Hepatocellular carcinoma (staging)

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Hepatocellular carcinoma staging classifications supersede the typical TNM staging system seen in most other epithelial cancers, as the TNM staging system has been found to not be as prognostically useful for stratification of patients with hepatocellular carcinoma. Several substitute staging systems have arisen to guide therapy choice and prognosis for hepatocellular carcinoma:

Of these, the BCLC system is the one most often used in Western countries to guide treatment.

In a related dimension, there are additional criteria for liver transplantation with hepatocellular carcinoma, which vary depending on one's institution:

  • Milan criteria
  • United Network of Organ Sharing (UNOS) criteria
  • University of California San Francisco (UCSF) criteria

Finally, in addition to these hepatocellular carcinoma therapies and prognostication models, models of hepatic dysfunction are a vital dimension in evaluating an individual patient's therapy options:

Overall models for a patient's general well-being are essential too, such as:

Some of the staging systems (such as the BCLC system and the JIS) incorporate hepatic function and patient well-being variables into the staging system.

Pathology

Vascular invasion, both macroscopic and microscopic, is correlated with a high rate of recurrence and plays an important role in most hepatocellular carcinoma staging systems. Microvascular invasion is determined on biopsy.

The importance of nodal metastases in hepatocellular carcinoma is not entirely defined but considered a late stage finding with poor prognosis.

Practical points

  • in patients with severe cirrhosis, the Child-Pugh score and MELD score may give a better idea of prognosis than an HCC staging classification
  • technical problems in resection planning (e.g. a small tumor across the middle hepatic vein) influence the overall prognosis​
  • twice a year ultrasound surveillance in at-risk patients results in early detection of HCC