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Adult Primary Liver Cancer Treatment (PDQ®)

  • Last Modified: 07/11/2014

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Stage Information for Adult Primary Liver Cancer

American Joint Committee on Cancer (AJCC) Staging System
        Definitions of TNM
Okuda Staging System
Barcelona Clinic Liver Cancer (BCLC) Staging System

Prognostic modeling in hepatocellular carcinoma (HCC) is complex because variables of two diseases--cirrhosis and cancer--are involved in as many as 80% of the cases. Tumor features and the factors related to functional hepatic reserve must be taken into account. The key prognostic factors are only partially known and vary at different stages of the disease. More than ten classifications are used throughout the world, but no system is accepted worldwide.

American Joint Committee on Cancer (AJCC) Staging System

Definitions of TNM

The TNM classification for staging, proposed by the AJCC, is not widely utilized. Clinical use of TNM staging is limited because liver function is not considered. It is also difficult to use this system to select treatment options because TNM staging relies on detailed histopathological examination available only after excision. TNM may be useful in prognostic prediction after liver resection.

The AJCC has designated staging by TNM to define liver cancer.[1]

Table 1. Primary Tumor (T)a
aReprinted with permission from AJCC: Liver. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual, 7th ed. New York, NY: Springer, 2010, pp 191-9.
TXPrimary tumor cannot be assessed.
T0No evidence of primary tumor.
T1Solitary tumor without vascular invasion.
T2Solitary tumor with vascular invasion or multiple tumors none >5 cm.
T3aMultiple tumors >5 cm.
T3bSingle tumor or multiple tumors of any size involving a major branch of the portal vein or hepatic vein.
T4Tumor(s) with direct invasion of adjacent organs other than the gallbladder or with perforation of visceral peritoneum.

Table 2. Regional Lymph Nodes (N)a
aReprinted with permission from AJCC: Liver. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual, 7th ed. New York, NY: Springer, 2010, pp 191-9.
NXRegional lymph nodes cannot be assessed.
N0No regional lymph node metastasis.
N1Regional lymph node metastasis.

Table 3. Distant Metastasis (M)a
aReprinted with permission from AJCC: Liver. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual, 7th ed. New York, NY: Springer, 2010, pp 191-9.
M0No distant metastasis.
M1Distant metastasis.

Table 4. Anatomic Stage/Prognostic Groupsa
aReprinted with permission from AJCC: Liver. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual, 7th ed. New York, NY: Springer, 2010, pp 191-9.
Stage T N M
IT1N0M0
IIT2N0M0
IIIAT3aN0M0
IIIBT3bN0M0
IIICT4N0M0
IVAAny TN1M0
IVBAny TAny NM1

Okuda Staging System

The Okuda staging system includes variables related to tumor burden and liver function, such as bilirubin, albumin, and ascites and has been extensively used in the past. However, many significant prognostic tumor factors confirmed in both surgical and nonsurgical series (e.g., unifocal or multifocal, vascular invasion, portal venous thrombosis, or locoregional lymph node involvement) are not included.[2,3] As a result, Okuda staging is unable to stratify prognosis for early-stage cancers and mostly serves to recognize end-stage cancer patients.

Barcelona Clinic Liver Cancer (BCLC) Staging System

New classifications have been proposed in an effort to overcome the difficulties of having several staging systems. The BCLC staging classification retains its usefulness in early tumors and is currently the most accepted staging system for HCC. Recent evidence from an American cohort has shown that BCLC staging offers better prognostic stratification power than other staging systems.[4]

The BCLC staging system attempts to overcome the limitations of previous staging systems by including variables related to the following:[5]

  • Tumor stage.
  • Functional status of the liver.
  • Physical status.
  • Cancer-related symptoms.

Five stages (0 and A through D) are identified based on the variables mentioned above. Of note, the BCLC staging system links each HCC stage to appropriate treatment modalities. According to the BCLC, patients with early-stage HCC may benefit from curative therapies (i.e., liver transplantation, surgical resection, and radiofrequency ablation techniques); those at intermediate- or advanced-disease stage may benefit from palliative treatments (i.e., transcatheter arterial chemoembolization and sorafenib); however, those at end-stage disease who have a very poor life expectancy are offered supportive care and palliation.

References
  1. Liver. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 191-5. 

  2. Poon RT, Ng IO, Fan ST, et al.: Clinicopathologic features of long-term survivors and disease-free survivors after resection of hepatocellular carcinoma: a study of a prospective cohort. J Clin Oncol 19 (12): 3037-44, 2001.  [PUBMED Abstract]

  3. Pompili M, Rapaccini GL, Covino M, et al.: Prognostic factors for survival in patients with compensated cirrhosis and small hepatocellular carcinoma after percutaneous ethanol injection therapy. Cancer 92 (1): 126-35, 2001.  [PUBMED Abstract]

  4. Marrero JA, Fontana RJ, Barrat A, et al.: Prognosis of hepatocellular carcinoma: comparison of 7 staging systems in an American cohort. Hepatology 41 (4): 707-16, 2005.  [PUBMED Abstract]

  5. Llovet JM, Brú C, Bruix J: Prognosis of hepatocellular carcinoma: the BCLC staging classification. Semin Liver Dis 19 (3): 329-38, 1999.  [PUBMED Abstract]