How is hepatocellular carcinoma (HCC) staged?

Updated: Jun 05, 2020
  • Author: Luca Cicalese, MD, FACS; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Answer

The prognosis of HCC is a reflection of both tumor characteristics (ie, size, location, tumor biology) and the degree of underlying liver disease. The traditional pathologic TNM (tumor-node-metastasis) staging system, while helpful in determining a prognosis in patients undergoing resection, is not as useful in planning treatment, because it fails to include measures of the severity of the liver disease. However, the tumor size is predictive of outcome, as it predicts the likelihood of major venous involvement. [47]

Likewise, the Child-Pugh-Turcotte score predicts perioperative survival after resection, but it does not incorporate tumor size, number, and location, which have important implications for respectability and treatment. Among the scales that integrate the tumor and liver disease characteristics, the Barcelona Clinic Liver Cancer (BCLC) system, [38] the Japan Integrated Staging System, and the Cancer of the Liver Italian Program (CLIP) are the most widely used staging systems.

BCLC algorithm

The Barcelona-Clinic Liver Cancer (BCLC) approach to hepatocellular carcinoma management. Adapted from Llovet JM, Fuster J, Bruix J, Barcelona-Clinic Liver Cancer Group. The Barcelona approach: diagnosis, staging, and treatment of hepatocellular carcinoma. Liver Transpl. Feb 2004;10(2 Suppl 1):S115-20.

The Barcelona-Clinic Liver Cancer (BCLC) approach The Barcelona-Clinic Liver Cancer (BCLC) approach to hepatocellular carcinoma management. Adapted from Llovet JM, Fuster J, Bruix J, Barcelona-Clinic Liver Cancer Group. The Barcelona approach: diagnosis, staging, and treatment of hepatocellular carcinoma. Liver Transpl. Feb 2004;10(2 Suppl 1):S115-20.

The BCLC system is very useful in deciding among potential treatment options and correlates best with patient outcome among the major staging systems. [48]

In the BCLC system, stage 0 patients have lesions smaller than 2 cm, normal bilirubin levels, and normal portal pressure measurements. These patients can often undergo resection safely with excellent long-term survival.

Patients with larger tumors (ie, single tumors < 5 cm or multiple [≤ 3] tumors < 3 cm) are considered for resection if they have preserved liver function or for transplantation if they have decompensated cirrhosis.

In patients whose tumor exceeds these measurements, palliative therapy can be offered depending upon hepatic reserve. Fewer than 10% of these patients survive longer than 3 years.

CLIP scoring system

A score of 0-2 is assigned for each of the 4 features listed below; a cumulative score ranging from 0-6 is the CLIP score.

Child-Pugh class:

  • Class A = 0
  • Class B = 1
  • Class C = 2

Tumor morphology:

  • Uninodular and extension less than 50% = 0
  • Multinodular and extension less than 50% = 1
  • Massive and extension greater than 50% = 2

Alpha-fetoprotein:

  • Less than 400 = 0
  • Greater than 400 = 1

Portal vein thrombosis:

  • Absent = 0
  • Present = 1

Estimated survival based on CLIP score

Patients with a total CLIP score of 0 have an estimated survival of 31 months; those with score of 1, about 27 months; score of 2, 13 months; score of 3, 8 months; and scores 4-6, approximately 2 months.

For more information, see Hepatocellular Carcinoma Staging.


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