LAUSR

The Barcelona Clinic Liver Cancer (BCLC) system, initially proposed in 1999, is certainly the most commonly used staging system for HCC in Western countries. Just a few days ago, the BCLC group released the 2022 update published in the Journal of Hepatology [1]. This latest version turns the previous rigid BCLC staging system toolbox into a flexible and versatile instrument, with which interventional radiologists (IRs) can play an even more central role. One major novelty in this update relates to the endorsement of treatment stage migration (TSM). The 2022 BCLC strategy incorporates an expert clinical decision-making component, formally permitting tailored treatment on the basis not only of the patient’s and tumor’s characteristics but also of local expertise and technical availability. TSM is applied when a specific patient profile or treatment failure/unfeasibility may induce a shift of the recommendation to the option that would be considered for a more advanced stage. In a 2021 issue of CVIR, deviation from BCLC first-treatment recommendation resulting from a multidisciplinary, individualized approach actually showed OS yielding or exceeding expected survival at each BCLC stage [2]. The second novelty in this update is the recognition of liver transplantation (LT) as one of the main objectives. Compared to the 2018 version where LT was (only) recommended in multifocal B 3 cm HCCs, three arrows are now directed toward LT, one from each of the following: small multifocal HCCs, a subgroup of BCLC B patients, in case of successful downstaging by TACE or TARE. The role of IRs now becomes central within MDT to reach the goal of increasing the number of transplanted patients. As a consequence, these novelties lead to a more complex BCLC algorithm. To improve clarity, we aimed to summarize below the role of IRs at each BCLC stage. In BCLC 0, ablation is the preferred option. However if it is not feasible for any reason, resection should be considered first and then TACE, in keeping with the concept of stage migration. TARE is considered as effective as TACE, but is recommended only in single HCC B 8 cm, given the results of the LEGACY trial [3]. In BCLC A, resection is favored in[ 2 cm HCC because of higher recurrence rate after ablation. In large tumors, radiation lobectomy by TARE is not explicitly recommended but can be considered in case of small future liver remnant. In non-LT candidates with multifocal tumors, the 2022 BCLC update does not recommend resection but rather ablation for HCCs B 3 cm and TACE otherwise. TARE might be indicated when meeting inclusion criteria of LEGACY. In LT candidates with[ 6 months waiting time, ablation, TACE or TARE can be used for bridging. The 2022 BCLC version stratifies the BCLC-B into three groups of patients according to tumor burden and liver function. The first subgroup corresponds to patients candidates for LT if they meet the ‘Extended Liver Transplant criteria’