Liver Cancer

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Early Detection, Diagnosis, and Staging TOPICS

Liver cancer stages

The stage of liver cancer is a description of how widespread it is when it is diagnosed. The cancer’s stage is one of the most important factors in choosing treatment options and predicting a patient’s outlook.

Liver cancer is staged based on the results of the physical exam, imaging tests (ultrasound, CT or MRI scan, etc.) and other tests, which are described in the section “Tests for liver cancer ” as well as by the results of surgery if it has been done.

There are several staging systems for liver cancer, and not all doctors use the same system.

The American Joint Committee on Cancer (AJCC) TNM system

A staging system is a standard way for the cancer care team to sum up information about how far a cancer has spread. Doctors use staging systems to get an idea about a patient's prognosis (outlook) and to help determine the most appropriate treatment.

The TNM system for staging contains 3 key pieces of information:

  • T describes the number and size of the primary tumor(s), measured in centimeters (cm), and whether the cancer has grown into nearby blood vessels or organs.
  • N describes the extent of spread to nearby (regional) lymph nodes, which are bean-sized collections of immune system cells to which cancers often spread first.
  • M indicates whether the cancer has metastasized (spread) to distant parts of the body.
  • Numbers or letters that appear after T, N, and M provide more details about each of these factors:

  • The numbers 0 through 4 indicate increasing severity.
  • The letter X means "cannot be assessed" because the information is not available.
  • T groups

    TX: Primary tumor cannot be assessed

    T0: No evidence of primary tumor

    T1: A single tumor (any size) that hasn't grown into blood vessels

    T2: Either a single tumor (any size) that has grown into blood vessels, OR more than one tumor but no tumor is larger than 5 cm (about 2 inches) across

    T3a: More than one tumor, with at least one tumor larger than 5 cm across

    T3b: At least one tumor (any size) that has grown into a major branch of a large vein of the liver (the portal or hepatic vein)

    T4: The tumor (any size) has grown into a nearby organ (other than the gallbladder), OR the tumor is growing into the thin layer of tissue covering the liver (called the visceral peritoneum)

    N groups

    NX: Regional (nearby) lymph nodes cannot be assessed.

    N0: The cancer has not spread to the regional lymph nodes.

    N1: The cancer has spread to the regional lymph nodes.

    M groups

    M0: The cancer has not spread to distant lymph nodes or other organs.

    M1: The cancer has spread to distant lymph nodes or other organs. Liver cancer most often spreads to the lining of the belly (peritoneum), the lungs, and to bones.

    Stages of liver cancer

    Once the T, N, and M groups have been determined, they are then combined to give an overall stage, using Roman numerals I to IV (1 to 4).


    Stage grouping

    Stage description


    T1, N0, M0

    There is a single tumor (any size) that has not grown into any blood vessels. The cancer has not spread to nearby lymph nodes or distant sites.


    T2, N0, M0

    Either there is a single tumor (any size) that has grown into blood vessels, OR there are several tumors, and all are 5 cm (2 inches) or less across. The cancer has not spread to nearby lymph nodes or distant sites.


    T3a, N0, M0

    There is more than one tumor, and at least one is larger than 5 cm (2 inches) across. The cancer has not spread to nearby lymph nodes or distant sites.


    T3b, N0, M0

    At least one tumor is growing into a branch of a major vein of the liver (portal vein or hepatic vein). The cancer has not spread to nearby lymph nodes or distant sites.


    T4, N0, M0

    A tumor is growing into a nearby organ (other than the gallbladder), OR a tumor has grown into the outer covering of the liver. The cancer has not spread to nearby lymph nodes or distant sites.


    Any T, N1, M0

    Tumors in the liver can be any size or number and they may have grown into blood vessels or nearby organs. The cancer has spread to nearby lymph nodes. The cancer has not spread to distant sites.


    Any T, Any N, M1

    The cancer has spread to other parts of the body. (Tumors can be any size or number, and nearby lymph nodes may or may not be involved.)

    Other liver cancer staging systems

    The staging systems for most types of cancer depend only on the extent of the cancer, but liver cancer is complicated by the fact that most patients have damage to the rest of their liver along with the cancer. This also affects treatment options and prognosis.

    Although the TNM system defines the extent of liver cancer in some detail, it does not take liver function into account. Several other staging systems have been developed that include both of these factors:

  • The Barcelona Clinic Liver Cancer (BCLC) system
  • The Cancer of the Liver Italian Program (CLIP) system
  • The Okuda system
  • These staging systems have not been compared against each other. Some are used more than others in different parts of the world, but at this time there is no single staging system that all doctors use. If you have questions about the stage of your cancer or which system your doctor uses, be sure to ask.

    Child-Pugh score (cirrhosis staging system)

    The Child-Pugh score is a measure of liver function, especially in people with cirrhosis. Many people with liver cancer also have cirrhosis, and in order to treat the cancer, doctors need to know how well the liver is working. This system looks at 5 factors, the first 3 of which are results of blood tests:

  • Blood levels of bilirubin (the substance that can cause yellowing of the skin and eyes)
  • Blood levels of albumin (a major protein normally made by the liver)
  • The prothrombin time (measures how well the liver is making blood clotting factors)
  • Whether there is fluid (ascites) in the abdomen
  • Whether the liver disease is affecting brain function
  • Based on these factors, liver function is divided into 3 classes. If all these factors are normal, then liver function is called class A. Mild abnormalities are class B, and severe abnormalities are class C. People with liver cancer and class C cirrhosis are often too sick for surgery or other major cancer treatments.

    The Child-Pugh score is actually part of the BCLC and CLIP staging systems mentioned previously.

    Liver cancer classification

    Formal staging systems (such as those described before) can often help doctors determine a patient's prognosis (outlook). But for treatment purposes, doctors often classify liver cancers more simply, based on whether or not they can be entirely cut out (resected). Resectable is the medical term meaning "able to be removed by surgery."

    Potentially resectable or transplantable cancers

    These cancers can be completely removed by surgery or treated with a liver transplant and the patient is healthy enough for surgery. This would include most stage I and some stage II cancers in the TNM system, in patients who do not have cirrhosis or other serious medical problems. Only a small number of patients with liver cancer have this type of tumor.

    Unresectable cancers

    Cancers that have not spread to the lymph nodes or distant organs but cannot be completely removed by surgery are classified as unresectable. This includes cancers that have spread throughout the liver or can’t be removed safely because they are close to the area where the liver meets the main arteries, veins, and bile ducts.

    Inoperable with only local disease

    The cancer is small enough and in the right place to be removed but you aren’t healthy enough for surgery. Often this is because the non-cancerous part of your liver is not healthy (because of cirrhosis, for example), and if the cancer is removed, there might not be enough liver tissue left for it to function properly. It could also mean that you have serious medical problems that make surgery unsafe.

    Advanced (metastatic) cancers

    Cancers that have spread to lymph nodes or other organs are classified as advanced. These would include stages IVA and IVB cancers in the TNM system. Most advanced liver cancers cannot be treated with surgery.

    Last Medical Review: 03/31/2016
    Last Revised: 04/28/2016