). Guideline Adherence and Implementation of Tumor Board Therapy Recommendations for Patients With Gastrointestinal Cancer. Research Square (preprint). https://doi.org/10.21203/rs.3.rs-1236704/v1. Retrieved November 2025.
43. AlFarhan, H. A., Algwaiz, G. F., Alzahrani, H. A., Alsuhaibani, R. S., Alolayan, A. S., Abdelhafiz, N., et al. (2018). Impact of GI Tumor Board on Patient Management and Adherence to Guidelines. Journal of Global Oncology, 4, 1–8. https://doi.org/10.1200/JGO.17.00164. Retrieved November 2025.
44. Alsuhaibani, R. S., Alzahrani, H., Algwaiz, G., Alfarhan, H., Alolayan, A., Abdelhafiz, N., et al. (2018). Enhancing the performance of gastrointestinal tumour board by improving documentation. BMJ Open Quality, 7(1), e000168. https://doi.org/10.1136/bmjoq-2017-000168. Retrieved November 2025.
45. Vista Mediclub. Metastatic Colorectal Cancer. Retrieved November 2025.
46. OECD. (2025, November 13). Health at a Glance 2025: Germany (Country note). Retrieved November 2025.
47. OECD. (2025). Health at a Glance 2025: Germany (Country note, PDF). Retrieved November 2025.
48. Eurostat. (2025, August 13). Healthcare resource statistics – technical resources and medical technology. Statistics Explained. Retrieved November 2025.
49. Holzgreve, A., Hellwig, D., Barthel, H., Beer, A. J., Kobe, C., Lapa, C., et al. (2025, May 3). PET imaging utilization and trends in Germany: A comprehensive survey. European Journal of Nuclear Medicine and Molecular Imaging, 52, 4390–4398. https://doi.org/10.1007/s00259-025-07323-x. Retrieved October 2025.
50. Freitas, P. S., Janicas, C., Veiga, J., Matos, A. P., Herédia, V., & Ramalho, M. (2021, December 27). Imaging evaluation of the liver in oncology patients: A comparison of techniques. World Journal of Hepatology, 13(12), 1936–1955. https://doi.org/10.4254/wjh.v13.i12.1936. Retrieved October 2025.
51. Cervantes, A., Adam, R., Roselló, S., Arnold, D., Normanno, N., Taieb, J., et al. (2023, January). Metastatic colorectal cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Annals of Oncology, 34(1), 10–32. https://doi.org/10.1016/j.annonc.2022.10.003. Retrieved October 2025.
52. Hackl, C., Neumann, P., Gerken, M., Loss, M., Klinkhammer-Schalke, M., & Schlitt, H. J. (2014, November 4). Treatment of colorectal liver metastases in Germany: A ten-year population-based analysis of 5772 cases of primary colorectal adenocarcinoma. BMC Cancer, 14, 810. https://doi.org/10.1186/1471-2407-14-810. Retrieved November 2025.
53. Filmann, N., Walter, D., Schadde, E., Bruns, C., Keck, T., Lang, H., Oldhafer, K., Schlitt, H. J., Schön, M. R., Herrmann, E., Bechstein, W. O., & Schnitzbauer, A. A. (2019, October). Mortality after liver surgery in Germany. British Journal of Surgery, 106(11), 1523–1529. https://doi.org/10.1002/bjs.11236. Retrieved November 2025.
54. Mertens, A., Essing, T., Minko, P., Möllenhoff, K., Mattes-György, K., Giesel, F. L., Antoch, G., Luedde, T., Roderburg, C., & Loosen, S. H. (2023, March 28). Selective internal radiotherapy in Germany: A review of indications and hospital mortality from 2012 to 2019. Journal of Clinical and Translational Research, 9(2), 123–132. https://doi.org/10.18053/jctres.09.202302.009. Retrieved November 2025.
55. Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF). (2021). Diagnostik und Therapie des Hepatozellulären Karzinoms und biliärer Karzinome. Langversion 2.0. S3-Leitlinie, AWMF-Registernummer 032/053OL. Retrieved November 2025.
56. Milana, F., Famularo, S., Luberto, A., Rimassa, L., Scorsetti, M., Comito, T., … Torzilli, G. (2022, August 16). Multidisciplinary Tumor Board in the Management of Patients with Colorectal Liver Metastases: A Single-Center Review of 847 Patients. Cancers, 14(16), 3952. Retrieved November 2025.
57. Pagani, M., De Vincenti, R., Cecchi, C., Apollinari, A., Pesi, B., Leo, F., … Fedi, M. (2023, March 10). Hepatic Resection in Patients with Colo-Rectal Liver Metastases: Surgical Outcomes and Prognostic Factors of Single-Center Experience. Journal of Clinical Medicine, 12(6), 2170. Retrieved November 2025.
58. Kow, A. W. C. (2019, December). Hepatic metastasis from colorectal cancer. Journal of Gastrointestinal Oncology, 10(6), 1274–1298. Retrieved November 2025.
59. Marschner, N., Seufferlein, T., Potthoff, K., Zahn, M.-O., Uhlig, J., Dörfel, S., … Jänicke, M. (2024, June). Changes in survival of >3800 patients with metastatic colorectal cancer in Germany: results from a 16-year prospective longitudinal real-world data analysis. ESMO Real World Data and Digital Oncology, 4, 100040. Retrieved November 2025.
60. Stüber, T. N., Handke, M., Lang, S., & Liese, J. (2022, April). Hospital volume and postoperative mortality after liver resection: a systematic review and meta-analysis. Best Practice & Research Clinical Anaesthesiology, 36(2), 303–313. https://doi.org/10.1016/j.bpa.2022.04.004. Retrieved November 2025.
61. Krieg, S., Essing, T., Krieg, A., Roderburg, C., Luedde, T., & Loosen, S. H. (2022, April 22). Recent Trends and In-Hospital Mortality of Transarterial Chemoembolization (TACE) in Germany: A Systematic Analysis of Hospital Discharge Data between 2010 and 2019. Cancers, 14(9), 2088. https://doi.org/10.3390/cancers14092088. Retrieved November 2025.
62. Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG). (2025, March 5). Major-Leberresektionen: Erfolgsaussichten steigen mit höheren Fallzahlen. Retrieved November 2025.
63. Andratschke, N., Alheid, H., Allgäuer, M., Becker, G., Blanck, O., Boda-Heggemann, J., et al. (2018, March 13). The SBRT database initiative of the German Society for Radiation Oncology (DEGRO): Patterns of care and outcome analysis of stereotactic body radiotherapy (SBRT) for liver oligometastases in 474 patients with 623 metastases. BMC Cancer, 18, 283. https://doi.org/10.1186/s12885-018-4191-2. Retrieved November 2025.
64. Horst, F., Bodenstein, E., Baumann, M., Beyreuther, E., Bokor, J., Enghardt, W., et al. (2025, June 5). The research beamlines at the Dresden proton therapy facility: available infrastructure and experimental capabilities. Frontiers in Oncology, 15, 1594973. https://doi.org/10.3389/fonc.2025.1594973. Retrieved November 2025.
65. ProtonTherapy.help. Proton Therapy Guide. Retrieved November 2025.
66. OnkoZert. (2025, November 18). OncoMap – Liste der zertifizierten Krebszentren. Retrieved October 2025.
67. Yamamura, K., Beppu, T., Miyata, T., Okabe, H., Imai, K., & Ishiko, T. (2023, March 24). A novel comprehensive ALPPS preoperative risk assessment (CAPRA) score is beneficial in creating a treatment strategy for advanced liver malignancy. Hepatobiliary Surgery and Nutrition, 12(2), 287–290. https://doi.org/10.21037/hbsn-23-121. Retrieved November 2025.
68. Bundesministerium für Gesundheit. ICD-Code C78.7: Secondary malignant neoplasm of liver and intrahepatic bile ducts. Retrieved November 2025.
69. German Clinical Trials Register (DRKS). (2025). Anatomical Resection of liver MetAstases iN patIents with RAS-mutated colorectal cancer (ARMANI) – DRKS00023792. Retrieved October 2025.
70. German Clinical Trials Register (DRKS). (2025). MR MIGHTY trial – Evaluation and optimization of MR-guided microwave ablation (MWA) of liver tumors avoiding ionizing radiation (DRKS00031953). Retrieved October 2025.
71. Cleveland Clinic. (2022, April 29). Hepatectomy (Liver Resection) Surgery: Procedure & Recovery. Retrieved November 2025.
72. Aragon, R. J., & Solomon, N. L. (2012). Techniques of hepatic resection. Journal of Gastrointestinal Oncology, 3(1), 28–40. https://doi.org/10.3978/j.issn.2078-6891.2012.006. Retrieved November 2025.
73. Abbas, S., Lam, V., & Hollands, M. (2011). Ten-year survival after liver resection for colorectal metastases: Systematic review and meta-analysis. ISRN Oncology, 2011, Article 763245. https://doi.org/10.5402/2011/763245. Retrieved November 2025.
74. Al-Qahtani, M., Alqahtani, S., Privitera, A., Al-Rashid, F., & Osian, G. (2016). Current Management of Colorectal Cancer with Liver Metastasis. Surgical Oncology & Clinical Practice Journal, 1(1), 1001. Retrieved November 2025.
75. Lorenz, E., Arend, J., Franz, M., Rahimli, M., Perrakis, A., Negrini, V., Gumbs, A. A., & Croner, R. S. (2021). Robotic and laparoscopic liver resection—comparative experiences at a high-volume German academic center. Langenbeck’s Archives of Surgery, 406(3), 753–761. https://doi.org/10.1007/s00423-021-02152-6. Retrieved November 2025.
76. Heil, J., & Schadde, E. (2021, August). Simultaneous portal and hepatic vein embolization before major liver resection. Langenbeck’s Archives of Surgery, 406(5), 1295–1305. https://doi.org/10.1007/s00423-020-01960-6. Retrieved November 2025.
77. Brouquet, A., Abdalla, E. K., Kopetz, S., Garrett, C. R., Overman, M. J., Eng, C., Andreou, A., Loyer, E. M., Madoff, D. C., Curley, S. A., & Vauthey, J.-N. (2011, March 20). High survival rate after two-stage resection of advanced colorectal liver metastases: Response-based selection and complete resection define outcome. Journal of Clinical Oncology, 29(8), 1083–1090. https://doi.org/10.1200/JCO.2010.32.6132. Retrieved November 2025.
78. DRAGON Collaborative. (2025). Welcome to DRAGON Collaborative. Retrieved November 2025.
79. Linecker, M., Petrowsky, H., & Clavien, P.-A. (2017). Two-Stage Liver Surgery with Portal Vein Occlusion. In E. de Santibañes, V. Ardiles, F. Alvarez, V. Busnelli, & M. de Santibañes (Eds.), Extreme Hepatic Surgery and Other Strategies: Increasing Resectability in Colorectal Liver Metastases (pp. 217–230). Springer. Retrieved November 2025.
80. Lang, H., Baumgart, J., & Mittler, J. (2020, November 15). Associated Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Registry: What Have We Learned? Gut and Liver, 14(6), 699–706. https://doi.org/10.5009/gnl19233. Retrieved November 2025.
81. Sretenovic, A., Nikolic, S., Krstovski, N., Zdujic, N., Slavkovic, M., Dasic, I., & Nikolic, D. (2025, February 21). Associating Liver Partition with Portal Vein Ligation and Staged Hepatectomy (ALPPS): Feasibility of Performing in Infants with Large Hepatic Tumor—Case Report. Healthcare, 13(5), 460. https://doi.org/10.3390/healthcare13050460. Retrieved November 2025.
82. Zhou, J., & Peng, Y. (2025, July 18). General Introduction. In J. Zhou (Ed.), Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) (pp. 1–33). Springer Singapore. https://doi.org/10.1007/978-981-96-7364-3_1. Retrieved November 2025.
83. Imai, K., Adam, R., Baba, H., et al. (2019, July 11). How to Increase the Resectability of Initially Unresectable Colorectal Liver Metastases: A Surgical Perspective. Annals of Gastroenterological Surgery, 3(5), 476–486. https://doi.org/10.1002/ags3.12276. Retrieved November 2025.
84. Sandström, P., Røsok, B. I., Sparrelid, E., Larsen, P. N., Larsson, A. L., Lindell, G., Schultz, N. A., Bjørnbeth, B. A., Isaksson, B., Rizell, M., & Björnsson, B. (2018, May). ALPPS Improves Resectability Compared with Conventional Two-Stage Hepatectomy in Patients with Advanced Colorectal Liver Metastasis: Results from a Scandinavian Multicenter Randomized Controlled Trial (LIGRO Trial). Annals of Surgery, 267(5), 833–840. https://doi.org/10.1097/SLA.0000000000002511. Retrieved November 2025.
85. Lang, H., Oldhafer, K. J., Weimann, A., Malagó, M., Nadalin, S., & Raab, R. (1999). Liver transplantation for hepatic metastases of neuroendocrine pancreatic tumors. Langenbeck’s Archives of Surgery, 384(4), 345–350. https://doi.org/10.1007/s004230050216. Retrieved November 2025.
86. Puia-Negulescu, S., Lebossé, F., Mabrut, J.-Y., Muller, X., Rossignol, G., Antonini, T., Erard, D., Radenne, S., Guillet, M., Souquet, J.-C., Mohkam, K., & Lesurtel, M. (2021, March 11). Liver Transplantation for Colorectal Liver Metastases: Current Management and Future Perspectives. International Journal of Molecular Sciences, 22(6), 3093. https://doi.org/10.3390/ijms22063093. Retrieved November 2025.
87. Zensen, S., Bücker, A., Meetschen, M., Haubold, J., Opitz, M., Theysohn, J. M., Schramm, S., Jochheim, L., Kasper, S., Forsting, M., & Schaarschmidt, B. M. (2024, May). Current use of percutaneous image-guided tumor ablation for the therapy of liver tumors: lessons learned from the registry of the German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR) 2018–2022. European Radiology, 34, 3322–3330. https://doi.org/10.1007/s00330-023-10412-w. Retrieved November 2025.
88. Olthof, S.-C., Wessling, D., Winkelmann, M. T., Rempp, H., Nikolaou, K., Hofmann, R., & Clasen, S. (2022, March 21). Single-centre survival analysis over 10 years after MR-guided radiofrequency ablation of liver metastases from different tumour entities. Insights into Imaging, 13(1), 48. https://doi.org/10.1186/s13244-022-01178-8. Retrieved November 2025.
89. Zhukova, Y. (2010). Die Radiofrequenzablation als alternative Behandlung von Lebertumoren. Dissertation, Charité – Universitätsmedizin Berlin. Retrieved November 2025.
90. Tatli, S., Tapan, Ü., Morrison, P. R., & Silverman, S. G. (2012). Radiofrequency ablation: technique and clinical applications. Diagnostic and Interventional Radiology, 18(5), 508–516. https://doi.org/10.4261/1305-3825.DIR.5168-11.1. Retrieved November 2025.
91. Pereira, P. L., Boss, A., Clasen, S., Gouttefangeas, C., Schmidt, D., & Claussen, C. D. (2006). Radiofrequency Ablation: The Percutaneous Approach. In C. Stroszczynski (Ed.), Minimally Invasive Tumor Therapies (Recent Results in Cancer Research, Vol. 167, pp. 39–52). Springer, Berlin, Heidelberg. https://doi.org/10.1007/3-540-28137-1_3. Retrieved November 2025.
92. Cirimbei, C., et al. (2017). Immediate and Long-term Results of Radiofrequency Ablation for Colorectal Liver Metastases. Anticancer Research, 37(11), 6489–6494. https://doi.org/10.21873/anticanres.12105. Retrieved November 2025.
93. Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF). (2019). S3-Leitlinie Kolorektales Karzinom. Langversion 2.1 – Januar 2019. AWMF-Registernummer 021/007OL. Retrieved November 2025.
94. Vogl, T. J., Nour-Eldin, N. A., Hammerstingl, R. M., Panahi, B., & Naguib, N. N. N. (2017, August 23). Microwave Ablation (MWA): Basics, Technique and Results in Primary and Metastatic Liver Neoplasms – Review Article. Fortschr Röntgenstr, 189, 1055–1066. https://doi.org/10.1055/s-0043-117410. Retrieved November 2025.
95. Vogl, T. J., Mack, M., Eichler, K., Lehnert, T., & Nabil, M. (2007). Laser-induced thermoablation and regional chemotherapy of liver metastases. In Interventional Oncology. Retrieved November 2025.
96. Blauth, S., Hübner, F., Leithäuser, C., Siedow, N., & Vogl, T. J. (2019, October 28). Mathematical Modeling of Vaporization during Laser-Induced Thermotherapy in Liver Tissue. arXiv preprint arXiv:1910.12515. https://doi.org/10.48550/arXiv.1910.12515. Retrieved November 2025.
97. Isbert, C., Ritz, J. P., Schilling, A., Roggan, A, Heiniche, A., Wolf, K. J., Müller, G., Buhr, H. J., & Germer, C. T. (2002). Laser induced thermotherapy (LITT) of experimental liver metastases – detection of residual tumors using Gd-DTPA enhanced MRI. Lasers in Surgery and Medicine, 30(4), 280–289. https://doi.org/10.1002/lsm.10041. Retrieved November 2025.
98. Murphy, K. P., Maher, M. M., & O’Connor, O. J. (2015, May). Abdominal ablation techniques. AJR American Journal of Roentgenology, 204(5), W495–W502. https://doi.org/10.2214/AJR.14.13222. Retrieved November 2025.
99. Keßler, D. E., Pereira, P. L., Clasen, S., & Claussen, C. D. (2015, March 10). Thermoablation. Radiologie up2date, 15(1), 43–63. https://doi.org/10.1055/s-0034-1391368. Retrieved November 2025.
100. Song, K. D. (2016, December 25). Percutaneous cryoablation for hepatocellular carcinoma. Clinical and Molecular Hepatology, 22(4), 509–515. https://doi.org/10.3350/cmh.2016.0079. Retrieved November 2025.
101. Düx, D. M., Heidrich, B., Wacker, F., & Ringe, K. I. (2025, August 12). Percutaneous Cryoablation of Central Liver Tumors with Thermal Protection of the Bile Duct. CardioVascular and Interventional Radiology, 48(9), 1361–1368. https://doi.org/10.1007/s00270-025-04146-z. Retrieved November 2025.
102. ScienceDirect. Irreversible electroporation – an overview. Retrieved November 2025.
103. Deipolyi, A. R., Golberg, A., Yarmush, M. L., Arellano, R. S., & Oklu, R. (2014, March–April). Irreversible electroporation: Evolution of a laboratory technique in interventional oncology. Diagnostic and Interventional Radiology, 20(2), 147–154. https://doi.org/10.5152/dir.2013.13304. Retrieved November 2025.
104. Niessen, C., Thumann, S., Beyer, L. P., Pregler, B., Kramer, J., Müller-Wille, R., Stroszczynski, C., & Wiggermann, P. (2017, March 7). Percutaneous irreversible electroporation: Long-term survival analysis of 71 patients with inoperable malignant hepatic tumors. Scientific Reports, 7, 43687. https://doi.org/10.1038/srep43687. Retrieved November 2025.
105. National Institute for Health and Care Excellence (NICE). (2019, November 27). Irreversible electroporation for primary liver cancer (IPG664). Interventional procedures guidance. Retrieved November 2025.
106. Cheung, T. T., Ma, K. W., & She, W. H. (2021). A review on radiofrequency, microwave and high-intensity focused ultrasound ablations for hepatocellular carcinoma with cirrhosis. Hepatobiliary Surgery and Nutrition, 10(2), 193–209. Retrieved November 2025.
107. Rahpeima, R., & Lin, C.-A. (2024, October 1). A comprehensive numerical procedure for high-intensity focused ultrasound ablation of breast tumour on an anatomically realistic breast phantom. PLOS ONE, 19(10), e0310899. Retrieved November 2025.
108. German Clinical Trials Register (DRKS). (2017; updated 2024). Prospective, single-center, randomized, two-arm, open phase I / II study on feasibility, safety and efficacy of local treatment with high intensity focused ultrasound (HIFU) in combination with standard chemotherapy in patients with inoperable pancreatic cancer. Retrieved November 2025.
109. Marinova, M., Rauch, M., Mücke, M., Rolke, R., Gonzalez-Carmona, M. A., Henseler, J., et al. (2016). High-intensity focused ultrasound (HIFU) for pancreatic carcinoma: evaluation of feasibility, reduction of tumour volume and pain intensity. European Radiology. Retrieved November 2025.
110. Dupré, A., Melodelima, D., Perol, D., Chen, Y., Vincenot, J., Chapelon, J.-Y., & Rivoire, M. (2019, January 9). Evaluation of the Feasibility, Safety, and Accuracy of an Intraoperative High-intensity Focused Ultrasound Device for Treating Liver Metastases. Journal of Visualized Experiments, (143), e57964. Retrieved November 2025.
111. Orsi, F., Zhang, L., Arnone, P., Orgera, G., Bonomo, G., Vigna, P. D., et al. (2010). High-intensity focused ultrasound ablation: effective and safe therapy for solid tumors in difficult locations. AJR American Journal of Roentgenology, 195(3), W245–W252. Retrieved November 2025.
112. Li, Y.-K., Wu, S., Wu, Y.-S., Zhang, W.-H., Wang, Y., Li, Y.-H., Kang, Q., Huang, S.-Q., Zheng, K., Jiang, G.-M., Wang, Q.-B., Liang, Y.-B., Li, J., Lakang, Y., Yang, C., Li, J., Wang, J.-P., Kui, X., & Ke, Y. (2024, July 9). Portal Venous and Hepatic Arterial Coefficients Predict Post-Hepatectomy Overall and Recurrence-Free Survival in Patients with Hepatocellular Carcinoma: A Retrospective Study. Journal of Hepatocellular Carcinoma, 11, 1389–1402. https://doi.org/10.2147/JHC.S462168. Retrieved November 2025.
113. Wang, D., & Rao, W. (2023). Bench-to-bedside development of multifunctional flexible embolic agents. Theranostics, 13(7), 2114–2139. https://doi.org/10.7150/thno.80213. Retrieved November 2025.
114. Li, X., He, G., Su, F., Chu, Z., Xu, L., Zhang, Y., Zhou, J., & Ding, Y. (2020). Regorafenib-loaded poly (lactide-co-glycolide) microspheres designed to improve transarterial chemoembolization therapy for hepatocellular carcinoma. Asian Journal of Pharmaceutical Sciences, 15(6), 739–751. https://doi.org/10.1016/j.ajps.2020.01.001. Retrieved November 2025.
115. Biolato, M., Marrone, G., Racco, S., Di Stasi, C., Miele, L., Gasbarrini, G., Landolfi, R., & Grieco, A. (2010, April). Transarterial chemoembolization (TACE) for unresectable HCC: A new life begins?. European Review for Medical and Pharmacological Sciences, 14(4), 356–362. Retrieved November 2025.
116. Lanza, C., Ascenti, V., Amato, G. V., Pellegrino, G., Triggiani, S., Tintori, J., Intrieri, C., Angileri, S. A., Biondetti, P., Carriero, S., Torcia, P., Ierardi, A. M., & Carrafiello, G. (2025, January 7). All You Need to Know About TACE: A Comprehensive Review of Indications, Techniques, Efficacy, Limits, and Technical Advancement. Journal of Clinical Medicine, 14(2), 314. https://doi.org/10.3390/jcm14020314. Retrieved November 2025.
117. Buisman, F. E., Homs, M. Y. V., Grünhagen, D. J., Filipe, W. F., Bennink, R. J., Besselink, M. G. H., et al. (2019, April 3). Adjuvant hepatic arterial infusion pump chemotherapy and resection versus resection alone in patients with low-risk resectable colorectal liver metastases – the multicenter randomized controlled PUMP trial. BMC Cancer, 19, 327. https://doi.org/10.1186/s12885-019-5515-6. Retrieved November 2025.
118. ProtonTherapy.help. University Hospital Heidelberg – Proton Therapy Center. Retrieved November 2025.
119. NHS England. (2018, December 28). Selective internal radiation therapy for chemotherapy refractory / intolerant metastatic colorectal cancer. Retrieved November 2025.
120. Thoduka, S. G., Flegar, L., Groeben, C., Huber, J., Eisenmenger, N., Paulus, T., Vogt, K., Luster, M., & Abolmaali, N. (2023). Trends in Selective Internal Radiation Therapy (SIRT) for Treating Hepatocellular Carcinoma, Cholangiocarcinoma, and Liver Metastasis: A Total Population Analysis from 2006 to 2021 in Germany. Current Oncology, 30(12), 10325–10335. https://doi.org/10.3390/curroncol30120752. Retrieved November 2025.
121. Walter, T., Hawkins, N. S., Pollock, R. F., Colaone, F., Shergill, S., & Ross, P. J. (2020, July 27). Systematic review and network meta-analyses of third-line treatments for metastatic colorectal cancer. Journal of Cancer Research and Clinical Oncology, 146(10), 2575–2587. https://doi.org/10.1007/s00432-020-03315-6. Retrieved November 2025.
122. House, M. G., Sikora, S. S., & Abdalla, E. K. (2010). Assessing the value of hepatic artery infusion chemotherapy for colorectal liver metastases. Chinese Clinical Oncology, 1(1), 16–23. Retrieved November 2025.
123. University of Toledo Health. Stereotactic Radiosurgery (SRS). Retrieved November 2025.
124. Salvatore, L., Aprile, G., Arnoldi, E., Aschele, C., Carnaghi, C., Cosimelli, M., Maiello, E., Normanno, N., Sciallero, S., Valvo, F., & Beretta, G. D. (2017, April 12). Management of metastatic colorectal cancer patients: guidelines of the Italian Medical Oncology Association (AIOM). ESMO Open, 2(1), e000147. https://doi.org/10.1136/esmoopen-2016-000147. Retrieved November 2025.
125. Gaede, S., & Lock, M. I. (2017, September 11). Advances in external beam stereotactic body radiotherapy: principle concerns in implementing a liver radiation program. Chinese Clinical Oncology, 6(Suppl 2), S13. https://doi.org/10.21037/cco.2017.06.25. Retrieved November 2025.
126. Sterzing, F., Brunner, T. B., Ernst, I., Baus, W. W., Greve, B., Herfarth, K., & Guckenberger, M. (2014, October). Stereotactic body radiotherapy for liver tumors: principles and practical guidelines of the DEGRO Working Group on Stereotactic Radiotherapy. Strahlentherapie und Onkologie, 190(10), 872–881. https://doi.org/10.1007/s00066-014-0714-1. Retrieved November 2025.
127. Voglhuber, T., Vogl, N., Weber, M., Combs, S. E., & Duma, M. N. (2021, July 8). Analysis of using high-precision radiotherapy in the treatment of liver metastases regarding toxicity and survival. BMC Cancer, 21, 784. https://doi.org/10.1186/s12885-021-08488-y. Retrieved November 2025.
128. Liu, H., & Chang, J. Y. (2011, May). Proton therapy in clinical practice. Chinese Journal of Cancer, 30(5), 315–326. https://doi.org/10.5732/cjc.010.10529. Retrieved November 2025.
129. Heidelberg University Hospital. (2025). Proton Beam Therapy and Carbon Ion Beam Therapy – High-Precision Cancer Treatment at Heidelberg Ion Beam Therapy Center (HIT). Retrieved November 2025.
130. Lischalk, J. W., König, L., Repka, M. C., Uhl, M., Dritschilo, A., Herfarth, K., & Debus, J. (2016, November 15). From Röntgen Rays to Carbon Ion Therapy: The Evolution of Modern Radiation Oncology in Germany. International Journal of Radiation Oncology, Biology, Physics, 96(4), 729–735. https://doi.org/10.1016/j.ijrobp.2016.08.026. Retrieved November 2025.
131. Hwang, S., Shin, D. J., Kang, B., Kang, H., Lee, S. H., Kim, J. S., et al. (2025, November 18). Clinical feasibility of ctDNA in patients with advanced hepatocellular carcinoma treated with atezolizumab plus bevacizumab. Liver Cancer. Advance online publication. https://doi.org/10.1159/000549565. Retrieved November 2025.
132. Goldberg, R. M. (2005, October). Advances in the treatment of metastatic colorectal cancer. The Oncologist, 10(Suppl 3), 40–48. https://doi.org/10.1634/theoncologist.10-90003-40. Retrieved November 2025.
133. Steup, C., Kennel, K. B., Neurath, M. F., Fichtner-Feigl, S., & Greten, F. R. (2025, December). Current and emerging concepts for systemic treatment of metastatic colorectal cancer. Gut, 74(12), 2070–2095. https://doi.org/10.1136/gutjnl-2025-335412. Retrieved November 2025.
134. Worldwide Cancer Research. (2025, June 17). What is immunotherapy? Retrieved November 2025.
135. André, T., Shiu, K.-K., Kim, T. W., Jensen, B. V., Jensen, L. H., Punt, C., et al. (2020, December 3). Pembrolizumab in microsatellite-instability–high advanced colorectal cancer. New England Journal of Medicine, 383(23), 2207–2218. https://doi.org/10.1056/NEJMoa2017699. Retrieved November 2025.
136. Gandhi, L., Rodríguez-Abreu, D., Gadgeel, S., Esteban, E., Felip, E., De Angelis, F., et al. (2018, May 31). Pembrolizumab plus chemotherapy in metastatic non–small-cell lung cancer. New England Journal of Medicine, 378(22), 2078–2092. https://doi.org/10.1056/NEJMoa1801005. Retrieved November 2025.
137. Wolchok, J. D., Chiarion-Sileni, V., Gonzalez, R., Grob, J.-J., Rutkowski, P., Lao, C. D., et al. (2024, September 16). Final, 10-year outcomes with nivolumab plus ipilimumab in advanced melanoma. New England Journal of Medicine, 391, 1234–1248. https://doi.org/10.1056/NEJMoa2407417. Retrieved November 2025.
138. Rini, B. I., Signoretti, S., Choueiri, T. K., McDermott, D. F., Motzer, R. J., George, S., et al. (2022, December). Long-term outcomes with nivolumab plus ipilimumab versus sunitinib in first-line treatment of patients with advanced sarcomatoid renal cell carcinoma. Journal for Immunotherapy of Cancer, 10(12), e005445. https://doi.org/10.1136/jitc-2022-005445. Retrieved November 2025.
139. Cortes, J., Cescon, D. W., Rugo, H. S., Nowecki, Z., Im, S.-A., Yusof, M. M., et al. (2022, July 21). Pembrolizumab plus chemotherapy in advanced triple-negative breast cancer. New England Journal of Medicine, 387(3), 217–226. https://doi.org/10.1056/NEJMoa2202809. Retrieved November 2025.
140. Stintzing, S., Modest, D. P., Benz, S., Kerkmann, M., & QS-mCRC Study Group. (2025, October). V372 Guideline adherence in clinical routine treatment of unresectable metastatic colorectal cancer in Germany: Real world data from the QS-mCRC Study (AIO-KRK-0424/ass). ResearchGate abstract. Retrieved November 2025.
141. Serra, C., Milana, F., Colasanti, M., Bimonte, D., Lorusso, V., Dalla Valle, R., & Torzilli, G. (2025, March 19). Liver surgery in colorectal cancer: past, present and future. Tumori Journal. https://doi.org/10.1177/03008916251336210. Retrieved November 2025.
142. Lee, C.-H., Lee, Y.-J., Kim, S. U., Cho, H., Baek, J. Y., Kim, D. Y., Ahn, S. H., Park, J. Y., Han, K.-H., & Chon, C. Y. (2017, May 8). Prognostic value of Barcelona Clinic Liver Cancer and Hong Kong Liver Cancer staging systems for hepatocellular carcinoma: A Korean cohort study. Frontiers in Oncology, 7, 132. https://doi.org/10.3389/fonc.2017.00132. Retrieved November 2025.
143. Società Italiana di Andrologia e Medicina della Sessualità (SIAMS). (2022). Linee guida sulla terapia ormonale maschile. Retrieved November 2025.
144. Université de Genève. (2023, November 24). Treating tumours with engineered dendritic cells. Retrieved November 2025.
145. IASO Cancer. Dendritic cell therapy. Retrieved November 2025.
146. Rodriguez, J., Prada, N., Moreno, A., Flores, I., Ortiz, C., Vergara, F., Osorio, C., & Bermúdez, A. (2018, May 4). A randomized phase II clinical trial of dendritic cell vaccination following complete resection of colon cancer liver metastasis. Journal for ImmunoTherapy of Cancer, 6(1), 96. https://doi.org/10.1186/s40425-018-0414-y. Retrieved November 2025.
147. German Guideline Program in Oncology (GGPO). (2015). Evidenced-based Guideline: Palliative care for patients with incurable cancer (Short version 1.1). Retrieved November 2025.
148. van den Beuken-van Everdingen, M. H. J., de Rijke, J. M., Kessels, A. G. H., Schouten, H. C., van Kleef, M., & Patijn, J. (2007, September). Prevalence of pain in patients with cancer: A systematic review of the past 40 years. Annals of Oncology, 18(9), 1437–1449. Retrieved November 2025.
149. Russell, K. B., Forbes, C., Qi, S., Link, C., Watson, L., Deiure, A., Lu, S., Silvius, J., Kelly, B., Bultz, B. D., & Schulte, F. (2024, March 27). End-of-life symptom burden among patients with cancer who were provided medical assistance in dying (MAID): A longitudinal propensity-score-matched cohort study. Cancers, 16(7), 1294. Retrieved November 2025.
150. Rogal, S. S., Hansen, L., Patel, A., Ufere, N. N., Verma, M., Woodrell, C. D., et al. (2022, September). AASLD practice guidance: Palliative care and symptom-based management in decompensated cirrhosis. Hepatology, 76(3), 819–853. Retrieved November 2025.
151. Gilbertson-White, S., Aouizerat, B. E., Jahan, T., & Miaskowski, C. (2011, March). A review of the literature on multiple symptoms, their predictors, and associated outcomes in patients with advanced cancer. Palliative & Supportive Care, 9(1), 81–102. Retrieved November 2025.
152. Hager, K. K. (2016, April 1). Management of weight loss in people with cancer. Journal of the Advanced Practitioner in Oncology, 7(3), 336–338. Retrieved October 2025.
153. Muscaritoli, M., Arends, J., Bachmann, P., Baracos, V., Barthelemy, N., Bertz, H., et al. (2021, May). ESPEN practical guideline: Clinical nutrition in cancer. Clinical Nutrition, 40(5), 2898–2913. https://doi.org/10.1016/j.clnu.2021.02.005. Retrieved November 2025.
154. Arends, J., Strasser, F., Gonella, S., Solheim, T. S., Madeddu, C., Ravasco, P., et al. (2021, June). Cancer cachexia in adult patients: ESMO clinical practice guidelines. ESMO Open, 6(3), 100092. https://doi.org/10.1016/j.esmoop.2021.100092. Retrieved October 2025.
155. Philipps-Universität Marburg. (2021). Doctoral dissertation archived under identifier z2021/0016 (dtb). Retrieved November 2025.
156. Ginger, V., Dreismann, L., & Zimmermann, T. (2025, October). Überweisung zur Psychoonkologie und psychoonkologische Versorgung aus Sicht behandelnder Psychoonkolog*innen. Onkologie, 31, 1020–1029. https://doi.org/10.1007/s00761-025-01772-7. Retrieved November 2025.
157. Technical University of Munich. Prof. Dr. Helmut Friess. Retrieved November 2025.
158. Universitätsklinikum Heidelberg. (2024). The LCCH – Liver Cancer Center Heidelberg. Retrieved November 2025.
159. National Center for Tumor Diseases (NCT), Heidelberg. (2024). Liver Cancer Center. Retrieved November 2025.
160. Helios Klinikum Berlin-Buch. (2024, May 3). Erstmalig durchgeführt: Erfolgreiche Behandlung von Lebermetastasen mit chirurgischem ALPPS-Verfahren. Retrieved November 2025.
161. Medias Klinikum Burghausen. (2025). Medias Klinikum – Private oncology hospital for regional chemotherapy and oncologic surgery. Retrieved November 2025.
162. Medias Klinikum Burghausen. (2025). Regionale Chemotherapie – Informationen für Ärztinnen und Ärzte. Retrieved November 2025.
163. Medias Klinikum Burghausen. (2025). Über uns – Medias Klinikum. Retrieved November 2025.