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
|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
|0 (very early stage)||
|A (early stage)||
|B (intermediate stage)||
|C (advanced stage)||
|D (end-stage disease)||
Eastern Cooperative Oncology Group (ECOG) Performance Status
|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
|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).|
|NX||Regional lymph nodes cannot be assessed.|
|N0||No regional lymph node metastasis.|
|N1||Regional lymph node metastasis.|
|M0||No distant metastasis.|
|GX||Grade cannot be assessed.|
Stages of Liver Cancer
|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.