Pitfalls of BCLC
Currently there is no ideal staging and prognostic system for HCC. BCLC seems to be the most
comprehensive, since it integrates information about tumour extension, liver function and the
presence of constitutional symptoms. It also provides prognostic information and guidance to
the therapeutic choices, and it has been endorsed by EASL and AASLD as standard for patients
with HCC. It does not represent a perfect model and it still has several unmet points.1
First, unlike CLIP, GRETCH and CUPI, the BCLC was not derived from a cohort of HCC
patients by a multivariate analysis, and therefore it is not a prognostic model able to predict the
mortality of HCC patients, being internally and externally validated just as a staging system.1
Second, acting as a classification model, it presents itself some inherent drawbacks. For
example, the intermediate stage (BCLC B) includes an extremely heterogeneous population in
terms of both liver function and tumour characteristics. In addition, according to the BCLC,
any patient with a PS equal to 1 automatically falls in the advanced stage (BCLC C), even if
this condition identifies a “subject capable of performing all the normal daily activities”
according the original ECOG (Eastern Cooperative Oncology Group) definition.1
In addition, acting as a treatment algorithm, the main limitation of the BCLC is represented by
its rigidity. First, some prognostic factors, such as the presence of clinically significant portal
hypertension, are outlined as contraindications that preclude a therapy, whereas evidence
suggest that hepatic resection can be performed successfully, in highly selected cases, even in
patients with portal hypertension and multiple hepatic lesions.2,3. Second, it should be noted
that not all patients defined by each stage of BCLC are ultimately candidates for the suggested
treatment modality. For instance, TACE can be performed at earlier stages in patients not
eligible to RFA or PEI because of tumour location (proximity to the gallbladder, biliary tree,
or blood vessel), or failure of previous curative treatments and/or presence of medical
comorbidities. Moreover, BCLC algorithm does not provide indications concerning second-
line therapies, retreatment choices or combined treatments.4,5
An important management problem is still represented by the indications for transplantation
suggested by BCLC. For example, several lines of evidence show that transplant can get similar
results in patients exceeding the Milan criteria, but conform to the “up-to-seven”6 or the “San
Francisco” 7 criteria. Furthermore, transplant is not indicated for end stage disease (BCLC D),
which includes, among others, also patients with early tumour but with severe hepatic
decompensation (Child-Pugh C). Despite the recommendations of the BCLC suggesting
supportive care as the only available therapy, this subset of patients gets anyway the best benefit
after transplantation.8,9 As a result of its rigidity and unmet points, the BCLC is frequently
difficult to apply, and its adherence in clinical practice is low.10 Finally, to date, none of these
staging systems including BCLC have been analysed or validated taking into account the
prognosis of OLT, and therefore cannot be recommended in the setting of liver
transplantation.11
References:
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literature. World J Gastroenterol. 2014 Apr 21;20(15):4141-50. doi: 10.3748/wjg.v20.i15.4141. PMID:
24764652; PMCID: PMC3989950.
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L, Pinna AD. Indication of the extent of hepatectomy for hepatocellular carcinoma on cirrhosis by a
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Nolfo MA, Benvegnù L, Zoli M, Borzio F, Giannini EG, Caturelli E, Chiaramonte M, Trevisani F, Cillo
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