This document provides information on tumor staging systems for hepatocellular carcinoma (HCC), including the TNM classification system and Barcelona-Clinic Liver Cancer (BCLC) staging system. The TNM system stages primary tumors (T) from T1 to T4 based on size and invasion. It also stages regional lymph nodes (N) and distant metastasis (M). The BCLC system additionally considers liver function and performance status to stratify HCC into early, intermediate, advanced, and end-stage groups to help guide treatment strategies. Other factors like cirrhosis severity assessed by Child-Pugh score and liver fibrosis assessed by Ishak score also impact HCC staging and prognosis.

1. TNM Classification for
Hepatocellular Carcinoma

2. Primary tumor (T)
TX
Primary tumor cannot be
assessed
T0 No evidence of primary tumor
T1
Solitary tumor < 2 cm, or >2
cm without vascular invasion
T1a Solitary tumor < 2 cm
T1b
Solitary tumor >2 cm without
vascular invasion
T2
Solitary tumor >2 cm with
vascular invasion; or multiple
tumors, none >5 cm

3. Primary tumor (T)
T3
Multiple tumors, at least one of
which is >5 cm
T4
Single tumor or tumors of any size
involving a major branch of the
portal vein or hepatic vein, or
tumor(s) with direct invasion of
adjacent organs other than the
gallbladder or with perforation of
visceral peritoneum

4. Regional lymph nodes (N)
NX
Regional lymph nodes cannot be
assessed
N0
No regional lymph node
metastasis
N1 Regional lymph node metastasis

5. Distant metastasis (M)
M0 No distant metastasis
M1 Distant metastasis

6. Anatomic stage/prognostic groups
Stage T N M
IA T1a N0 M0
IB T1b N0 M0
II T2 N0 M0
IIIA T3 N0 M0
IIIB T4 N0 M0
IVA Any T N1 M0
IVB Any T Any N M1

7. Histologic grade (G)
GX Grade cannot be accessed
G1 Well differentiated
G2 Moderately differentiated
G3 Poorly differentiated
G4 Undifferentiated

8. • In addition to the TNM staging for HCC, other
systems have been proposed to help guide
therapeutic strategies.
• One of these validated systems is the Barcelona-
Clinic Liver Cancer staging system (BCLC).
• The BCLC system stratifies HCC patients based on
tumor size, extent, liver function, and
performance status.
• The BCLC staging system is thought to be better
than other staging systems for determining
prognosis, given the inclusion of liver function
and performance status.

9. Barcelona-Clinic Liver Cancer staging
system
Stage
Performanc
e Status
Tumor
Stage
Okuda
Stage
Liver
function
A: Early
HCC
A1 0
Single, < 5
cm
I
No portal
hypertensio
n, normal
bilirubin
A2 0
Single, < 5
cm
I
Portal
hypertensio
n, normal
bilirubin

10. Barcelona-Clinic Liver Cancer staging
system
A3 0
Single, < 5
cm
I
Portal
hypertensio
n, abnormal
bilirubin
A4 0
3 tumors, <
3 cm
I-II
Child-Pugh
A-B
Stage B:
Intermediate
HCC
0
Large,
multinodula
r
I-II
Child-Pugh
A-B
Stage
Performanc
e Status
Tumor
Stage
Okuda
Stage
Liver
function
Stage C:
Advanced
HCC
1-2
Vascular
invasion or
extrahepati
c spread
I-II
Child-Pugh
A-B

11. Barcelona-Clinic Liver Cancer staging
system
Stage
Performanc
e Status
Tumor
Stage
Okuda
Stage
Liver
function
Stage D:
End-Stage
HCC
3-4 Any I-II
Child-Pugh
C

12. Stage A and B:
All criteria need to be fulfilled
Stage C:
At least one of the following criteria needs to be
filled: performance status 1-2 or vascular
invasion/extrahepatic spread.
Stage D:
At least one of the following criteria needs to be
filled: performance status 3-4 or Okuda Stage
III/Child Pugh C.

13. • Cirrhosis is an important component of HCC
staging.
• Cirrhosis is not only an independent predictor
of survival but also guides management
decisions and determines candidacy for
different therapies.
• The Child-Pugh score can be used to classify
the prognosis based on the degree of cirrhosis
and therefore can help in determining
operative risk

14. • Another consideration in determining stage
and prognosis in patients with HCC is the
degree of liver fibrosis.
• There are many different scoring systems used
to determine the degree of liver fibrosis.
• With one such scoring system, the Ishak
fibrosis staging system, stages 1 through 5
had no direct correlation with survival,
however, stage 6 was associated with poor
overall survival

15. Ishak fibrosis score
Architectural Change Score
No fibrosis 0
Fibrous expansion of some portal areas, with or
without short fibrous septa
1
Fibrous expansion of most portal areas, , with or
without short fibrous septa
2
Fibrous expansion of most portal areas, with
occasional portal-to-portal bridging
3
Fibrous expansion of portal areas with marked
bridging as well as portal-central
4
Marked bridging (portal-to-portal and/or portal-
central) with occasional nodule (incomplete
cirrhosis)
5
Cirrhosis, probable or definite 6

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