2. Introduction :
Hepatocellular carcinoma (HCC) is a primary malignant tumor of the
liver with hepatocellular differentiation.
Its incidence is increasing; becoming 5th most common malignancy
HCC is the commonest primary liver malignancy (90%). however,
secondaries are the most common malignancy in the liver (20 times
more common than primary).
It is common in cirrhotics and hepatitis B and hepatitis C virus
Male to female ratio is 4:1.
Right lobe is commonly involved.
3. Eggel's Classification :
Nodular form : (65%)
occurs as solitary or multiple nodules
vary in size
Massive form : (23%)
involving the whole of the right or left lobe.
not well demarcated
accompanied by small intrahepatic metastatic nodules.
Diffuse form : (12%)
Numerous small foci
Difficult to distinguish from the pseudolobules of liver
4. Macroscopic classification :
Vaguely nodular type
Expanding nodular type
Multinodular confluent type
Nodular with perinodular
Specific types :
5. Vaguely nodular type multinodular confluent type
nodular with perinodular
infiltrative type cirrhotomimetic type
expanding nodular type
6. Vaguely nodular (VN) type :
defined as a nodule with indistinct
Expanding nodular (EN) type :
defined by as a round expansile nodule
with a distinct margin.
Multinodular confluent (MC) type :
defined as a cluster of small and
7. Nodular with perinodular
extension (NP) type :
defined as an expanding nodule
similar to EN type that had
extranodular growth in less than 50%
of the tumor circumference.
Infiltrative (INF) type :
showed extranodular growth in more
than 50% of the tumor
9. Staging systems in hepatocellular
The Okuda classification
The Cancer of the Liver Italian Program
The Barcelona‐Clínic Liver Cancer (BCLC)
The French classification
Chinese University Prognostic Index
Japan Integrated Staging (JIS)
10. Okuda staging system :
The Okuda system is a prognostic score
introduced in 1985.
Okuda and colleagues devised a staging system
based on four factors representing advanced
disease. This includes:
1. tumor occupying greater or less than 50% of the
2. the presence or absence of ascites.
3. serum albumin level.
4. serum bilirubin level.
11. The system’s biggest shortcoming is its
relatively crude classification of early stage
patients and subsequent staging systems have
tried to better characterize Okuda Stage I
the Okuda system remains the standard against
which newer scoring systems are compared.
13. Cancer of the Liver Italian Program
(CLIP) score :
was proposed by an Italian group in 1998.
takes into account both liver function and tumor
It has been found superior to Okuda staging
and TNM staging with greater predictive power.
14. It is based on 4 factors :
1. the Child-Pugh status of the patient.
2. tumor characteristics including tumor
morphology and extension.
3. portal vein thrombosis.
4. levels of alfa-fetoprotein (AFP).
16. • Patients are classified into 7 groups according to the sum of these
• clip 0-3 : Early disease with potential long-term survival.
• clip 4-6 : Advanced stage.
17. The Barcelona-Clinic Liver Cancer
(BCLC) staging system :
The BCLC classification was first published in 1999.
is considered the standard HCC system by the
American Association of the Study of Liver Disease
(AASLD) and European Association for the Study of
takes into account size and extent of the primary
tumor, liver function, physiological factors and
incorporates the Okuda stage and Child-Pugh score.
18. this classification is best suited for treatment
guidance, and particularly to select early
stage patients who could benefit from
curative therapies. In that sense, it has been
validated as the best staging system in
patients with early HCC.
19. Performance status (PS) :
is a scale to grade how well the patient is. The BCLC staging
system uses the Eastern Cooperative Oncology Group (ECOG)
• PS 0 : fully active, able to carry on all pre-disease performance
• PS 1 : restricted in physically strenuous activity but ambulatory
and able to carry out work of a light or sedentary nature.
• PS 2 : ambulatory and capable of all self-care but unable to
carry out any work activities, up about more than 50% of
• PS 3 : capable of only limited self-care, confined to bed or chair
more than 50% of waking hours.
• PS 4 : completely disabled, cannot carry on any self-care,
totally confined to bed or chair.