What are the BCLC (Barcelona Clinic Liver Cancer) criteria for treating hepatocellular carcinoma (HCC)?

Barcelona Clinic Liver Cancer (BCLC) Criteria for Hepatocellular Carcinoma

The Barcelona Clinic Liver Cancer (BCLC) staging system is the most widely validated and recommended system for staging hepatocellular carcinoma (HCC), as it comprehensively incorporates tumor burden, liver function, and performance status to guide treatment decisions and predict outcomes. 1, 2

BCLC Staging Classification

The BCLC system divides HCC patients into five prognostic categories:

• Stage 0 (Very Early Stage) 1, 2:

  • Single tumor <2 cm
  • Child-Pugh A liver function
  • Performance status 0 (asymptomatic)
  • No vascular invasion/satellites

• Stage A (Early Stage) 1, 2:

  • Single tumor ≤5 cm or up to three nodules ≤3 cm (Milan criteria)
  • Child-Pugh A-B liver function
  • Performance status 0

• Stage B (Intermediate Stage) 1, 2:

  • Multinodular tumors
  • Child-Pugh A-B liver function
  • Performance status 0
  • No vascular invasion or extrahepatic spread

• Stage C (Advanced Stage) 1, 2:

  • Portal vein invasion, nodal involvement, and/or extrahepatic metastases
  • Child-Pugh A-B liver function
  • Performance status 1-2

• Stage D (Terminal Stage) 1, 2:

  • Any tumor burden
  • Child-Pugh C liver function (unless transplant candidate)
  • Performance status >2

Treatment Allocation Based on BCLC Stage

The BCLC system uniquely links staging with specific treatment recommendations:

• Stage 0 and A (Very Early/Early) 1, 2, 3:

  • Curative treatments with 5-year survival rates of 50-75%
  • Options include:
    • Surgical resection (first choice for non-cirrhotic patients)
    • Liver transplantation (for patients within Milan criteria)
    • Radiofrequency ablation/Percutaneous ethanol injection

• Stage B (Intermediate) 1, 2, 3:

  • Transarterial chemoembolization (TACE)
  • Median overall survival: 20 months

• Stage C (Advanced) 1, 2, 3:

  • Systemic therapy (sorafenib as first-line)
  • Median overall survival: 11 months

• Stage D (Terminal) 1, 2, 3:

  • Best supportive care
  • Median overall survival: <3 months

Key Components of BCLC Assessment

The BCLC system evaluates three critical dimensions 1:

• Tumor status:

  • Size and number of nodules
  • Presence of vascular invasion
  • Extrahepatic spread

• Liver function:

  • Child-Pugh classification (bilirubin, albumin, ascites, prothrombin time, encephalopathy)
  • Portal hypertension assessment

• Performance status:

  • ECOG (Eastern Cooperative Oncology Group) scale

Strengths and Limitations of BCLC

Strengths:

• Only staging system that assigns treatment strategies based on specific prognostic subclasses 1, 4
• Externally validated in different clinical settings 1
• Dynamic system that can incorporate advancements in HCC management 1
• Endorsed by major liver societies including EASL, AASLD, and ESMO 1

Limitations:

• May be too conservative for surgical resection or other locoregional therapy according to some Asian guidelines 1
• Does not adequately account for treatment sequences or combination therapies 1
• Includes a very heterogeneous population in the intermediate stage (BCLC B) 1, 5
• Performance status is subjective and often disregarded in clinical practice 6
• Not favorable as classification system in non-cirrhotic patients 1

Recent Developments and Modifications

• Some guidelines have modified the original BCLC system:

  • The ESMO guideline excluded portal hypertension from the algorithm to provide more flexibility for resection decisions 1
  • Patients with Child-Pugh C and tumor burden within Milan criteria may still be considered for liver transplantation rather than classified as terminal stage 1
  • The Kinki criteria has been proposed to subclassify the heterogeneous BCLC B stage population 5

• Recent proposals suggest moving from a stage-dictated treatment allocation to a more patient-tailored therapeutic approach through multidisciplinary tumor board decisions 7

Clinical Application

The BCLC staging system should be used to guide initial treatment planning, with understanding that:

• Treatment decisions should consider the full spectrum of patient factors beyond the stage alone 1, 3
• Adjuvant therapy with atezolizumab and bevacizumab after resection may improve recurrence-free survival 1
• Antiviral therapy is important for patients with HBV or HCV-related HCC to reduce recurrence risk 3
• Bridge therapy with TACE or RFA can be used for patients awaiting liver transplantation 2

The BCLC system remains the benchmark for HCC management, providing a structured framework for both prognostic evaluation and treatment allocation in this complex disease 1, 8.