What are the latest BCLC (Barcelona Clinic Liver Cancer) guidelines for the treatment of hepatocellular carcinoma (HCC)?

Latest BCLC Guidelines for Hepatocellular Carcinoma

The 2022 updated BCLC staging system remains the primary framework for HCC treatment allocation, integrating tumor burden, liver function (Child-Pugh class), and performance status to guide therapeutic decisions from curative interventions to palliative care. 1

Core BCLC Staging Framework

The BCLC system stratifies patients into five prognostic categories with stage-specific treatment recommendations 2:

BCLC Stage 0 (Very Early Stage)

• Criteria: Single tumor <2 cm, Child-Pugh A, performance status 0 2
• Treatment: Resection or ablation with 5-year survival rates of 50-75% 2

BCLC Stage A (Early Stage)

• Criteria: Single tumor ≤5 cm OR up to 3 nodules ≤3 cm (Milan criteria), Child-Pugh A-B, performance status 0 2
• Treatment options 1, 2:
  • Resection: Preferred for non-cirrhotic patients or selected cirrhotic patients with single lesions and no portal hypertension 1
  • Liver transplantation: For patients meeting Milan criteria with decompensated cirrhosis 1
  • Ablation: For tumors ≤3 cm when surgery is not feasible 2
• Expected outcomes: 5-year survival 40-70% with curative intent treatment 1

BCLC Stage B (Intermediate Stage)

• Criteria: Multinodular tumors, Child-Pugh A-B, performance status 0 2
• Standard treatment: Transarterial chemoembolization (TACE) with median survival 16-22 months 2
• Important update: The 2022 BCLC revision recognizes heterogeneity within Stage B, allowing consideration of resection in selected patients with preserved liver function (Child-Pugh A, 93% of cases), particularly those requiring minor resections 3
• Combination approaches: TACE plus radiofrequency ablation or radiotherapy may improve local control in selected cases 2

BCLC Stage C (Advanced Stage)

• Criteria: Vascular invasion and/or extrahepatic spread, Child-Pugh A-B, performance status 1-2 2
• First-line treatment: Sorafenib (median survival 10.7 vs 7.9 months in SHARP trial) 2
• Newer options: Atezolizumab plus bevacizumab has emerged as an alternative first-line systemic therapy 4

BCLC Stage D (End-Stage)

• Criteria: Any tumor burden, Child-Pugh C, performance status 3-4 2
• Treatment: Best supportive care and symptomatic management 2
• Exception: Highly selected Child-Pugh C patients with tumors within Milan criteria may be considered for transplantation 2

Critical Assessment Parameters

Liver Function Evaluation

• Child-Pugh classification is essential for treatment selection 4
• ALBI grade provides improved liver functional estimation compared to Child-Pugh alone 1
• Portal pressure measurement is emphasized by AASLD for optimizing patient selection for resection 1

Surgical Planning Considerations

When resection is considered, calculate future liver remnant (FLR) 2:

• Normal liver: Minimum FLR ≥20%
• Chronic liver disease: Minimum FLR ≥30%
• Cirrhotic liver: Minimum FLR ≥40%
• Portal vein embolization may be used to induce hypertrophy when FLR is inadequate 2

Key Updates in the 2022 BCLC Revision

The 2022 update represents a shift toward more personalized management 1:

• Expanded resection criteria: Recognition that selected patients with portal hypertension or multiple lesions may benefit from resection, contrary to older restrictions 1
• Transplantation flexibility: Downstaging therapy can render initially ineligible patients suitable for transplantation 1
• UCSF criteria acceptance: Extension beyond strict Milan criteria with comparable outcomes 1
• Stage B heterogeneity: Acknowledgment that intermediate-stage patients represent diverse populations requiring individualized approaches beyond TACE alone 5

Common Pitfalls and Practical Considerations

Treatment Selection Challenges

• Up to one-third of patients do not fit standard recommendations due to advanced age, comorbidities, or strategic tumor location 2
• TACE timing: Recognize when to discontinue TACE before liver function deterioration; repeated TACE in unsuitable patients worsens outcomes 5
• Switching to systemic therapy: Consider molecular targeted agents before liver function decline in TACE-unsuitable patients 5

Bridging and Adjuvant Strategies

• Bridge therapy with TACE or ablation prevents tumor progression in patients awaiting transplantation 2
• Antiviral therapy is critical for HBV/HCV-related HCC to reduce postoperative decompensation and prevent late recurrence 2, 4
• Adjuvant atezolizumab plus bevacizumab improves recurrence-free survival post-resection, though long-term data are still maturing 4

Staging Workup Requirements

Complete staging must include 4:

• Abdominal dynamic CT or MRI
• Chest imaging to detect extrahepatic disease
• Serum alpha-fetoprotein levels
• Pathological confirmation if systemic therapy is planned

Geographic Variations in Application

While BCLC is endorsed by EASL, AASLD, and ESMO 1, Asian guidelines (JSH, Korean) often adopt more aggressive surgical approaches for intermediate-stage disease 1. The Korean guideline uses the modified UICC staging system as primary, with BCLC as complementary 1. These differences reflect regional expertise and patient populations, but the 2022 BCLC update has narrowed these gaps by acknowledging broader resection indications 1.