Liver Cancer Stages

After someone is diagnosed with liver cancer, doctors will try to figure out if it has spread, and if so, how far. This process is called staging. The stage of a cancer describes how much cancer is in the body. It helps determine how serious the cancer is and the best way to treat it. Doctors also use a cancer's stage when talking about survival statistics.

Liver cancer stages range from stage I (1) through IV (4). As a rule, the lower the number, the less the cancer has spread. A higher number, such as stage IV, means cancer has spread more. Although each person’s cancer experience is unique, cancers with similar stages tend to have a similar outlook and are often treated in much the same way.

How is the stage determined?

There are several staging systems for liver cancer, and not all doctors use the same system. The staging system most often used in the United States for liver cancer is the AJCC (American Joint Committee on Cancer) TNM system, which is based on 3 key pieces of information:

• The extent (size) of the main (primary) tumor (T): How large is the tumor? Is there more than one tumor in the liver? Has the cancer reached nearby structures like the veins in the liver?

• The spread to nearby lymph nodes (N): Has the cancer spread to nearby lymph nodes?
• The spread (metastasis) to distant parts of the body (M): Has the cancer spread to distant lymph nodes or distant organs such as the bones or lungs?

Numbers or letters after T, N, and M provide more details about each of these factors. Higher numbers mean the cancer is more advanced. Once a person’s T, N, and M categories have been determined, this information is combined in a process called stage grouping to assign an overall stage.

Liver cancer can be staged in 2 ways:

• The clinical stage is based on the results of the physical exam, biopsies (if done), and imaging tests  (ultrasound, CT or MRI scan, etc.). The clinical stage can be used, along with other factors, to help determine the best treatment options.
• If surgery is done, the pathological stage (also called the surgical stage) can be determined by examining tissue removed during an operation. Sometimes the pathological stage might be more advanced than the clinical stage, for example, if surgery finds cancer in places that didn’t show up on imaging tests.

For more on how cancer staging is done, see Cancer Staging.

Liver cancer staging can be complex, so ask your doctor to explain it to you in a way you understand.

 

AJCC Stage	Stage grouping	Stage description*
IA	T1a N0 M0	A single tumor 2 cm (4/5 inch) or smaller (T1a). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body (M0).
IB	T1b N0 M0	A single tumor larger than 2cm (4/5 inch) that hasn't grown into blood vessels (T1b). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body (M0).
II	T2 N0 M0	Either a single tumor larger than 2 cm (4/5 inch) that has grown into blood vessels, OR more than one tumor but none larger than 5 cm (about 2 inches) across (T2). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body (M0).
IIIA	T3 N0 M0	More than one tumor, with at least one tumor larger than 5 cm across (T3). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body (M0).
IIIB	T4 N0 M0	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), or that has grown directly into a nearby organ (other than the gallbladder) (T4). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body  (M0).
IVA	Any T N1 M0	A single tumor or multiple tumors of any size (Any T). The cancer has spread to nearby lymph nodes (N1) but not to distant parts of the body (M0).
IVB	Any T Any N M1	A single tumor or multiple tumors of any size (any T). The cancer might or might not have spread to nearby lymph nodes (any N). The cancer has spread to distant organs such as the bones or lungs (M1).

* The following additional categories are not listed on the table above: 

• TX: Main tumor cannot be assessed due to lack of information.
• T0: No evidence of a primary tumor.
• NX: Regional lymph nodes cannot be assessed due to lack of information. 

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. This also affects treatment options and survival outlook.

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. For example, the BCLC system is the most widely used staging system in major medical centers. BCLC stage groupings include:

• Very early stage
• Early stage
• Intermediate stage
• Advanced stage

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 measures liver function, especially in people with cirrhosis. Many people with liver cancer also have cirrhosis, so to treat the cancer, doctors need to know how well the liver is working. This system looks at 5 factors. The first 3 can be measured on 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 (encephalopathy)

Based on these factors, there are 3 classes of liver function. 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 part of the BCLC and CLIP staging systems mentioned previously.

Liver cancer classification

Formal staging systems (such as those described above) can often help doctors determine a patient's prognosis (outlook). But for treatment purposes, doctors often classify people into groups based on whether the liver cancer can be removed (resected) completely by surgery.

Patients with potentially resectable cancers or who are eligible for a transplant

If the patient is healthy enough for surgery, these cancers can be completely removed by surgery or the person can be treated with a liver transplant. 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 portion of people with liver cancer have resectable tumors.

Patients with unresectable (inoperable) cancers that have only spread locally

These cancers haven’t spread to the lymph nodes or distant organs, but they can’t be removed completely by surgery for some reason. This includes:

• Cancers that have spread throughout the liver or that can’t be removed safely because they are too close to the area where the liver meets the main arteries, veins, and bile ducts.
• Cancers in people who aren’t healthy enough for major liver surgery. Often this is because the non-cancerous part of the liver isn’t healthy (because of cirrhosis, for example), so if the cancer was removed, there might not be enough healthy liver tissue left for it to function properly. It could also mean that a person has other serious medical problems that would make surgery unsafe.

Patients with advanced (metastatic) cancers

These cancers have spread to nearby lymph nodes or to other parts of the body. These would include stage IVA and IVB cancers in the TNM system. Advanced liver cancers typically cannot be treated with surgery.