Prof. Dr. med. Thomas Vogl, Director of the Department of Radiology and Nuclear Medicine at the University Medical Center Frankfurt at Johann Wolfgang Goethe University in Frankfurt am Main, is at the forefront of current developments in the fight against liver tumors. As a renowned expert in the field of diagnostic and interventional radiology, Prof. Dr. Vogl has made groundbreaking advances by developing and successfully applying new procedures.
Prof. Dr. Vogl is particularly well known for his groundbreaking work in the field of interventional oncology and vascular procedures. His research findings have led to improvements and new surgical methods worldwide. Together with his experienced team, he developed the angiography robot, which provides high-resolution images from inside the body and helps detect previously undetected tumors. This innovative device enables the precise treatment of small metastases by targeting them with a therapeutic agent while minimizing the risk of additional injury.
As Director of Radiology and Nuclear Medicine, Prof. Dr. Vogl places great emphasis on adhering to the highest scientific standards and all current radiation safety criteria. In doing so, he focuses equally on the well-being of patients and the welfare of his highly qualified team. Prof. Dr. Vogl fosters an intensive professional exchange within his team as well as with other specialties and institutions to continuously improve the quality of medical care.
His outstanding expertise and dedication have made Prof. Dr. Vogl a highly respected expert in the international medical community. He is the author of several standard reference works and groundbreaking publications, a member of various international associations and committees, and a sought-after reviewer for scientific publications. Prof. Dr. med. Thomas Vogl is a renowned liver specialist who uses his extensive knowledge and experience to ensure radiological care of the highest standard, thereby improving the lives of many patients.
The editorial team of the Leading Medicine Guide had the opportunity to speak with Prof. Dr. Vogl, focusing on treatment options for liver metastases and which new methods lead to a significantly higher survival rate.
The liver plays a central role in the human body, as it performs a variety of vital functions, including detoxification, metabolism, and the production of digestive enzymes. Despite its ability to regenerate, the liver is susceptible to metastases that can spread from other primary cancers.
“Liver metastases pose a serious threat to health because they are often asymptomatic and are not detected until advanced stages. Due to its high metabolic rate, the liver is extremely well-perfused, and everything eventually flows through the liver at some point, whether via arteries or veins. As a result, tumor cells have a particular affinity for the liver and find a fertile environment there, along with everything they need, which is why cells can easily establish themselves there,” Prof. Dr. Vogl explains at the beginning of our conversation. Prof. Dr. Vogl explains which tumors are particularly dangerous for the liver: “First and foremost, these are tumors originating in the abdominal cavity that metastasize to the liver, since the liver serves as the first filtration station here. At the top of the list is colorectal carcinoma (colon cancer), followed by pancreatic, ovarian, and uterine cancers. The second group consists of tumors that release a large number of cells into the bloodstream, such as lung cancer.”
Liver metastases can also increase the risk of life-threatening bleeding, especially if they are located near vital blood vessels. The liver has an extremely rich blood supply, and the metastases can infiltrate and damage these vessels, which can then lead to bleeding. Another reason why liver metastases are so dangerous is that they are often difficult to remove surgically. Due to their location, size, or number, they may not be suitable for surgical removal. As a result, alternative treatment methods such as chemotherapy, radiation therapy, or minimally invasive procedures like thermal ablation must be used, though these do not always produce the desired results.
Liver metastases can often develop unnoticed for a long time, as they frequently do not cause any specific symptoms.
“Generally speaking, a process known as ‘staging’ is performed with the patient. This is done through imaging—typically using ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), or PET (positron emission tomography)—and is then used to establish the diagnosis. If the patient has already noticed symptoms indicating that they have liver metastases, it is actually already too late for successful treatment—not always, but it is then very difficult. In such a case, for example, the patient might feel a sense of pressure because the liver has become too large. It is therefore of paramount importance that cancer patients undergo regular screening—ideally every three months—for possible metastases in the liver (and also in the lungs). If metastases are found during these examinations, a tumor board will discuss the best course of action,” says Prof. Dr. Vogl, describing the preventive measures.
Noticeable symptoms of liver metastases may include:
Abdominal pain: Pain in the upper right abdomen may occur, especially if the metastases stretch or impair the liver capsule.
Jaundice (icterus): Yellowing of the skin and eyes due to impaired liver function caused by the breakdown of bilirubin.
Nausea and vomiting: Impaired liver function can lead to digestive disorders, which may cause nausea and vomiting.
Weight loss and loss of appetite: Liver metastases can impair metabolism and lead to unintentional weight loss and reduced food intake.
Enlarged liver (hepatomegaly): The liver may become enlarged due to the growth of metastases and may be palpable during a physical examination.
Enlarged spleen (splenomegaly): In some cases, the spleen may also be enlarged, especially if the liver metastases affect blood flow patterns in the abdomen.
Laboratory tests, such as liver function tests and tumor markers, can reveal abnormalities in the blood that may indicate the presence of liver metastases, and a tissue sample can also be obtained via biopsy to identify the tumor and determine whether it is a metastasis. This can be done using a fine-needle biopsy guided by imaging such as ultrasound or CT.
Various surgical options are available for the treatment of liver metastases, which can be used depending on the individual circumstances of the patient and the tumor.
“Regardless of where the patient’s primary tumor is located, if liver metastases are detected, it must be determined whether there are other tumors elsewhere in the body. This is because if multiple other areas of the body are affected by a tumor—whether the head, lungs, lymph nodes, or bones—surgical removal of liver metastases alone is generally not an option. Let’s take, for example, a patient with a single tumor in whom liver metastases are detected. This finding is then discussed in a tumor board meeting with the oncologist responsible for chemotherapy, the surgeon who intends to perform the operation, and the interventional oncologist who is considering a local procedure. To decide which treatment would be most successful for the patient, the patient’s overall condition is discussed. Are there any pre-existing conditions? How old is the patient? What is the patient’s general state of health? If the detected metastasis is less than 3 cm in size, everything points toward a purely minimally invasive procedure. If there is a large liver metastasis—for example, in the right lobe of the liver measuring 5 cm—surgical removal would initially be the preferred option, but it would be better to combine it with chemotherapy to shrink the metastasis before the procedure. “The tricky thing about liver metastases is that as they continue to grow, they become enormous and eventually compress the bile ducts, which can lead to liver failure,” explains Prof. Dr. Vogl, outlining the treatment options, and adds: “In some cases, a liver metastasis can be surgically removed so effectively that the patient remains tumor-free for at least the next five years, especially if there is only one metastasis. For patients who, for example, have five metastases smaller than four centimeters, local procedures using interventional oncology can be successfully applied. The patient’s life expectancy is always determined by the primary tumor. It is important for the patient to know the risks involved in any course of treatment.”
Interventional oncology includes procedures such as radiofrequency ablation, which uses high-frequency alternating current to target the tumor, and cryoablation, which destroys the malignant tissue using cold via a catheter.
Liver resection and liver transplantation are two surgical treatment options that can be used to combat liver metastases. These procedures are used when the metastases are confined to specific areas of the liver and sufficient liver function is preserved after surgery. Liver resection involves the surgical removal of the affected parts of the liver. During this procedure, the metastases are removed along with a margin of healthy liver tissue surrounding them. This procedure can be particularly effective when the metastases are confined to a specific area of the liver and no other organs or structures are affected. A successful resection can help control tumor growth and improve the patient’s quality of life.
Liver transplantation is another option for certain patients with liver metastases. This procedure involves removing the entire diseased liver and replacing it with a donor liver. Transplantation is typically considered for patients with advanced liver disease when other treatment options have been unsuccessful or are not feasible. Transplantation offers the opportunity to treat not only the metastases but also the underlying liver disease, giving the patient a new chance at a healthy life.
In addition to surgical options, there are various other treatment methods: laser-induced thermal therapy (LITT), transarterial chemoembolization (c-TACE), and microwave ablation. Each of these techniques has its own advantages and disadvantages, which must be taken into account when deciding on the optimal treatment.
“It is important to distinguish between regional chemotherapy, chemoperfusion, and chemoembolization, even though they all belong to the same group. In all three procedures, a catheter is inserted into the liver’s blood vessels to deliver high concentrations of medication, offering a good chance that the metastases will shrink and, as a result, most of the tumor cells will be destroyed. This is done, for example, in patients who have a large number of tumors or large tumors, or who do not respond to chemotherapy or cannot tolerate it. Then there is also the option of radioembolization. This involves targeted radiation of liver tumors and metastases, which are actively destroyed by the injection of radioactively labeled beads. So we have the vascular procedures (via the blood vessels) and the ablative procedures (radiofrequency ablation or microwave ablation). “We’re not very keen on using cryoablation (destruction using cold) on the liver, as it tends to bleed,” explains Prof. Vogl, adding regarding the choice of therapy:
“Here in Frankfurt am Main, we can offer all of these therapies. The choice of procedure always depends on the patient’s condition and a risk assessment. Microwave ablation is the most commonly used method worldwide. For this procedure, the patient comes to our clinic (having fasted for three hours). We perform 95% of these procedures on an outpatient basis. The procedure takes about 45 minutes, and afterward the patient should rest for about four hours and, provided everything is fine, can then go home. Otherwise, the patient can also stay in the hospital overnight.”
Radioembolization (SIRT) is a form of targeted radiation therapy for liver tumors and metastases. It involves injecting small radioactively loaded beads (microspheres) through the hepatic artery into the small blood vessels supplying the liver tumors and metastases.
Laser-induced thermal therapy (LITT) is a minimally invasive treatment method for the local destruction of tumor tissue in the liver. In this technique, a laser applicator is inserted through the skin directly into the tumor. The applicator is connected to a laser fiber that emits laser beams of a specific wavelength (typically 1064 nm). These laser beams heat the surrounding tissue, leading to coagulation and ultimately the death of the tumor cells. One advantage of LITT is its precision, as the laser can be targeted specifically at the tumor, thereby sparing the surrounding healthy tissue. This procedure is particularly suitable for smaller liver metastases and can also be used in patients who are not candidates for surgery.
Transarterial chemoembolization (c-TACE) is a technique in which chemotherapy drugs are injected directly into the blood vessels supplying the tumor. First, a catheter is inserted into the hepatic artery, through which the chemotherapy drugs are administered. At the same time, the blood vessels are occluded through embolization, thereby blocking the blood supply to the tumor. This results in the tumor receiving fewer nutrients, which inhibits the growth of cancer cells. c-TACE is often used for larger or hard-to-reach tumors and can be repeated to increase its effectiveness.
Microwave ablation is a minimally invasive procedure in which a probe emitting microwave energy is inserted into the tumor. The microwaves generate heat in the tumor tissue, leading to rapid heating and ultimately the destruction of the cancer cells. This procedure is particularly effective for smaller tumors and can be performed on an outpatient basis. Compared to LITT, microwave ablation provides faster and deeper heating of the tissue, which can lead to more effective tumor destruction.
The long-term study by Prof. Dr. Vogl from Frankfurt am Main, which spanned the period from 1996 to 2020, was crucial for understanding the efficacy of transarterial chemoembolization (c-TACE) in the treatment of liver metastases.
The Institute for Diagnostic and Interventional Radiology at the University Hospital of Johann Wolfgang Goethe University in Frankfurt am Main has developed two innovative treatment methods to help patients with liver metastases and hepatocellular carcinoma. Under the direction of Prof. Dr. Thomas J. Vogl, two new treatment options were researched and applied as part of the university’s interdisciplinary liver center; these not only extend patients’ life expectancy but also enable a more tolerable treatment. A total of 130 patients were treated with this procedure during this period, with 41 of them also undergoing a thermoablative procedure to treat the tumors. The study provided deep insight into the long-term effects of these treatment options and their impact on patient survival and quality of life.
“The data we were able to collect rank very highly internationally. We observed a higher life expectancy among patients following therapy; in some cases, it was even significantly higher. And now we need to identify these patients. After all, the primary goal of all our efforts is to prolong life while maintaining a good quality of life. Based on our experience, the trend suggests that patients with liver metastases are best served by a combination of local chemotherapy followed by ablative treatment, which offers them better chances of survival. This is because this approach kills tumor cells even in the peripheral areas—that is, those hidden in the surrounding tissue. Immunotherapy can be used as an additional treatment. The fact is that when I surgically remove a tumor from the liver, the liver then regrows. However, this growth stimulates any remaining tumor cells, causing them to grow again as well. With the immunotherapy we use, the patient’s immune system is trained to actively destroy tumor cells without significant side effects. This is an autoimmune therapy in which the patient’s dendritic cells are stimulated to recognize tumor cells as such and eliminate them. This is also the path that will ultimately be taken in the future: chemotherapy + surgery + immunotherapy. For such a promising combination of therapies, of course, the patient’s overall health must be taken into account. We treat 10–12 patients this way every day. And especially when patients are younger, this approach is always worth a try,” reports Prof. Dr. Vogl.
In particular, the combination of c-TACE and the thermoablative procedure showed promising results. A higher rate of tumor regression was observed in these patients, indicating more effective tumor destruction. The study provides important insights into how different therapeutic approaches can be effectively combined to improve treatment outcomes and increase patient survival rates. The combination of various therapeutic methods could play an increasingly significant role in significantly improving the quality of life and survival prospects of patients with liver metastases.
“A diagnosis of liver metastases doesn’t have to be devastating. There’s always a glimmer of hope, and we’re working tirelessly here to ensure the optimal use of life-prolonging therapies. Ultimately, it comes down to this: If you don’t try, you don’t stand a chance!” emphasizes Prof. Dr. Vogl, and with that, we conclude our conversation on a positive note.
Thank you very much, Prof. Dr. Vogl, for this optimistic insight into the various therapies in the fight against liver metastases. Thank you very much for your dedication!
