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Digestive System Tumours
Liver (ICD‐O‐3 C 22.0) Rules for Classification The classification applies to hepatocellular carcinoma. Cholangio‐ (intrahepatic bile duct) carcinoma of the liver has a separate classification (see page 83). There should be histological confirmation of the disease. The following are the procedures for assessing T, N, and M categories. T categories Physical examination, imaging, and/or surgical exploration N categories Physical examination, imaging, and/or surgical exploration M categories Physical examination, imaging, and/or surgical exploration Note Although the presence of cirrhosis is an important prognostic factor it does not affect the TNM classification, being an independent prognostic variable.
Regional Lymph Nodes The regional lymph nodes are the hilar, hepatic (along the proper hepatic artery), periportal (along the portal vein), inferior phrenic, and caval nodes.
TNM Clinical Classification T – Primary Tumour TX T0
Primary tumour cannot be assessed No evidence of primary tumour
T1a Solitary tumour 2 cm or less in greatest dimension with or without vascular invasion T1b Solitary tumour more than 2 cm in greatest dimension without vascular invasion T2 Solitary tumour with vascular invasion more than 2 cm dimension or multiple tumours, none more than 5 cm in greatest dimension T3 Multiple tumours any more than 5 cm in greatest dimension T4 Tumour(s) involving a major branch of the portal or hepatic vein with direct invasion of adjacent organs (including the diaphragm), other than the gallbladder or with perforation of visceral peritoneum
Liver
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N – Regional Lymph Nodes NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis
M – Distant Metastasis M0 No distant metastasis M1 Distant metastasis
pTNM Pathological Classification
Stage – Liver Stage IA Stage IB Stage II Stage IIIA Stage IIIB Stage IVA Stage IVB
T1a T1b T2 T3 T4 Any T Any T
N0 N0 N0 N0 N0 N1 Any N
M0 M0 M0 M0 M0 M0 M1
Digestive System
The pT and pN categories correspond to the T and N categories. For pM see page 8. pN0 Histological examination of a regional lymphadenectomy specimen will ordinarily include 3 or more lymph nodes. If the lymph nodes are negative, but the number ordinarily examined is not met, clas sify as pN0.
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Digestive System Tumours
Prognostic Factors Grid – Liver Prognostic factors for liver cancer (HCC) Prognostic Tumour related Host related factors Essential
Major vascular invasion* Microvascular invasion* Size >5 cm Multiple (vs single) Tumour differentiation
Fibrosis of underlying liver* Tumour growth rate Patient performance status at diagnosis Liver function Degree of portal hypertension
Additional
AFP level DCP/PIVKA‐II level
Hepatitis activity
New and promising
5‐gene score (genetic profile) Cancer stem cell markers Circulating microRNA, DNA, circulating cancer cells
IGF‐1 combined with CLIP Regulatory T cells C‐reactive protein (CRP), interleukin 10 (IL‐10), vascular endothelial growth factor (VEGF), neutrophilto‐ lymphocyte ratio, MnSOD (magnesium superoxide dismutase)
Environment related Treatment factors: Post‐resection residual disease (R0, R1, R2) Post‐ablation residual disease Post‐embolization residual disease
* Dominant prognostic factors in resected/transplanted patients. Source: UICC Manual of Clinical Oncology, Ninth Edition. Edited by Brian O’Sullivan, James D. Brierley, Anil K. D’Cruz, Martin F. Fey, Raphael Pollock, Jan B. Vermorken and Shao Hui Huang. © 2015 UICC. Published 2015 by John Wiley & Sons, Ltd.