Hepatocellular Carcinoma Staging 

Updated: Apr 02, 2018
  • Author: Anand D Patel, MD; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
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TNM Classification for Hepatocellular Carcinoma

Staging systems for hepatocellular carcinoma (HCC) have not been universally adopted. One system implemented is the American Joint Committee on Cancer (AJCC) tumor/node/metastasis (TNM) classification system. The TNM classification system takes into account tumor characteristics including size, number, and vascular invasion, as well as lymph node involvement and metastatic disease. [1, 2]  

Table 1. TNM Classification for Hepatocellular Carcinoma (Open Table in a new window)

Primary tumor (T)

TX

Primary tumor cannot be assessed

T0

No evidence of primary tumor

T1

Solitary tumor 2 cm without vascular invasion

T1a

Solitary tumor <2 cm

T1b

Solitary tumor >2 cm without vascular invasion

T2

Solitary tumor >2 cm with vascular invasion; or multiple tumors, none >5 cm

T3

Multiple tumors, at least one of which is >5 cm

T4

Single tumor or tumors of any size involving a major branch of the portal vein or hepatic vein, or tumor(s) with direct invasion of adjacent organs other than the gallbladder or with perforation of visceral peritoneum

Regional lymph nodes (N)

NX

Regional lymph nodes cannot be assessed

N0

No regional lymph node metastasis

N1

Regional lymph node metastasis

Distant metastasis (M)

M0

No distant metastasis

M1

Distant metastasis

Table 2. Anatomic stage/prognostic groups (Open Table in a new window)

Stage

T

N

M

IA

T1a

N0

M0

IB

T1b

N0

M0

II

T2

N0

M0

IIIA

T3

N0

M0

IIIB

T4

N0

M0

IVA

Any T

N1

M0

IVB

Any T

Any N

M1

Table 3. Histologic grade (Open Table in a new window)

Histologic grade (G)

GX

Grade cannot be accessed

G1

Well differentiated

G2

Moderately differentiated

G3

Poorly differentiated

G4

Undifferentiated

In addition to the TNM staging for HCC, other systems have been proposed to help guide therapeutic strategies. One of these validated systems is the Barcelona-Clinic Liver Cancer staging system (BCLC). The BCLC system stratifies HCC patients based on tumor size, extent, liver function, and performance status. The BCLC staging system is thought to be better than other staging systems for determining prognosis, given the inclusion of liver function and performance status. [3, 4]  

Table 4. Barcelona-Clinic Liver Cancer staging system (Open Table in a new window)

Stage

Performance Status

Tumor Stage

Okuda Stage

Liver function

A: Early HCC

       

A1

0

Single, < 5 cm

I

No portal hypertension, normal bilirubin

A2

0

Single, < 5 cm

I

Portal hypertension, normal bilirubin

A3

0

Single, < 5 cm

I

Portal hypertension, abnormal bilirubin

A4

0

3 tumors, < 3 cm

I-II

Child-Pugh A-B

Stage B: Intermediate HCC

0

Large, multinodular

I-II

Child-Pugh A-B

Stage C: Advanced HCC

1-2

Vascular invasion or extrahepatic spread

I-II

Child-Pugh A-B

Stage D: End-Stage HCC

3-4

Any

I-II

Child-Pugh C

Stage A and B: All criteria need to be fulfilled

Stage C: At least one of the following criteria needs to be filled: performance status 1-2 or vascular invasion/extrahepatic spread.

Stage D: At least one of the following criteria needs to be filled: performance status 3-4 or Okuda Stage III/Child Pugh C.

Cirrhosis is an important component of HCC staging. Cirrhosis is not only an independent predictor of survival but also guides management decisions and determines candidacy for different therapies. The Child-Pugh score can be used to classify the prognosis based on the degree of cirrhosis and therefore can help in determining operative risk 

Another consideration in determining stage and prognosis in patients with HCC is the degree of liver fibrosis. There are many different scoring systems used to determine the degree of liver fibrosis. With one such scoring system, the Ishak fibrosis staging system, stages 1 through 5 had no direct correlation with survival, however, stage 6 was associated with poor overall survival  [5]

Table 5. Ishak fibrosis score (Open Table in a new window)

Architectural Change

Score

No fibrosis

0

Fibrous expansion of some portal areas, with or without short fibrous septa

1

Fibrous expansion of most portal areas, , with or without short fibrous septa

2

Fibrous expansion of most portal areas, with occasional portal-to-portal bridging

3

Fibrous expansion of portal areas with marked bridging as well as portal-central

4

Marked bridging (portal-to-portal and/or portal-central) with occasional nodule (incomplete cirrhosis)

5

Cirrhosis, probable or definite

6