Liver Cancer


Staging is how physicians determine the extent of cancer, where it is located and whether it has spread to nearby organs or tissues or to other parts of the body. Your doctor will consider the results of your physical exam, diagnostic tests and pathology report to stage your cancer and develop your treatment plan. Staging can also assist with determining a prognosis (outlook).

The most common staging system used for hepatocellular carcinoma is the Barcelona Clinic Liver Cancer (BCLC) system. This system is based on three main factors:

  1. Tumor characteristics, including the size of the tumor(s), how many tumors are present and if the tumor(s) causes symptoms.
  2. The Eastern Cooperative Oncology Group (ECOG) Performance Status measures how the disease is affecting your ability to do daily activities.
  3. The Child-Pugh score is used to evaluate liver function. This classification system uses five factors to determine the type of treatment that may be required. The measures are combined into a scoring system that provides doctors with information on how well the liver is working.
    • Albumin is a protein made by the liver.
    • Bilirubin is a part of bile, which is made in the liver.
    • Prothrombin time is how quickly the blood clots. It is sometimes reported as part of the International Normalized Ratio (INR).
    • Ascites is an accumulation of fluid in the abdomen.
    • Encephalopathy indicates if liver disease is affecting brain function.

Each of these measures is scored into a point system, which tallies the number of points to assign one of three classes:

  • Class A: a well-functioning liver
  • Class B: liver function is significantly compromised
  • Class C: severe liver damage

The results of the three factors, which include the tumor characteristics, the ECOG Performance Status and the Child-Pugh score, are then combined to determine an overall stage.

In general, using the BCLC system, liver cancer may be classified into one of the following five stages:

Stage 0 (very early stage): The tumor is less than 2 cm. The ECOG Performance Status is 0, meaning you are as active as before diagnosis. The Child-Pugh score is A, meaning the liver is working normally.

Stage A (early stage): There may be one lesion that is more than 2 cm, or there are up to three lesions that measure less than 3 cm. The ECOG Performance Status is 0, meaning you are as active as before diagnosis. The Child-Pugh score is A to C, meaning the liver may be working normally, may have mild to moderate damage or may have severe damage.

Stage B (intermediate stage): There may be more than one lesion with at least one that is more than 3 cm, or there are more than three lesions regardless of their size. The ECOG Performance Status is 0, meaning you are as active as before diagnosis. The Child-Pugh score is A to C, meaning the liver may be working normally, may have mild to moderate damage or may have severe damage.

Stage C (advanced stage): The cancer has invaded nearby blood vessels and/or has spread to lymph nodes and/or has spread to other parts of the body. The ECOG Performance Status is 1 to 2, meaning you may not be able to do heavy physical work but can do anything else, or you may be up about half the day and are unable to do any work activities. The Child-Pugh score is A to C, meaning the liver may be working normally, may have mild to moderate damage or may have severe damage.

Stage D (end-stage disease): The tumor may have grown into large blood vessels or spread to other parts of the body, and liver damage is severe. The ECOG Performance Score is 3 or 4, meaning you may be in bed or in a chair for more than half the day and you need help looking after yourself, or you are in bed or in a chair all the time and need complete care. The Child-Pugh score is C, meaning there is severe liver damage.

In addition, doctors may classify liver cancer based on whether it can be entirely resected (surgically removed). Liver cancer may be called localized resectable (confined to the liver and able to be surgically removed), localized unresectable (confined to the liver but cannot be surgically removed), or advanced (has spread beyond the liver and likely can’t be treated with surgery).

The BCLC system staging table, Child-Pugh scoring system and ECOG Performance Status tables, along with liver cancer staging illustrations, can be found here.

Another staging system that may be used is the TNM system developed by the American Joint Committee on Cancer (AJCC). AJCC system staging content and illustrations can be found here.

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.

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.

Reading Your Pathology Report

Your pathology report is an essential document that provides information about the unique characteristics of your liver cancer. It guides your health care team in planning the treatment most likely to be effective based on your cancer’s specific features.

If a biopsy is determined necessary, your doctor may perform a percutaneous (through the skin) needle biopsy before treatment or collect a tissue biopsy following definitive surgery, which is the removal of the tumor(s). A pathology report on the specimen is prepared by a pathologist, a physician with specialized training in diagnosing disease by studying its cells under a microscope. The pathologist examines the sample (or entire tumor) with and without a microscope, documenting size and appearance, and sometimes performing special testing. The final report is based on all findings of the examination.

Diagnosing liver cancer and accurately identifying all the characteristics of the tumor(s) are challenging. The expertise of physician specialists is required because the planning of your treatment (or further treatment) will be based on the results of the pathology report.

Getting a second opinion from another pathologist with extensive experience in interpreting pathologic findings for liver cancer can be beneficial, especially if there was difficulty or controversy in interpreting the findings. Be sure to ask your doctor to seek a second opinion if the pathology report does not contain a definitive diagnosis or if your liver cancer is a rare type or has metastasized (spread). Another interpretation can confirm your diagnosis or suggest an alternative diagnosis.

Ask your doctor to go over the pathology report with you to explain any information that isn’t clear to you, and be sure to get a copy of the report.


Key Takeaways

  • Staging is how your doctor determines if cancer is confined to the liver or if it has spread to other parts of the body.
  • Staging helps your doctor determine the best treatment plan for you.
  • A second opinion from an experienced liver specialist could offer valuable additional information.
  • Ask your doctor to explain anything you don’t understand. Feeling well-informed will help you make important decisions going forward.

Additional Resources


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