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 grown into 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 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 where no tumor is larger than 5 cm (about 2 inches) across
• T3: Multiple tumors that are greater than 5 cm (about 2 inches) across, OR a tumor that has grown into a major branch of the large veins of the liver (the portal and hepatic veins)
• T4: The tumor has grown into a nearby organ (other than the gallbladder), OR the tumor is growing into the thin layer of tissue covering and surrounding the liver (called the visceral peritoneum)

N groups

• NX: Regional lymph nodes cannot be assessed.
• N0: The cancer has not spread to the regional (nearby) 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 has not grown into any blood vessels.

Stage II: 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 less than 5 cm (2 inches) in diameter.

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

Stage IIIB: 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.

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 only 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 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, 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 (ascites) 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

The numbers below come from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database, and are based on patients who were diagnosed with liver cancer (hepatocellular type) between 1996 and 2001. There are some important points to note about these numbers:

• The 5-year survival rate refers to the percentage of patients who live at least 5 years after being diagnosed with cancer. Many of these patients live much longer than 5 years after diagnosis. Five-year relative survival rates assume that some people will die of other causes and compare the observed survival with that expected for people without the cancer. This is a more accurate way to describe the prognosis for patients with a particular type and stage of cancer.

• The SEER database does not divide liver cancer survival rates by AJCC stages. Instead, it groups cancer cases into summary stages. Localized means only one or 2 tumors in one lobe of the liver, and includes stage I and some stage II cancers. Regional means many tumors, spread to other lobes or parts of the liver, and/or spread to lymph nodes (includes some stage II cancers and all stage III). Distant means that the cancer has spread to distant organs or tissues and is the same as stage IV.

• These numbers were taken from patients treated several years ago. Although they are among the most current numbers we have available, improvements in treatment since then mean that the survival rates for people now being diagnosed with these cancers may be higher.

• Although survival statistics can sometimes be useful as a general guide, they may not accurately represent any one person's prognosis. A number of other factors, including other tumor characteristics and a person's age and general health, can also affect outlook. Your doctor can tell you how these numbers may apply to you, as he or she is familiar with the aspects of your particular situation.

For all stages combined, the relative 5-year survival rate from liver cancer is about 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.

Studies have shown that patients with small, resectable tumors who do not have cirrhosis or other serious health problems, are likely to do well if their cancers are removed. Their overall 5-year survival is over 50%.

Last Medical Review: 11/05/2009
Last Revised: 11/05/2009