Objective: To attempt to establish a new clinical staging system for hepatocellular carcinoma (HCC) based on analysis of the critical prognostic factors for HCC. 
Methods: A total of 338 HCC specimens were collected from Xiangya Hospital of Central South University and the Affiliated Tumor Hospital of Guangxi Medical University, and then, the presence of tumor necrosis and incidence of microvascular invasion were detected. The incidence of lymph node metastasis in HCC was analyzed through review of the relevant literature. Based on the follow-up survival data of 236 HCC patients in Xiangya Hospital, the recurrence and survival rates of the patients were determined using tumor necrosis and vascular invasion as variables. The T (tumor) “N” (necrosis plus vascular invasion) M (metastasis) staging system was established by integrating the tumor necrosis with or without concomitant vascular invasion as a component into the AJCC 8th edition TNM staging system, and then, the efficacy of prognosis judgment of the T“N”M staging system and 8th edition TNM staging system was compared through survival analysis.
Results: In the two HCC cohorts, the incidence of tumor necrosis was 75.4% (177/236) and 59.8% (61/102), and the detection rate of microvascular invasion was 71.6% (169/236) and 86.2% (88/102), respectively. The incidence of HCC with lymph node metastasis was only 0.8%–8.33% reported in the literature. The area under the ROC curve for the recurrence and 1-, 3- and 5-year overall survival of HCC patients was 0.940, 0.834, 0.748 and 0.721, respectively. The prognosis differences among patients with Ia, Ib, IIIa and IIIc HCC were clearly distinguished by the T“N”M staging system. The C index of 5-year survival rate (0.672) and the linear trend χ2 test value (0.732) were higher while the AIC value (1 798.142) was lower than the corresponding values of the 8th edition TNM staging system (0.537, 0.626, 1 806.256).
Conclusion: The established T“N”M staging system based on the clinical pathological features of HCC is a simple and effective staging system, which can overcome the limitations in predictive efficiency of the N category of the TNM staging system, with more relevance to the actual clinical situation.