Current Management of BCLC Stage B Hepatocellular Carcinoma
Transarterial chemoembolization (TACE) is the standard first-line treatment for BCLC stage B hepatocellular carcinoma, providing median survival of 16-22 months in patients with multinodular tumors, preserved liver function (Child-Pugh A-B), and good performance status (ECOG PS 0). 1, 2, 3
Primary Treatment Approach
TACE should be performed as the initial therapy for patients meeting BCLC B criteria: multinodular HCC beyond Milan criteria, no vascular invasion, no extrahepatic spread, Child-Pugh A or B liver function, and ECOG performance status 0. 1, 2
The survival benefit with TACE ranges from 20-60% at 2 years compared to untreated patients, with median survival of 16-22 months. 1, 3
Multiple TACE modalities are available including conventional TACE, balloon-occluded TACE, and drug-eluting beads TACE, which may improve efficacy and reduce adverse events. 4
Alternative Curative Treatments for Selected BCLC B Patients
Surgical resection should be considered in selected BCLC B patients with favorable tumor characteristics, particularly in centers with hepatic surgery expertise, as this can provide superior survival outcomes compared to TACE alone. 1, 3, 5
Liver resection is an option for BCLC B patients with 2-3 nodules >3 cm or >4 nodules, provided adequate liver function and remnant volume are maintained. 1
Radiofrequency ablation (RFA) may be considered in selected BCLC B patients with appropriate tumor location and size. 1
Selective internal radiotherapy (SIRT) with Yttrium-90 radioembolization can be considered as an alternative locoregional therapy. 1, 6
Treatment Stage Migration and Systemic Therapy
When TACE becomes unsuitable due to contraindications, untreatable progression, or repeated failure, patients should be transitioned to systemic therapy before liver function deteriorates. 1, 4
Sorafenib is recommended for BCLC B patients with contraindications to TACE or those progressing despite chemoembolization, provided they maintain Child-Pugh A liver function and ECOG PS 0-2. 1
Lenvatinib (12 mg for body weight ≥60 kg or 8 mg for <60 kg) demonstrated non-inferiority to sorafenib in first-line systemic therapy for advanced HCC and can be considered for BCLC B patients unsuitable for TACE. 1, 7
For patients progressing on sorafenib who tolerated the medication, regorafenib 160 mg daily (21 days on, 7 days off) is recommended as second-line therapy in those maintaining Child-Pugh A and ECOG PS 0-1. 1, 8
Critical Decision Points for TACE Continuation
TACE should be discontinued when patients develop TACE unsuitability or refractoriness, defined by lack of objective response after 2-3 sessions, progressive disease despite treatment, or deteriorating liver function. 4, 5
Repeated TACE reduces treatment efficacy and induces liver function impairment, making timely transition to systemic therapy crucial. 4
Switching to molecular targeted agents before significant liver function deterioration (while still Child-Pugh A) improves prognosis compared to continued ineffective TACE. 4
Important Caveats and Pitfalls
BCLC stage B encompasses significant heterogeneity in tumor burden, with survival ranging widely depending on specific patient characteristics. 1, 9, 5
Only approximately 60% of intermediate stage HCC patients receive TACE in real-world practice, with the remainder receiving alternative therapies based on individual tumor and patient factors. 5
The presence of subsegmental or segmental portal vein invasion should not automatically exclude patients from locoregional therapy, as surgery and TACE/SIRT can be performed in Child-Pugh A patients with limited intrahepatic macrovascular invasion. 9
Combination approaches such as TACE plus RFA or TACE plus radiotherapy may improve local tumor control in selected cases. 2, 6
Bridge therapy with TACE or RFA should be used for BCLC B patients awaiting liver transplantation to prevent tumor progression. 2