Diagnosis of liver cancer

In most instances, hepatocellular carcinomas develop on livers that already present a chronic disease state. This means that the prognosis and treatment options are closely dependent on the extent of the underlying liver disease. Furthermore, an accurate study is essential to assess the size of the tumour. The prognosis depends on the number and size of lesions on the liver and, above all, on whether the disease has spread beyond the liver or invaded the blood vessels supplying the liver (the portal vein is often affected).  

Finally, oncologists must determine whether patients have symptoms that are specifically associated with cancer (more tired than usual, weight loss and/or loss of appetite), as their presence has a significant impact on the prognosis. 

There are a lot of staging and prognostic assessment systems, but the most used and recommended by Spanish and European scientific societies is the BCLC staging system (Barcelona Clinic Liver Cancer) developed by the Hospital Clínic de Barcelona.  

The BCLC system identifies five broad stages of the disease: 

• Very early stage (BCLC 0). This stage constitutes a group with a particularly good prognosis, including asymptomatic patients with single tumours measuring less than 2 cm, preserved liver function and no vascular invasion or spread outside the liver. These patients can be treated through percutaneous ablation or surgical resection with a high probability of curing the disease. 

• Early stage (BCLC A). Early-stage patients are still symptomless, have preserved liver function and just one tumour (of any size) or up to three nodules that are all less than 3 cm in diameter. These patients are candidates for treatments with curative intent such as surgical resection, percutaneous ablation or a liver transplant. The expected 5year survival rate is 50–75%.  

• Intermediate stage (BCLC B). Patients with multiple tumours, preserved liver function and a normal general condition, and no vascular invasion or spread outside the liver. The first-choice treatment in this group of patients is chemoembolisation (transarterial chemoembolisation, TACE).  

• Advanced stage (BCLC C). These patients have normal liver function, but there is also vascular invasion and/or spread outside the liver or they notice a mild decline in their general condition. They will benefit from systemic treatments (targeted therapy).  

• End-stage (BCLC D). This group of patients suffers a severe decline in their general condition and/or compromised liver function for which liver transplant would not be viable. Supportive, symptomatic treatment is recommended in such cases. 

With respect to cholangiocarcinomas, the prognostic assessment is essentially based on whether or not surgical resection is a viable option. If the tumour cannot be operated on, the prognosis will depend on the intratumoral extension (number and size of the lesions) and whether there is any invasion into blood vessels or nearby lymph nodes. If it is inoperable, then the tumour’s spread outside the liver must be taken into account.