Liver Cancer

Staging Systems

Staging system: Barcelona Clinic Liver Cancer (BCLC)

Following is the Barcelona Clinic Liver Cancer (BCLC) staging system along with staging illustrations. Factors taken into consideration include the Eastern Cooperative Oncology Group (ECOG) Performance Status, which measures how the disease is affecting your ability to conduct daily activities, and the Child-Pugh scoring system, the most commonly used staging system for hepatocellular carcinoma, which is used to evaluate liver function.

Using BCLC, Stage 0 indicates the smallest amount of tumor cells present, and Stage D represents the largest amount. Once the stage is determined, it is subcategorized to signify the health of the liver: “A” indicates a well-functioning liver, “B” represents liver function that is significantly compromised, and “C” indicates severe liver damage.

BCLC - Illustrated Stages of Liver Cancer

Child-Pugh Scoring

Clinical Measures 1 point 2 points 3 points
Albumin (g/dL) > (more than) 3.5 2.8-3.5 < (less than) 2.8
Bilirubin (mg/dL) < (less than) 2.0 2.0-3.0 > (more than) 3.0
Prothrombim time (in seconds) < (less than) 4 4-6 > (more than) 6
International Normalized Ratio (INR) < (less than) 1.7 1.7-2.3 > (more than) 2.3
Presence of ascites None Moderate Severe
Presence of hepatic encephalopathy None Grades I-II (or suppressed with medication) Grades III-IV (or refractory)
Classification Class A Class B Class C
Total points 5-6 points 7-9 points 10-15 points
Indication Indicates a well-functioning liver Indicates liver function is significantly compromised Indicates severe liver damage

The Barcelona Clinic Liver Cancer (BCLC) System

BCLC Stage Details
0 (very early stage)
  • Tumor less than 2 cm
  • ECOG Performance Status 0
  • Child-Pugh A
A (early stage)
  • Solitary lesion more than 2 cm or early multifocal disease characterized by up to 3 lesions measuring less than 3 cm
  • ECOG Performance Status 0
  • Child- Pugh A to C
B (intermediate stage)
  • Multifocal disease: More than one lesion with at least one over 3 cm, or more than 3 lesions regardless of their size
  • ECOG Performance Status 0
  • Child- Pugh A to C
C (advanced stage)
  • Vascular incasion and/or nodal disease and/or metastatic disease
  • ECOG Performance Status 1-2
  • Child- Pugh A to C
D (end-stage disease)
  • Tumor may have grown into large blood vessels or spread to other parts of the body. Severe liver damage.
  • ECOG Performance Status 3 or 4
  • Child- Pugh C

Eastern Cooperative Oncology Group (ECOG) Performance Status

Grade ECOG
0 Fully active, able to carry on all pre-disease performance without restriction
1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
2 Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours
3 Capable of only limited self-care; confined to bed or chair more than 50% of waking hours
4 Completely disabled; cannot carry on any self-care; totally confined to bed or chair

Developed by the Eastern Cooperative Oncology Group, Robert L. Comis, MD, Group Chair. Oken M, Creech R, Tormey D, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982;5:649-655.

Staging system: American Joint Committee on Cancer (AJCC)

The American Joint Committee on Cancer’s (AJCC) TNM staging system may be used to classify and stage liver cancer. Although cancers with similar stages tend to have a similar outlook and are often treated in much the same way, your doctor will also consider the results of your physical exam, biopsy and imaging tests.

The AJCC system classifies the cancer by tumor (T), node (N) and metastasis (M), as well as histologic grade. The T category describes the size and location of the primary tumor. The N category indicates whether the lymph nodes show evidence of cancer cells. The number and location of these lymph nodes are important because they show how far the disease has spread. The M category describes metastasis (spread of cancer to another part of the body), if any. The grade describes how abnormal the cancer cells and tissue look under a microscope and how likely they are to grow and spread. The results of the TNM analysis are then combined to determine the overall stage of the cancer for each individual.

In general, using the TNM system, liver cancer may be classified into one of these four stages:

Stage I: A tumor has formed but is confined to the liver and has not yet invaded any blood vessels, nearby lymph nodes or distant sites.

Stage II: There may be more than one tumor, and cancerous cells may have grown into nearby blood vessels.

Stage III: There is a large tumor or more than one tumor, but the cancer has not yet spread in lymphatic channels or bloodstream to regional lymph nodes or distant sites.

Stage IV: The tumor(s) may be any size and has spread to regional lymph nodes and/or distant parts of the body.

Despite treatment, it is possible or even likely for HCC to return. If that happens, your treatment team will use additional diagnostic tests, such as a biopsy or surgical procedure, to verify your cancer stage. Final staging may occur after treatment has begun. Once your stage is confirmed, your treatment team will be able to determine whether another form of treatment is necessary.

AJCC - Illustrated Stages of Liver Cancer

AJCC TNM System for Classifying Liver Cancer

Category Definition
Tumor (T)
TX Primary tumor cannot be assessed.
T0 No evidence of a primary tumor.
T1 Solitary tumor is not more than 2 cm, or more than 2 cm without vascular incasion
   T1a Solitary tumor not more than 2 cm.
   T1b Solitary tumor more than 2 cm without vascular invasion.
T2 Solitary tumor more than 2 cm with vascular invasion, or multiple tumors, none more than 5 cm.
T3 Multiple tumors, at least one of which is more than 5 cm.
T4 Single tumor or multiple 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 (outer layer of the liver).
Nodes (N)
NX Regional lymph nodes cannot be assessed.
N0 No regional lymph node metastasis.
N1 Regional lymph node metastasis.
Metastasis (M)
M0 No distant metastasis.
M1 Distant metastasis.
Grade (G)
GX Grade cannot be assessed.
G1 Well differentiated.
G2 Moderately differentiated.
G3 Poorly differentiated.
G4 Undifferentiated.

Stages of Liver Cancer

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

Additional Staging Systems

Also, ask your doctor to explain how the staging system used will influence your treatment plan. Understanding as much as you can about your exact diagnosis will make you feel better prepared to make informed decisions about your care.

Along with BCLC and AJCC, other staging systems that may be used include the Cancer of the Liver Italian Program (CLIP) system and the Okuda system. If a doctor uses one of these systems, be sure to ask questions about your stage of cancer.