Staging is the process of finding out how widespread a cancer is. The stage of a liver cancer is one of the most important factors in considering treatment options.

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

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

The American Joint Committee on Cancer (AJCC) TNM system is a major system used to describe the stages of liver cancer. It is 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 "How is liver cancer diagnosed?"

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 spread to organs next to the tumor.
• N describes the extent of spread to nearby (regional) lymph nodes.
• M indicates whether the cancer has metastasized (spread) to other organs of the body. (The most common sites of liver cancer spread are the lungs and bones.)

Numbers or letters appear after T, N, and M to 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: Single tumor (any size) without invasion into blood vessels
• T2: Single tumor (any size) with invasion into blood vessels, OR multiple tumors where none are greater than 5 cm (about 2 inches) across
• T3: Multiple tumors that are greater than 5 cm (about 2 inches) across, OR a tumor involving a major branch of the portal or hepatic vein(s)
• T4: The tumor is invading a nearby organ (other than the gallbladder), OR the tumor is invading the visceral peritoneum (covering surrounding the liver)

N groups

• NX: Regional 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

• MX: Distant spread cannot be assessed.
• 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.

Stage grouping

The T, N, and M groups are then combined to give an overall stage:

Stage I: T1, N0, M0: There is a single tumor (any size) that does not invade blood vessels.

Stage II: T2, N0, M0: There is a single tumor (any size) that does invade blood vessels; OR there are several tumors, and all are less than 5 cm (2 inches) in diameter.

Stage IIIA: T3, N0, M0: There are several tumors, and at least one is larger than 5 cm (2 inches) in diameter; OR a tumor invades a branch of the major liver blood vessels (portal vein or hepatic vein).

Stage IIIB: T4, N0, M0: A tumor invades a nearby organ (other than the gallbladder); OR a tumor has penetrated the outer covering of the liver.

Stage IIIC: Any T, N1, M0: The cancer has invaded nearby lymph nodes. (Tumors can be any size or number.)

Stage IV: 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 solely on the extent of the cancer, but liver cancer is complicated by the fact that most patients have liver damage along with their cancer. This also has an effect on treatment options and prognosis.

Although the TNM system defines the extent of liver cancer in some detail, it does not take into account liver function. 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, and 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 you 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. Because people with liver cancer often have 2 diseases, their cancer and cirrhosis, doctors treating liver cancer need to know the extent of liver function. This system looks at 5 factors, the first 3 of which are 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 in the abdomen
• whether the liver disease is affecting brain function

Based on the score, 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 generally too sick for any treatment.

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

Localized resectable, localized unresectable, and advanced liver cancer

For treatment purposes, doctors often classify liver cancers by whether or not they can be entirely cut out (resected). Resectable is the medical term meaning "able to be removed by surgery."

Localized resectable cancers: Only a small number of patients with liver cancer have tumors that can be completely removed by surgery. This would include most stage I and some stage II cancers in the TNM system, in patients who do not have cirrhosis.

Localized unresectable cancers: Cancers that have not spread to the lymph nodes or distant organs but cannot be completely removed by surgery are classified as localized unresectable. This would include some early stage cancers, as well as stage IIIA and IIIB cancers in the TNM system. There are several reasons that it might not be possible to safely remove a localized liver cancer. If the non-cancerous part of your liver is not healthy (due to cirrhosis, for example), surgery might not leave enough liver tissue behind for it to function properly. Also, curative surgery may not be possible if your cancer is spread throughout the liver or is close to the area where the liver meets the main arteries, veins, and bile ducts.

Advanced cancers: Cancers that have spread to lymph nodes or other organs are classified as advanced. These would include stage IIIC and stage IV cancers in the TNM system. Most advanced liver cancers cannot be treated with surgery.

Survival rates for liver cancer

Only a small number of liver cancers are found in the early stages and can be removed with surgery. The 5-year survival rate for patients with resectable early stage cancer is in the range of 30% to 60%. This percentage drops for more advanced cancers or with more severe liver disease.

The 5-year survival rate for people with cancer that has spread widely throughout the liver or to distant sites is less than 5%, and the average survival time is often measured in months.

The overall 5-year survival rate from liver cancer is less than 10%. Part of the reason for this low survival rate is that most patients with liver cancer also have other liver problems such as cirrhosis, which itself can be fatal.

The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. Five-year rates are used to produce a standard way of discussing prognosis. Of course, some people live much longer than 5 years.

Last Medical Review: 12/07/2008
Last Revised: 05/12/2009