From the Guidelines
Hepatocellular carcinoma (HCC) should be staged using the Barcelona Clinic Liver Cancer (BCLC) staging system, which is the most widely accepted approach and has been extensively validated 1.
Staging Criteria
The BCLC system classifies HCC into five stages: 0 (very early), A (early), B (intermediate), C (advanced), and D (terminal). This system considers tumor characteristics (size, number, vascular invasion), liver function (using Child-Pugh classification), and patient performance status.
Key Components of the BCLC Staging System
- Tumor characteristics: size, number, vascular invasion
- Liver function: Child-Pugh classification
- Patient performance status: Eastern Cooperative Oncology Group (ECOG) performance status
Importance of Staging
Proper staging is crucial as it guides treatment decisions, with early stages (0-A) potentially eligible for curative treatments like resection, transplantation, or ablation, while advanced stages may require systemic therapies or palliative care.
Multidisciplinary Approach
The staging process should be performed by a multidisciplinary team including hepatologists, oncologists, radiologists, and surgeons for optimal management 1.
Diagnostic Evaluation
To stage HCC properly, patients should undergo:
- Contrast-enhanced imaging studies such as CT or MRI to assess tumor size, number, and vascular invasion
- Laboratory tests to evaluate liver function (albumin, bilirubin, INR) and tumor markers (AFP)
- Assessment of portal hypertension and performance status completes the evaluation.
Treatment Allocation
Treatment stage migration concept applies, and refinement of BCLC classes by clinical data, molecular classes, or biomarker tools should further facilitate understanding of outcome data, treatment allocation, and trial stratification 1.
From the Research
Criteria for Staging Hepatocellular Carcinoma (HCC)
The staging of HCC is based on several factors, including:
- Tumor status, defined by tumor size and number, presence of vascular invasion, and extrahepatic spread 2
- Liver function, defined by the Child-Pugh's class 2
- Patient performance status, defined by the Eastern Cooperative Oncology Group scale 3
- Presence of symptoms 2
Staging Systems
Several staging systems are used for HCC, including:
- Barcelona Clinic Liver Cancer (BCLC) staging system, which is considered one of the best staging systems for HCC 2
- European systems, such as the French staging system and the cancer of the liver Italian program (CLIP) 2
- Asian systems, such as the Okuda staging system, Japan integrated Staging (JIS), Tokyo score, and Chinese University Prognostic Index (CUPI) 2
BCLC Staging System
The BCLC staging system is a widely used and well-validated system that incorporates tumor status, liver function, and patient performance to stage patients with newly diagnosed HCC 4. The system is as follows:
- Stage 0: very early HCC, with a single tumor less than 2 cm in size, and well-preserved liver function 5
- Stage A: early HCC, with a single tumor or up to 3 nodules less than 3 cm in size, and well-preserved liver function 5
- Stage B: intermediate HCC, with large or multinodular HCC, well-preserved liver function, and no cancer-related symptoms or evidence of vascular invasion or extrahepatic spread 6, 5
- Stage C: advanced HCC, with vascular invasion or extrahepatic spread, and poor liver function 5
- Stage D: terminal HCC, with very poor liver function and severe cancer-related symptoms 5
Assessment of Extrahepatic Spread
The assessment of extrahepatic spread in HCC can be done with either PET/CT or a combination of CT (Chest and abdomen) and a bone scan 2.