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TABLE 1

Diagnosis work-up in HCC ¹¹

Diagnosis by imaging

Multiphasic contrast enhanced CT or MRI of typical vascular hallmarks of HCC in a nodule of more than 1 cm diameter

Multiphasic MRI is more sensitive than multiple detector CT

Diagnosis by pathology

Histopathological diagnosis of tumour biopsies relies on haematoxylin and eosin staining and may be supplemented with immunohistochemistry

Required to diagnose HCC in non-cirrhotic liver

MRI with diffusion-weighted imaging and hepatobiliary contrast agents might identify risk nodules .

Table 2 shows the scoring system and parameters . The Child-Pugh score is calculated by adding the scores of the five factors and can range from 5 to 15 . Child-Pugh class can be A ( score of 5 – 6 ), B ( 7 – 9 ), or C ( 10 or above ). Decompensation indicates cirrhosis with a Child-Pugh score of > 7 ( Class B ). This level is the accepted criterion for listing liver transplantation .

BCLC staging ¹² There are five stages in the BCLC system : Stage 0 – Very early Stage A – Early Stage B – Intermediate Stage C – Advanced Stage D – Severe / end stage

Table 3 shows the stages / corresponding Child-Pugh stages . The BCLC system uses the Eastern Cooperative Oncology

Group ( ECOG ) performance status . ¹⁴ This assesses disease progression and how the disease is affecting the daily living abilities of the patient Table 4 summarises the grades .

ALBI score Albumin-Bilirubin ( ALBI ) is a useful score to evaluate liver function objectively and uses objective parameters and stratifies patients into grades . In combination with other liver cancer scores , the prognosis and survival of patients can be evaluated with more accuracy . The ALBI grade has emerged as an alternative , reproducible and objective measure of liver functional reserve in patients with HCC , defining worsening liver impairment across 3 grades ( I to III ). ¹⁵ The ALBI score is calculated as :

ALBI score = −0.085 × ( albumin g / l ) + 0.66 × l g ( TBil μmol / l )

Management of early and intermediate HCC The management of HCC can be complex and requires treatment of not only HCC but the underlying liver disease , as well as a consideration of the tumour extent and any patient

TABLE 2

Child-Pugh scoring system and parameters

Parameter Assign 1 point Assign 2 points Assign 3 points

Ascites Absent Slight Moderate

Bilirubin ( mg / dl ) < 2 2 – 3 > 3

Encephalopathy None Grade 1 – 2 ( mild-moderate ) Grade 3 – 4 ( severe )

TABLE 3

BCLC staging

Stage 0 ( Child-Pugh A ) Stage B ( Child-Pugh A or B ) Stage C ( Child-Pugh A or B ) Stage D ( Child-Pugh C )