for Health Care Providers
Staging and Prognosis - Liver Cancer
Prognosis and choosing a staging system
Staging is essential for the optimal management of HCC, as a wide variety of treatments are applied based on stage. Residual hepatic function and tumor extent tend to be the two factors that most influence prognosis. Hepatic function is usually assessed by the Child-Pugh classification or the MELD score.
No single scoring system for HCC staging has been accepted as the best one. Widely used systems include the Okuda system, the tumor, node, metastasis (TNM) system of the International Union Against Cancer, the Cancer of the Liver Italian Program (CLIP) score, the Barcelona Clinic Liver Cancer (BCLC) system, and several others. The TNM system takes into account only the extent of the tumor; the Okuda system adds serum albumin, serum bilirubin, and the extent of ascites; and the CLIP system includes Child-Pugh class, tumor morphology, whether the AFP is 400 ng/mL or greater, and the presence or absence of portal vein thrombosis. The BCLC system is similar to the CLIP but incorporates the patient's performance status and does not include AFP. A study comparing 7 staging systems in a group of U.S. HCC patients found that all 7 were valid, with survival declining in direct correlation with higher score, but that the BCLC system had the best independent predictive power for survival. Practitioners caring for many HCC patients will find it useful to have a working knowledge of several of the systems.
The median survival of HCC patients after diagnosis has generally been a little more than 1 year. Survival is usually between 3 and 6 months if a patient is diagnosed after the onset of symptoms. Median survivals as short as 8 to 10 weeks have been reported in some studies, including a retrospective study of 157 untreated patients, 18% of whom had extrahepatic metastases at diagnosis. Causes of death in these patients were upper gastrointestinal bleeding in 34%, cancer-related causes (cachexia and metastatic disease) in 32%, and hepatic failure in 25%.
Tumor-Node-Metastasis (TNM) staging system
| Stage | TNM | Regional LNM | Distant Metastasis |
|---|---|---|---|
| I | T1 | N0 | M0 |
| II | T2 | N0 | M0 |
| III | T1 | N1 | M0 |
| T2 | N1 | M0 | |
| T3 | N0, N1 | M0 | |
| IVA | T4 | Any N | M0 |
| IVB | Any T | Any N | M1 |
- LNM: lymph node metastasis
- T1: solitary <= 2 cm, no vascular invasion
- T2: i) solitary <= 2 cm, vascular invasion; ii) multiple, one lobe, <= 2 cm, no vascular invasion; or iii) solitary, > 2 cm, no vascular invasion
- T3: i) solitary, > 2 cm, vascular invasion; ii) multiple, one lobe >= 2 cm, no vascular invasion; or iii) multiple, one lobe, > 2 cm, with or without vascular invasion
- T4: multiple, more than one lobe, invasion of major branch of portal or hepatic vein
- N0: no regional lymph node metastasis
- N1: regional lymph node metastasis
- M0: no distant metastasis
- M1: distant metastasis
Adapted from Yu AS and Keeffe EB. Management of Hepatocellular Carcinoma. Rev Gastroenterol Disord 2003;3(i):8-24.
Okuda staging system
The Okuda staging system classifies patients into three stages based on the following variables.
| Criterion | Cut-Off |
|---|---|
*Largest cross-sectional area of tumor relative to largest cross-sectional area of liver. | |
| Tumor size* | > 50% = "+", < 50% = "-" |
| Ascites | Clinically detectable = "+"; undetectable = "-" |
| Serum albumin | < 3 g/dl = "+"; >= 3 g/dl = "-" |
| Serum bilirubin | > 3 mg/dl = "+"; < 3 mg/dl = "-" |
Adapted from: Okuda K, Ohtsuki T, Obata H, et al. Natural history of hepatocellular carcinoma and prognosis in relation to treatment. Study of 850 patients
. Cancer 1985;56:918-928.
CLIP scoring system
| Variables | Score: 0 | Score: 1 | Score: 2 |
|---|---|---|---|
The CLIP score for a patient with hepatocellular carcinoma is calculated by assigning a score (0, 1, or 2) to each of four clinical factors: a) Child-Pugh stage; b) number of tumor nodules and whether the tumor extends through 50% or less, or more than 50%, of the liver; c) AFP; and d) portal vein thrombosis. These scores are added together to yield a CLIP score of 0-6, with median survival by CLIP score as follows:
0 = 42.5 months | |||
| Child-Pugh stage | A | B | C |
| Tumor morphology | uninodular and extension ≤ 50% | multinodular and extension ≤ 50% | massive or extension > 50% |
| AFP (ng/dL) | < 400 | ≥ 400 | |
| Portal vein thrombosis | no | yes | |
References
References for this page are listed on the Background and Epidemiology page.
