Liver Cancer: Stages

Approved by the Cancer.Net Editorial Board, 03/2015

ON THIS PAGE: You will learn about how doctors describe a cancer’s growth or spread. This is called the stage. To see other pages, use the menu on the side of your screen.

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body. Doctors use diagnostic tests to find out the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor decide what kind of treatment is best and may help predict a patient's prognosis, which is the chance of recovery.

There are two types of liver cancer: primary and metastatic. Primary liver cancer begins in the liver. Metastatic (secondary) liver cancer is cancer that has spread from another part of the body. This section describes the stages of primary liver cancer. For information about the stages of metastatic liver cancer, read about the primary type of cancer. For example, lymphoma that has spread to the liver will still be staged as lymphoma.

BCLC staging system

For HCC, doctors often use the Barcelona Clinical Liver Cancer (BCLC) system to describe the cancer and recommend treatment. The BCLC system categorizes HCC based on characteristics of the tumor, liver function, performance status, and cancer-related symptoms.

BCLC stage groupings include:

  • Very early stage. The tumor is less than 2 cm. There is no increased pressure in the portal vein and bilirubin levels are normal. Surgery is usually recommended.
  • Early stage. The tumor is less than 5 cm. Liver function varies. There may be no increased pressure in the portal vein, increased portal vein pressure and normal bilirubin levels, or increased portal vein pressure and increased bilirubin levels. People with early-stage disease may potentially be candidates for a liver transplant, surgery, or radiofrequency ablation (RFA).
  • Intermediate stage. The tumor may be large or there may be multiple tumors. Doctors usually recommend regional therapies, such as transarterial chemoembolization.
  • Advanced stage. The tumor has invaded the portal vein or spread to other parts of the body, such as the lungs and bones. Doctors usually recommend targeted therapy.

TNM staging system

To describe the stage in more detail, doctors sometimes use the TNM system. This staging system is most useful for patients whose tumor can be surgically removed. It is also important to note that TNM staging has significant limitations for staging HCC if there is cirrhosis of the liver. Cirrhosis can become equally or even more important than tumor characteristics.

Doctors use the results from diagnostic tests and scans to answer these questions:

  • Tumor (T): How large is the primary tumor? Where is it located?
  • Node (N): Has the tumor spread to the lymph nodes? If so, where and how many?
  • Metastasis (M): Has the cancer metastasized to other parts of the body? If so, where and how much?

The results are combined to determine the stage of cancer for each person. There are four stages: stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

Here are more details on each part of the TNM system for liver cancer.

Tumor (T)

Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail. If there is more than one tumor, the lowercase letter “m” (multiple) is added to the “T” category. Specific tumor stage information for HCC is listed below.

TX: The primary tumor cannot be evaluated.

T0: There is no evidence of a primary tumor.

T1: The tumor is 2 cm or smaller. It does not involve nearby blood vessels.

T2: Either of these:

  • Any tumor that involves nearby blood vessels.
  • More than one tumor, but none larger than 5 cm.

T3a: There is more than one tumor, and at least one is larger than 5 cm.

T3b: A tumor of any size involves the major veins around the liver.

T4: Either of these:

  • The tumor has spread to the organs near the liver, except the gallbladder.
  • The tumor has broken through the visceral peritoneum, which is the layer of tissue that lines the abdomen.

Node (N)

The "N" in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes near the liver are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.

NX: The regional lymph nodes cannot be evaluated.

N0: Cancer has not spread to the regional lymph nodes.

N1: The cancer has spread to the regional lymph nodes.

Metastasis (M)

The “M” in the TNM system indicates whether the cancer has spread to other parts of the body, called distant metastasis.

MX: The tumor cannot be evaluated.

M0: The cancer has not spread to other parts of the body.

M1: The tumor has spread to another part of the body.

Cancer stage grouping using TNM

Doctors assign the stage of the HCC by combining the T, N, and M classifications.

Stage I: This is the earliest stage of HCC. The tumor has not spread to the blood vessels, lymph nodes, or other parts of the body (T1, N0, M0).

Stage II: The tumor involves nearby blood vessels, but it has not spread to the regional lymph nodes or other parts of the body (T2, N0, M0).

Stage IIIA: The cancer has not spread beyond the liver, but the area of the cancer is larger than stage I or II (T3a, N0, M0).

Stage IIIB: The cancer involves a major vein around the liver, but it has not spread to nearby lymph nodes or other parts of the body (T3b, N0, M0).

Stage IIIC: Any tumor that has spread to the organs near the liver (except the gallbladder), or if the tumor has broken through the visceral peritoneum. There is no spread to nearby lymph nodes or other parts of the body (T4, N0, M0).

Stage IVA: Any tumor that has spread to the regional lymph nodes but not to other parts of the body (any T, N1, M0).

Stage IVB: Any tumor that has spread to other parts of the body (any T, any N, M1).

Recurrent: Recurrent cancer is cancer that has come back after treatment. If the cancer has returned, there will be another round of tests to learn about the extent of the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis.

TNM system outline used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Seventh Edition, published by Springer-Verlag New York, www.cancerstaging.net.

Information about the cancer’s stage will help the doctor recommend a specific treatment plan. The next section in this guide is Treatment Options. Or, use the menu on the side of your screen to choose another section to continue reading this guide.