Liver Cancer TNM Staging
Stage 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.
Stage 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.
Stage 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.
Stage 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
Stage 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.
Stage 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.
Stage 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.
Scoring Systems used to asses the Liver Function
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.
It 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.
Liver Cancer Staging Investigations
This is a test recommended to be used for screening of high-risk individuals. This test can detect solid tumor masses (cancerous) within the liver of high-risk patients, which can be further evaluated with the help of other diagnostic tools. This technique can sometimes be used to guide a biopsy needle to collect biopsy samples from the affected area to establish the diagnosis of liver cancer.
Blood tests cannot confirm liver cancer themselves but these tests can provide certain important information that can provide direction to the diagnostic workup of liver cancer. Following are commonly employed blood test for this purpose:
This is another test recommended to be used for screening of high-risk individuals. AFP is glycoprotein generally produced by the immature liver cells of a fetus. The level of AFP decreases significantly after birth and approaches to normal by 1 year of birth.
Abnormally high level of AFP in adults is usually associated with liver disease, liver cancer, or some other conditions. Thus, in the high-risk individuals, abnormally high level of AFP may signal the development of liver cancer. Monitoring of AFP level can be helpful in assessing the efficacy of the treatment/surgery (that should bring down the AFP level in patients with high AFP levels detected before treatment start) and to assess disease progression/recurrence.
It is raised in 50 to 90% of symptomatic HCC and correlates with ethnicity. Levels more than 400ng/ml have 95% positive predictive value. Levels of 20 to 400 ng/ml may be seen in cirrhosis or active hepatitis also. Lectin reactive isoenzyme of AFP (AFP-L3) showed increased sensitivity as compared to conventional AFP. Des-gamma-carboxy-PT protein induced by Vit K abnormality (PIVKA-2) also has greater sensitivity than AFP.
Liver function tests (LFTs)
These are a group of blood tests which give an estimate of overall liver functionality as a function of the blood levels of certain substances. These tests include prothrombin time (PT), albumin, bilirubin (direct and indirect), alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and others. These tests are employed for the assessment of suitability for liver resection.
One or more of the following imaging tests are required for initial staging and reassessment after treatment-
- Computed tomography (CT) scan
- Triple-phase CT scan is used if there is a suspicion of hepatocellular cancer. Contrast enhancement in the arterial phase and washout in the delayed venous phase may be suggestive of hepatocellular cancer.
- Magnetic resonance imaging (MRI) scan
- Positron emission tomography (PET) scan
- Bone Scan
Laboratory Tests for Biopsy Samples
Biopsy is not always required in hepatocellular cancer, as in some cases imaging and tumor markers may be sufficient for diagnosis.
American Association for the study of Liver Diseases ( AASLD) criteria for diagnosis of HCC in a hepatic mass within a cirrhotic liver –
- If mass >2cm & AFP >200 with a radiologic features of HCC (arterial vascularization with washout in 1 study or arterial vascularization on 2 separate dynamic study), biopsy not essential
- 1 to 2 cm-do image guided biopsy
- < 1cm -observe