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The information on this page was reviewed and approved by
Maurie Markman, MD, President, Medicine & Science at CTCA.

This page was updated on September 21, 2021.

Liver cancer stages

Making an educated treatment decision begins with determining the stage, or progression, of the disease. The stage of liver cancer is one of the most important factors in evaluating treatment options.

At Cancer Treatment Centers of America® (CTCA), our doctors use a variety of diagnostic tests to evaluate liver cancer. If you’ve been recently diagnosed, we’ll review your pathology to confirm you have received the correct diagnosis and staging information. If you have a recurrence, we will perform comprehensive testing. Either way, we will identify and develop a personalized treatment plan that’s tailored to your specific needs.

What does staging tell you?

Staging helps:

Your care team speak the same language: The stage is a quick way for your care team to communicate how advanced the cancer is—where it’s spread, how large it is, and how much it’s affecting the body.

Inform treatment: Most importantly, your stage informs a treatment plan—more advanced cases may need a different approach than smaller tumors caught early on. Liver cancers in the same stage are typically treated in similar ways.

Determine clinical trial eligibility: Clinical trials are programs researching new drugs or treatments intended to improve a person’s chances of survival. You and your care team may work together to decide on a treatment plan that best manages a particular cancer and its symptoms and provides the best quality of life.

TNM staging system

The TNM system is used to describe many cancers, and it’s the most common system used to stage liver cancer in the United States. However, TNM—created by the American Joint Committee on Cancer—doesn’t look at liver function. This is why other staging systems, such as the Barcelona Clinic Liver Cancer system, are sometimes used for primary liver cancer.

The TNM system bases the staging criteria on the evaluation of three primary factors:

T (tumor) describes the size of the original tumor.

N (node) indicates whether the cancer is present in the regional (nearby) lymph nodes.

M (metastasis) refers to whether cancer has spread to distant parts of the body. (The most common sites of liver cancer spread are the lungs and bones.)

A number (0-4) or the letter X is assigned to each factor. A higher number indicates increasing severity. For example, a T1 score indicates a smaller tumor than a T2 score. The letter X means the information couldn’t be assessed. Once the T, N and M scores have been assigned, an overall liver cancer stage is assigned.

Stage 1 liver cancer: The single primary tumor (any size) hasn’t grown into any blood vessels. The cancer hasn’t spread to nearby lymph nodes nor distant sites.

Stage 2 liver cancer: A single primary tumor (any size) has grown into blood vessels, or several tumors are present (all smaller than 5 cm). The cancer hasn’t spread to nearby lymph nodes nor distant sites.

Stage 3 liver cancer: This stage has three subcategories.

  • Stage 3A: Several tumors have been found, and at least one is larger than 5 cm. The cancer hasn’t spread to nearby lymph nodes nor distant sites.
  • Stage 3B: Several tumors have been found, and at least one tumor is growing into a branch of the portal vein or the hepatic vein. The liver cancer hasn’t spread to nearby lymph nodes nor distant sites.

Stage 4 liver cancer: The cancer may have spread to nearby lymph nodes and/or to distant sites within the body. Advanced liver cancer doesn’t often metastasize, but when it does, it’s most likely to spread to the lungs and bones.

Unlike other cancers, liver cancer is complicated by the fact that most patients have damage that limits the organ’s function. The liver provides a crucial service for the body, aiding in digestion and detoxification. Reduced liver function may result in severe, even life-threatening, conditions. Reduced liver function may also have implications when choosing treatment options.

Other liver cancer staging systems

Several liver cancer staging systems have been developed that take into account how the function of the liver may affect the prognosis:

  • Barcelona-Clinic Liver Cancer (BCLC) system
  • Cancer of the Liver Italian Program (CLIP) system
  • Okuda system

Though the TNM system is the most common, there’s no single staging system consistently used by the medical community, so if you have questions about your liver cancer stage, make sure to discuss them with your oncology team.

Child-Pugh score

The Child-Pugh score is part of the BCLC staging system and describes liver function using blood tests and imaging. Liver cancer patients often have cirrhosis as well, which is scarring of liver tissue due to disease or toxins. Cirrhosis may be described with this scale.

Child-Pugh measures liver function by looking at five factors:

  • Blood levels of bilirubin, which is made by the liver and results in yellowing of the skin and eyes when there is too much (jaundice)
  • Blood levels of albumin, a protein normally made by the liver
  • The time it takes for clotting factors to work
  • Fluid levels in the abdomen
  • Whether the liver disease is affecting brain function

The Child-Pugh score is used to determine the class of liver function:

  • Class A means the liver function is normal.
  • Class B means there are some abnormalities in the way the liver is working.
  • Class C indicates severe abnormalities in liver function. Individuals with class C liver function may not be good candidates for aggressive treatment or surgery because of the intensity of their disease.

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