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 (Barcelona Clinic Liver Cancer) defines five main stages of liver cancer:

• Very early stage (BCLC 0): This group has a particularly favorable prognosis. It includes people without symptoms, with good liver function, a single tumor smaller than two centimeters, and no blood vessel involvement or cancer spread. In these cases, curative treatments such as surgery, ablation, or liver transplantation are possible, with a high chance of curing the disease.

• Early stage (BCLC A): These are individuals without symptoms, with preserved liver function, and either a single tumor or up to three nodules, each no larger than three centimeters. Curative treatments such as surgery, ablation, or liver transplantation can be applied. The expected 5-year survival rate is between 50% and 75%.

• Intermediate stage (BCLC B): These patients have multiple liver tumors but remain in good general health, and their liver still functions properly. There is no blood vessel involvement or spread outside the liver. The first-line treatment depends on whether the patient meets the criteria for liver transplantation. If transplant is an option, it is the preferred choice. If not, alternatives include transarterial chemoembolization (TACE), immunotherapy, or systemic therapy.

• Advanced stage (BCLC C): At this stage, although liver function may still be preserved, the tumor affects blood vessels, has spread beyond the liver, or there may be mild deterioration in the patient’s overall condition. These individuals may benefit from immunotherapy. If that is not an option, systemic therapy with targeted treatments may be considered.

• Terminal stage (BCLC D): In this stage, patients have severe deterioration in general condition and/or significantly impaired liver function, making it impossible to receive specific treatments such as liver transplantation or direct cancer therapies. In such cases, symptomatic treatment and palliative care are recommended to maintain the best possible quality of life.

In the case of cholangiocarcinoma, prognostic evaluation is mainly based on whether surgical resection is possible. If the tumor is operable, prognosis depends on the extent of the tumor (number and size of the lesions), and whether there is involvement of blood vessels or lymph nodes near the liver. If the tumor is not operable, the extent of spread outside the liver must be assessed to define the most appropriate treatment option for each patient.