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BCLC staging system and the Child-Pugh system

Find out what BCLC staging system and the Child-Pugh system for cancer that started in the liver (primary liver cancer) mean and about treatment options.

The Tumour, Node, Metastases (TNM) staging system describes the size and position of liver cancer. However, because people with liver cancer often have cirrhosis, doctors also need a system that describes how well the liver is working. Then they can decide what sort of treatment would be best.

To help them decide this, they use a system such as the Barcelona Clinic Liver Cancer (BCLC) staging system or the Child-Pugh system.

The BCLC staging system

The BCLC staging system looks at the number and size of tumours and at how well the person is (the performance status - PS). It also takes into account how well the liver is working, using the Child-Pugh score. There are 5 stages:

  • stage 0 means the tumour is less than 2 cm, the person feels well (PS 0) and the liver is working normally (Child-Pugh A)
  • stage A means there is a single tumour less than 5 cm, or up to 3 tumours all less than 3cm. The person feels well and is active (PS 0) and the liver is working well (Child-Pugh A or B)
  • stage B means there are many tumours in the liver, but the person feels well (PS 0) and the liver is working well (Child-Pugh A or B)
  • stage C means the cancer has spread into the blood vessels, lymph nodes or other body organs. Or the person does not feel well (PS 1 or 2). The liver is still working (Child-Pugh A or B)
  • stage D means there is severe liver damage (Child-Pugh C) or the person is not well and needs help in being looked after (PS 3 or 4)

The Child-Pugh system

The Child-Pugh system looks at the following 5 things that tell how well the liver is working:

  • bilirubin levels in the blood
  • albumin levels in the blood
  • how quickly the blood clots (prothrombin time)
  • if fluid has collected in the abdomen (ascites)
  • brain function (encephalopathy)

Each one is given a number score, and based on that score, people fall into 1 of 3 classes:

  • class A means the liver is working normally
  • class B means mild to moderate illness and people may be offered treatment such as surgery or chemoembolisation – you can read more about these treatments in the treatment section
  • class C means there is severe liver damage – unfortunately the outlook is then quite poor. They are often too sick to have treatment for the cancer


The stage of your cancer helps your doctor to decide which treatment you need. Treatment also depends on:

  • your type of cancer (the type of cells the cancer started in)
  • where the cancer is
  • other health conditions that you have

The main treatment for liver cancer is surgery. This might be a liver transplant or surgery to remove part of your liver. 

You will have surgery if the cancer is only in your liver and has not spread to another part of your body.

You might have a local treatment into your liver if you can't have surgery such as:

  • radiofrequency ablation or heat treatment
  • chemoembolisation 
  • alcohol (ethanol) injection

For advanced primary liver cancer you might have a biological therapy or chemotherapy.

Other stages

Last reviewed: 
25 Feb 2015
  • DeVita, Hellman, and Rosenberg's Cancer: Principles & Practice of Oncology (Cancer: Principles & Practice (10th Revised edition)
    VT DeVita (Ed) and TS Lawrence (Ed) 
    Lippincott Williams and Wilkins, 2014

  • Hepatocellular Carcinoma: ESMO-ESDO Clinical Practice Guidelines
    C Verslype, O Rosmorduc and P Rougier
    Ann Oncol 2012; 23 (Suppl 7): vii41-vii48.

  • Cancer and Its Management (7th Edition)
    Jeffrey S. Tobias and Daniel Hochhauser

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