What are the guidelines on hepatocellular carcinoma (HCC) staging?

Updated: Jan 31, 2021
  • Author: Luca Cicalese, MD, FACS; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Answer

The tumor-node-metastasis (TNM) classification of the American Joint Cancer Committee/Union for International Cancer Control/ (AJCC/UICC) is useful only in patients who undergo surgical resection, which is a small minority of patients. Only the NCCN guidelines follow TNM for staging. [49]

Since most patients have unresectable disease and prognosis depends more on the state of the liver than on the size of the tumor, the AASLD and ESMO guidelines recommend the Barcelona Clinic Liver Cancer (BCLC) system for prognostic prediction and treatment stratification. [4, 106]

The BCLC staging system attempts to overcome the limitations of previous staging systems by identifying prognostic stages (0 and A through D) based on five variables:

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

See Table 4, below.

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

Stage

Criteria

0 – Very Early

Child-Pugh class A

Single < 2 cm nodule

ECOG PS 0-1

A – Early

Child-Pugh class A-B

Single or 2-3 nodules < 3 cm

ECOG PS 0-1

B – Intermediate

Child-Pugh class A-B

Multinodular

ECOG PS 0-1

C - Advanced

Child-Pugh class A-B

Portal vein invasion, N1, M1

ECOG PS 0-2

D - Terminal

Child-Pugh class C

Any T, N, or M

ECOG PS > 2

ECOG PS  = Eastern Cooperative Oncology Group Performance Status

The BCLC staging system also links each HCC stage to appropriate treatment modalities, as follows:

  • Patients with early-stage HCC (stage 0 and A) may benefit from curative therapies (ie, liver transplantation, surgical resection, radiofrequency ablation).
  • Patients with intermediate-stage(stage B) or advanced-stage (stage C) disease may benefit from palliative treatments (ie, transcatheter arterial chemoembolization and sorafenib)
  • Patients with end-stage disease (stage D) are offered supportive care and palliation

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