Is it time to reconsider the BCLC/AASLD therapeutic flow-chart?

Area of Science:

• Hepatology
• Oncology
• Clinical Practice Guidelines

Background:

• The Barcelona Clinic Liver Cancer (BCLC) therapeutic flow-chart, endorsed by the American Association for the Study of Liver Diseases (AASLD), is widely adopted globally.
• Recent years have seen increasing debate among referral centers regarding BCLC treatment allocations, prompting proposals for alternative strategies.

Purpose of the Study:

• To review and discuss proposed alternative strategies to the current BCLC/AASLD recommendations.
• To evaluate the evidence supporting modifications to existing BCLC/AASLD treatment guidelines for liver cancer.

Main Methods:

• A comprehensive literature search was conducted in the MEDLINE database.
• Included studies encompassed randomized controlled trials, meta-analyses, reviews, case-control studies, clinical trials on novel therapies, and expert opinions.
• Results and conclusions were systematically compared against BCLC/AASLD recommendations on a stage-by-stage basis.

Main Results:

• Stage 0: Radiofrequency ablation is suggested to replace resection for very early-stage liver cancer.
• Stage A: Indications for radiofrequency ablation and resection should be expanded for early-stage disease.
• Stage B: Resection and transplantation indications should be broadened for intermediate-stage liver cancer, with a shift towards selective intra-arterial therapies.
• Stage C: Advanced-stage liver cancer may benefit from novel promising systemic therapies.

Conclusions:

• Substantial evidence suggests a need to reconsider several BCLC/AASLD recommendations for liver cancer treatment.
• Alternative treatments may offer comparable efficacy to current guidelines but differ in cost, availability, and complication profiles, necessitating a re-evaluation of treatment algorithms.