The Child-Pugh score is a scoring system to measure the severity of chronic liver disease

inclusive of cirrhosis. The intention is to provide a system with which clinicians can
objectively communicate about liver function.

The score is composed from several categories:

 total bilirubin, μmol/L (mg/dL)

o <34: 1 point
o 34-50: 2 points
o >50: 3 points
 serum albumin, g/L
o >35: 1 point
o 28-35: 2 points
o <28: 3 points
 INR
o <1.7: 1 point
o 1.7-2.3: 2 points
o >2.3: 3 points
 presence of ascites
o none: 1 point
o mild: 2 points
o moderate to severe: 3 points
 presence of hepatic encephalopathy
o none: 1 point
o grades I-II (or suppressed with medication): 2 points
o grades III-IV (or refractory): 3 points

The point scores are then added up and classified as:

 class A: 5-6 points

 class B: 7-9 points
 class C: 10-15 points

Barcelona clinic liver cancer (BCLC) staging uses a set of criteria to guide the
management of patients with hepatocellular carcinoma (HCC).

The classification takes the following variables into account 1,2:

 performance status (PS)

 Child-Pugh score
 radiologic tumor extent
o tumor size
o multiple tumors
o vascular invasion
o nodal spread and extrahepatic metastases

The classification system sorts patients into one of four categories:

 stage 0 (very early stage)

 o asymptomatic early tumors
 PS 0
 Child-Pugh A
 solitary lesion measuring less than 2 cm in diameter
o management
 resection
 if portal hypertension/hyperbilirubinemia, transplant is then
recommended
 if other clinical comorbidities, radiofrequency ablation is then
recommended
 stage A (early stage)
o asymptomatic early tumors
 PS 0-2
 Child-Pugh A to C
 solitary lesion > 2 cm or early multifocal disease characterized by up to
3 lesions measuring less than 3 cm
o management
 usually, resection is viable for single lesions
 if multiple lesions, transplant is then recommended
 if other clinical comorbidities are present, radiofrequency ablation is
then recommended
 stage B (intermediate stage)
o asymptomatic multifocal disease
 PS 0
 Child-Pugh A to C
 multifocal disease: more than one lesion with at least one over 3 cm, or
more than 3 lesions regardless of their size
o management is usually recommended with transcatheter arterial
chemoembolisation (TACE)
 stage C (advanced stage)
o symptomatic tumors and invasive and/or metastatic disease
 PS 1-2
 Child-Pugh A to C
 vascular invasion and/or nodal disease and/or metastatic disease
o management is usually palliative: sorafenib, phase II trial agents, or other
palliative treatments
 stage D (end-stage disease)
o terminal stage
 PS > 2
 Child-Pugh C
 it is not a radiological stage, only clinical
o symptomatic treatment only
o equivalent to Okuda stage III

Esophageal and esophagogastric junction squamous cell carcinoma staging

Primary tumor (T)

 Tx: primary tumor cannot be assessed

 T0: no evidence of primary tumor
  Tis: high grade dysplasia (malignant cells confined to the epithelium by the basement
membrane)
 T1: tumor invades lamina propria, muscularis mucosae or submucosa
o T1a: invades lamina propria or muscularis mucosae
o T1b: invades submucosa
 T2: tumor invades muscularis propria
 T3: tumor invades adventitia
 T4: tumor invades adjacent structures
o T4a: tumor invades pleura, pericardium, azygos vein, diaphragm, or
peritoneum
o T4b: tumor invades other adjacent structures, e.g. aorta, vertebra, or trachea

Regional lymph node (N)

 NX: regional nodes cannot be assessed

 N0: no regional lymph node metastasis
 N1: metastasis in 1-2 regional nodes
 N2: metastasis in 3-6 regional nodes
 N3: metastasis in ≥7 regional nodes

The regional lymph node stations are defined separately: esophageal lymph node stations.

Distant metastasis (M)

 cM0: no distant metastasis

 cM1: distant metastasis clinically present
 pM1: distant metastasis pathologically (microscopically) confirmed

The AJCC (American Joint Committee on Cancer) 8th edition gallbladder cancer
staging system was introduced in 2018.

TNM system

T: primary tumor

 Tis: carcinoma in situ - tumor only within the epithelium (the inner layer of the gallbladder)
 T1: tumor invades the lamina propria or muscularis
o T1a: limited to lamina propria
o T1b: invades muscularis
 T2: tumor invades the perimuscular fibrous tissue
o T2a: tumor invades the perimuscular fibrous tissue on the side of the peritoneum
(the lining of the abdominal cavity)
o T2b: tumor invades the perimuscular fibrous tissue on the side of the liver, but has
not invaded the liver
 T3: tumor invades the serosa (the outermost covering of the gallbladder) and/or directly
invades the liver and/or one other adjacent structure (stomach, duodenum, colon, pancreas,
omentum or extra-hepatic bile ducts)
 T4: tumor invades the hepatic artery, main portal vein, or two or more extra-hepatic organs

N: regional lymph node involvement

  N0: no regional lymph node metastasis
 N1: metastasis in 1-3 regional lymph nodes
 N2: metastasis in ≥4 regional lymph nodes

M: distant metastasis

 M0: no distant metastasis

 M1: distant metastasis present

Staging of pancreatic cancer

Primary tumor staging (T)

 Tx, T0, Tis: see TNM system

 T1: tumor ≤ 2 cm in greatest dimension
 T2: tumor >2 cm in greatest dimension but less than ≤ 4 cm
 T3: tumor >4 cm in greatest dimension
 T4: involvement of superior mesenteric artery or celiac axis

Regional lymph nodes (N)

 Nx: nodes cannot be assessed

 N0: no evidence of nodal involvement
 N1: 1-3 regional node metastases present
 N2: 4 or more regional node metastases present

Metastases (M)

 Mx: presence of metastases cannot be assessed

 M0: no evidence of metastases
 M1: distant metastases present

The Bismuth-Corlette classification is a classification system for perihilar

cholangiocarcinomas, which is based on the extent of ductal infiltration.

Classification

 type I
o limited to the common hepatic duct, below the level of the confluence of the
right and left hepatic ducts
 type II
o involves the confluence of the right and left hepatic ducts
 type IIIa
o type II and extends to involve the origin of the right hepatic duct (confluence
of the right posterior and anterior sectoral ducts)
 type IIIb
o type II and extends to involve the origin of the left hepatic duct (confluence of
the 2nd, 3rd and 4th segmental ducts)
 type IV
 o extending to and involving the origins of both right and left hepatic ducts (i.e.,
combination of types IIIa and IIIb)
or
o multifocal involvement
 type V
o stricture at the junction of common bile duct and cystic duct

Renal cell carcinoma

Primary tumor staging (T)

 Tx: tumor cannot be assessed

 T0: tumor not seen
 T1
o T1a: tumor confined to kidney, <4 cm
o T1b: tumor confined to kidney, >4 cm but <7 cm
 T2: limited to kidney >7 cm
o T2a: tumor confined to kidney, >7 cm but not >10 cm
o T2b: tumor confined to kidney, >10 cm
 T3: tumor extension into major veins or perinephric tissues, but not into ipsilateral
adrenal gland or beyond Gerota's fascia
o T3a: tumor grossly extends into the renal vein or its segmental (muscle-
containing) branches, or tumor invades perirenal and/or renal sinus fat but not
beyond the Gerota fascia
o T3b: spread to infra diaphragmatic IVC
o T3c: spread to supra diaphragmatic IVC or invades the wall of the IVC
 T4: involves ipsilateral adrenal gland or invades beyond Gerota's fascia

Regional lymph nodes (N)

 N0: no nodal involvement

 N1: metastatic involvement of regional lymph node(s)

Metastases (M)

 M0: no distant metastases

 M1: distant metastases

Transitional cell carcinoma of the bladder staging uses the TNM system which has
replaced the previously widely used Jewett-Strong-Marshall tumor staging system. It is very
similar to the staging of TCC of the renal pelvis and staging of TCC of the ureter.

TNM staging (8th edition)

 Ta: non-invasive papillary tumor

 Tis: in situ (non-invasive flat)
 T1: through lamina propria into sub-epithelial connective tissues
  T2: into muscularis propria
o T2a: only invades inner half of the muscle
o T2b: invades into outer half of the muscle
 T3: invasion into perivesical tissues
o T3a: microscopic extravesical invasion
o T3b: macroscopic extravesical invasion
 T4: direct invasion into adjacent structures
o T4a: prostate, seminal vesicles, uterus, vaginal vault
o T4b: pelvic side wall and/or abdominal wall

 N0: no nodal involvement

 N1: single node in the true pelvis (hypogastric, obturator, external iliac or presacral
nodes)
 N2: multiple nodes in the true pelvis
 N3: metastasis in a common iliac node

 M0: no metastases
 M1a: non-regional lymph node involvement
 M1b: other distant metastasis

Prostate Imaging-Reporting and Data System (PI-RADS).

T2 weighted imaging (T2W) score

Transition zone

 1: normal appearing transition zone (rare) or a round, completely encapsulated nodule

("typical nodule" of benign prostatic hyperplasia)
 2: a mostly encapsulated nodule or a homogeneous circumscribed nodule without
encapsulation ("atypical nodule"), or a homogeneous mildly hypointense area between
nodules
 3: heterogeneous signal intensity with obscured margins; includes others that do not qualify
as 2, 4, or 5
 4: lenticular or non-circumscribed, homogeneous, moderately hypointense, and <1.5 cm in
greatest dimension
 5: same as 4, but ≥1.5 cm in greatest dimension or definite extraprostatic extension/invasive
behavior

For transition zone lesions, the overall PI-RADS assessment usually follows the T2W
score, but scores of 2 or 3 can be upgraded by the DWI (see below).

Peripheral zone

 1: uniform high signal intensity (normal)

 2: linear or wedge-shaped hypointensity or diffuse mild hypointensity, usually indistinct
margin
  3: heterogeneous signal intensity or non-circumscribed, rounded, moderate
hypointensity; includes others that do not qualify as 2, 4, or 5
 4: circumscribed, homogeneous, moderate hypointensity, and <1.5 cm in greatest dimension
 5: same as 4 but ≥1.5 cm in greatest dimension or definite extraprostatic extension/invasive
behavior

For peripheral zone lesions, the T2W score is only used for the overall PI-RADS assessment
if the DWI is inadequate or absent. Scores of 3 can be upgraded by presence of dynamic
contrast enhancement.

Diffusion weighted imaging (DWI) score

Signal intensity in the lesion is visually compared to the average signal of normal prostate
tissue elsewhere in the same histologic zone.

Transition zone or peripheral zone

 1: no abnormality on ADC or high b-value DWI

 2: linear/wedge shaped, hypointensity on ADC and/or hyperintensity on high b-value DWI
 3: focal (discrete and different from background), mild/moderate hypointensity on ADC
and/or mild/moderate hyperintensity on high b-value DWI; may be markedly hypointense on
ADC or markedly hyperintense on high b-value DWI, but not both
 4: focal, marked hypointensity on ADC and marked hyperintensity on high b-value DWI; <1.5
cm in greatest dimension
 5: same as 4 but ≥1.5 cm in greatest dimension or definite extraprostatic extension/invasive
behavior

For peripheral zone lesions, the overall PI-RADS assessment usually follows the DWI score,
but a score of 3 can be upgraded by the presence of dynamic contrast enhancement (see
below).

For transition zone lesions with a T2W score of 2 or 3, a DWI score that is two higher (i.e. 4
or 5, respectively) is used to upgrade the overall PI-RADS assessment by one point (i.e. to 3
or 4, respectively).

Dynamic contrast enhancement (DCE)

 (-) negative:
o no early or contemporaneous enhancement, or
o diffuse multifocal enhancement not corresponding to a focal finding on T2W and/or
DWI, or
o focal enhancement corresponding to a lesion demonstrating features of benign
prostatic hyperplasia on T2W (including features of extruded benign prostatic
hyperplasia nodule in the peripheral zone)
 (+) positive:
o focal, and
o earlier than or contemporaneous with enhancement of adjacent normal prostatic
tissues, and
o corresponds to suspicious finding on T2 and/or DWI
For peripheral zone lesions with DWI score of 3, the presence of dynamic contrast
enhancement is used to upgrade the overall PI-RADS assessment category to 4.

Revised FIGO staging of cervical carcinoma (2018)

 FIGO no longer includes stage 0 (Tis)

 I: confined to cervix uteri (extension to the corpus should be disregarded)
o IA: invasive carcinoma only diagnosed by microscopy
 IA1: stromal invasion <3 mm in depth
 IA2: stromal invasion ≥3 mm and <5 mm in depth
o IB: invasive carcinoma with measured deepest invasion ≥5 mm (greater than stage
IA), lesion limited to the cervix uteri
 IB1: invasive carcinoma ≥5 mm depth of stromal invasion and <2 cm in
greatest dimension
 IB2: invasive carcinoma ≥2 cm and <4 cm in greatest dimension
 IB3: invasive carcinoma ≥4 cm in greatest dimension
 II: beyond the uterus, but has not extended onto the lower third of the vagina or to the
pelvic wall
o IIA: involvement limited to the upper 2/3 of vagina without parametrial invasion
 IIA1: invasive carcinoma <4 cm in greatest dimension
 IIA2: invasive carcinoma ≥4 cm in greatest dimension
o IIB: with parametrial involvement but not up to the pelvic wall
 III: carcinoma involves the lower third of the vagina and/or extends to the pelvic wall and/or
causes hydronephrosis or non‐functioning kidney and/or involves pelvic and/or paraaortic
lymph nodes
o IIIA: carcinoma involves the lower third of the vagina, with no extension to the pelvic
wall
o IIIB: extension to the pelvic wall and/or hydronephrosis or non‐functioning kidney
(unless known to be due to another cause)
o IIIC: involvement of pelvic and/or para-aortic lymph nodes, irrespective of tumor size
and extent
 IIIC1: pelvic lymph node metastasis only
 IIIC2: para-aortic lymph node metastasis
 with r (imaging) and p (pathology) notations to indicate how lymph nodes
were identified
 IV: carcinoma has extended beyond the true pelvis or has involved (biopsy-proven) the
mucosa of the bladder or rectum (bullous edema, as such, does not permit a case to be
allotted to stage IV)
o IVA: spread to adjacent organs
o IVB: spread to distant organs 8

Revised 2009 FIGO staging for carcinoma of the endometrium 7:

 stage 0: carcinoma in situ

 stage I: limited to the body of the uterus
o Ia: no or less than half (≤ 50%) myometrial invasion
o Ib: invasion equal to or more than half (≥ 50%) of the myometrium
 stage II: cervical stromal involvement
o endocervical glandular involvement only is stage I
 stage III: local or regional spread of the tumor
o IIIa: tumor invades the serosa of the body of the uterus and/or adnexa
 o IIIb: vaginal or parametrial involvement
o IIIc: pelvic or para-aortic lymphadenopathy
 IIIc1: positive pelvic nodes
 IIIc2: positive para-aortic nodes with or without pelvic nodes
 stage IV: involvement of rectum and/or bladder mucosa and/or distant metastasis
o IVa: bladder or rectal mucosal involvement
o IVb: distant metastases, malignant ascites, peritoneal involvement

The most commonly adopted ovarian cancer staging system is the FIGO staging
system. The most recent staging system is from 2014 1:

CT is considered the best imaging modality for staging ovarian cancer 4.

 stage I: tumor limited to the ovaries

o stage Ia:
 tumor limited to one ovary
 capsule intact
 no tumor on ovarian surface
 no malignant cells in ascites or peritoneal washings
o stage Ib:
 tumor involves both ovaries; otherwise similar to stage Ia
 capsule intact
 no tumor on ovarian surface
 no malignant cells in ascites or peritoneal washings
o stage Ic:
 tumor involves one or both ovaries, with any of the following:
 stage Ic1: surgical/intraoperative spill
 stage Ic2: capsule ruptured before surgery, or tumor on ovarian
or fallopian tube surface
 stage Ic3: malignant cells in the ascites or peritoneal washings
 stage II: tumor involves one or both ovaries with pelvic extension or primary
peritoneal cancer (below pelvic brim)
o stage IIa: extension or implants on the uterus or fallopian tubes
o stage IIb: extension to other pelvic intraperitoneal tissues
 stage III: tumor involves one or both ovaries or fallopian tubes with cytologically or
histologically confirmed spread to the peritoneum outside the pelvis and/or metastasis
to the retroperitoneal lymph nodes
o stage IIIa: positive retroperitoneal lymph nodes and /or microscopic
metastasis beyond the pelvis:
 stage IIIa1: positive (cytologically or histologically proven)
retroperitoneal lymph nodes only
 stage IIIa1(i): metastatic retroperitoneal node measuring ≤10
mm
 stage IIIa1(ii): metastatic retroperitoneal node measuring >10
mm
 stage IIIa2: microscopic extrapelvic (above the pelvic brim) peritoneal
involvement with or without positive retroperitoneal lymph nodes
o stage IIIb: macroscopic peritoneal metastasis beyond the pelvis up ≤2 cm in
greatest dimension, with or without metastasis to the retroperitoneal lymph
nodes
  includes extension of tumor to the capsule of liver and spleen
o stage IIIc: macroscopic extrapelvic peritoneal metastases >2 cm in greatest
dimension, with or without metastasis to the retroperitoneal lymph nodes
 includes extension of tumor to the capsule of liver and spleen
 stage IV: consists of distant metastasis, excluding peritoneal metastases, and includes
the following:
o stage IVa: pleural effusion with positive cytology
o stage IVb: distant metastases
 parenchymal metastases and metastases to extra-abdominal organs
(including inguinal lymph nodes and lymph nodes outside of the
abdominal cavity)

Gastric cancer staging is routinely performed using the TNM staging system. This article is
based on the 8th edition of the TNM classification of malignant tumors. This is technically the
clinical TNM staging (cTNM).

cTNM staging (8th edition)

 Tx: primary tumor cannot be assessed

 T0: no evidence of primary tumor
 Tis: carcinoma in situ: intraepithelial tumor without invasion of the lamina propria,
high grade dysplasia
 T1
o T1a: tumor invades the lamina propria and or muscularis mucosae
o T1b: tumor invades submucosa
 T2: tumor invades muscularis propria
 T3: tumor penetrates the subserosal connective tissue without invasion of the visceral
peritoneum or adjacent structures
 T4
o T4a: tumor invades the serosa (visceral peritoneum)
o T4b: tumor invades adjacent structures

 Nx: regional lymph node (s) cannot be assessed

 N0: no regional nodal involvement
 N1: metastases in 1 to 2 regional lymph nodes
 N2: metastases in 3 to 6 regional lymph nodes
 N3
o N3a: metastases in 7 to 15 regional lymph nodes
o N3b: metastases in more than 15 regional lymph nodes

 M0: no distant metastases

 M1: distant metastases