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Liver Cancer Staging: TNM Classification System

Liver cancer staging helps to determine the disease prognosis and to select an appropriate treatment strategy.

TNM is the most commonly used system for staging liver cancers in the US. “T” stands for “Tumor Size”, “N” for “Lymph Nodes”, and “M” for “Metastasis”. Numbers and/or letters after T (1a, 1b, 2, 3, and 4), N (0 and 1), and M (0 and 1) provide more details about each of these factors.

Once T, N, and M categories are determined, this information is combined to assign an overall stage (from I to IV).

Following table describes the characteristics of liver cancer according to different TNM stages:

STAGE TNM DESCRIPTION
IA T1a N0 M0 A solitary tumor in the liver that measures </=2 cm in largest dimension and has not invaded any blood vessel. No spread of disease to nearby lymph nodes or distant body parts.
IB T1b N0 M0 A solitary tumor in the liver that measures >2 cm and has not invaded any blood vessel. No spread of disease to nearby lymph nodes or distant body parts.
II T2 N0 M0 A solitary tumor in the liver that measures >2 cm and has invaded a blood vessel OR multiple tumors but none measuring >5 cm. No spread of disease to nearby lymph nodes or distant body parts.
IIIA T3 N0 M0 Multiple tumors in the liver with at least one measuring >5 cm. No spread of disease to nearby lymph nodes or distant body parts.
IIIB T4 N0 M0 A solitary tumor or multiple tumors in the liver of any size with at least one tumor invading a large blood vessel (for example, portal or hepatic vein) or any adjacent organ except gallbladder or perforation of visceral peritoneum. No spread of disease to nearby lymph nodes or distant body parts.
IVA Any T N1 M0 A solitary tumor or multiple tumors of any size in the liver with or without invasion into a large blood vessel but with the spread of disease to nearby lymph nodes. No spread of disease to distant body parts.
IVB Any T Any N M1 A solitary tumor or multiple tumors in the liver of any size with or without invasion into a large blood vessel and the disease might or might not has spread to nearby lymph nodes. The disease has spread to distant body parts such as lungs or bones.

Child-Pugh Score: Child-Pugh Score is used to assess liver function (or liver cirrhosis) in liver cancer patients. Most patients with liver cancer have accompanying liver cirrhosis or other liver disorder due to which liver function is generally diminished in such patients.

An assessment of liver function help in selecting an appropriate treatment approach for liver cancer. The Child-Pugh scoring system is most commonly used for this purpose, which takes into consideration following 5 parameters: bilirubin level in blood, albumin level in blood, prothrombin time, presence or absence of ascites, and whether the liver disease is affecting brain function.

Based on the status of the above parameters liver cirrhosis/functioning is divided into 3 classes, that is, Class A, B, and C, where C represents the worse liver function. However, this system does not take into consideration any parameter of liver cancer itself. Thus, this system is used along with the TNM staging system for the assessment of overall disease.

Okuda staging system was the first validated system used for staging of liver cancer, which takes into consideration both cancer parameters and liver function parameters.

Many other staging systems have been developed and used for staging of liver cancer that accommodated different parameters related to liver cancer and liver function.

Examples for such systems include Cancer of the Liver Italian Program (CLIP) scoring system, Barcelona Clinic Liver Cancer (BCLC) system, Chinese University Prognostic Index (CUPI) scoring system, the Groupe d’Etude et de Traitement du Carcinoma Hepatocellulaire (GETCH) staging system, and the Japan Integrated Staging (JIS) system.

These staging systems have their own advantages and disadvantages and are used in different geographical regions as per physician’s preference and local practice.

Based on the extent of liver cancer and liver function, liver cancers can also be classified into following clinical categories:

  1. Potentially resectable or transplantable cancer: This category includes TNM stage I and II liver cancer that can be completely removed with surgery or treated with liver transplant and patient is healthy enough (sufficient liver function) to tolerate the surgical treatment.

  2. Unresectable cancer: This category includes TNM stage III liver cancer that cannot be completely removed with surgery as it has invaded important blood vessels or other structures. The patient may or may not have sufficient liver function.

  3. Inoperable with only local disease: This category includes TNM stage I and II liver cancer that has not invaded important structures but the patient is not healthy enough (liver function is significantly compromised or poor performance status) to tolerate surgery.

  4. Advanced (metastatic) cancer: This category includes TNM stage IV liver cancers that has spread to distant body parts and cannot be surgically removed. The patient may or may not have sufficient liver function.

Now let's understand the treatment for liver cancer according to stage.

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