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. 2025 Jul 14;9(8):e0750.
doi: 10.1097/HC9.0000000000000750. eCollection 2025 Aug 1.

The impact of BCLC recommendations on survival for patients with hepatocellular carcinoma

Massimo Iavarone  1   2 , Eleonora Alimenti  1 , Lorenzo Canova  1   3 , Mariangela Bruccoleri  1 , Barbara Antonelli  4 , Anna Maria Ierardi  5 , Angelo Sangiovanni  1 , Giuseppe Cabibbo  6 , Annalisa De Silvestri  7 , Lucio Caccamo  4 , Gianpaolo Carrafiello  5 , Pietro Lampertico  1   2
Affiliations

The impact of BCLC recommendations on survival for patients with hepatocellular carcinoma

Massimo Iavarone et al. Hepatol Commun. .

Abstract

Background: The Barcelona Clinic Liver Cancer (BCLC) system for HCC was updated in 2022. The aim of the study was to assess the suitability and impact on overall survival (OS) of BCLC_2022, along with "clinical decision-making" (CDM), using BCLC_2018 as a benchmark.

Methods: We retrospectively evaluated 798 patients with de novo HCC followed prospectively from 2006 to 2022: 187 in BCLC 0, 371 in A, 132 in B, 87 in C, and 21 in D, all managed by a multidisciplinary team. Patients were followed until death or at the end of the follow-up period in December 2022.

Results: The suitability of the algorithm increased from 51% for BCLC_2018 to 69% for BCLC_2022 (p<0.001). Among those treated with the newly introduced "lower priority options," 22% were in BCLC 0 and 37% in A, showing lower rates of complete response (CR) and shorter OS compared to first-line treatments. In BCLC 0 and A, CDM was associated with a significant decrease in "downward stage migration" with BCLC_2022 (from 33% to 16%, p<0.001). Conversely, in BCLC B and C, "upward stage migration" correlated with higher CR rates and longer OS [63 (36-72) vs. 28 (18-44) months, p=0.003 in BCLC B; 21 (15-44) vs. 11 (4-25) months, p<0.001 in BCLC C]. Independent predictors of mortality included AFP >200 ng/mL, Child-Pugh score C, advanced BCLC stage, and noncurative treatment.

Conclusions: BCLC_2022 and CDM provide greater flexibility in clinical practice without adversely affecting patient survival. Access to curative treatments improves the outcomes of selected patients in all stages.

Keywords: HCC; ablation; liver transplantation; surgery; systemic therapy.

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Conflict of interest statement

Massimo Iavarone participated in the advisory board and received speaker fees from Gilead Sciences, Bayer, AstraZeneca, Roche, Roche Diagnostics, EISAI, IPSEN, and MSD. Barbara Antonelli received speaker fees and travel grants from Chiesi SpA and Roche. Eleonora Alimenti received speaker fees from Roche and Gilead. Giuseppe Cabibbo participated in advisory boards and received speaker fees from Bayer, Eisai, Ipsen, AstraZeneca, MSD, Roche, and Gilead. Pietro Lampertico participated in the advisory board and received speaker fees for AbbVie, Aligos, Altona, Antios, Eiger, Gilead Sciences, GlaxoSmithKline, Grifols, Janssen, MYR, Roboscreen, Roche Pharma/Diagnostics, and Vir. The remaining authors have no conflicts to report.

Figures

None
Graphical abstract
FIGURE 1
FIGURE 1
Patients’ disposition.
FIGURE 2
FIGURE 2
Suitability of BCLC_2022 recommendations for treatment allocation according to each stage, compared to BCLC_2018 recommendations. (A) Suitability; (B) “upward stage migration”; (C) “downward stage migration.” Abbreviation: BCLC, Barcelona Clinic Liver Cancer.
FIGURE 3
FIGURE 3
Overall survival rate stratified according to BCLC at HCC first diagnosis. Abbreviations: BCLC, Barcelona Clinic Liver Cancer; OS, overall survival.
FIGURE 4
FIGURE 4
Overall survival rate stratified according to treatment allocation. (A) BCLC 0, BCLC_2022 recommendations versus “upward stage migration” versus “downward stage migration with curative intent” versus “downward stage migration without curative intent”. (B) BCLC A, BCLC_2022 recommendations versus “upward stage migration” versus “downward stage migration with curative intent” versus “downward stage migration without curative intent”. (C) BCLC A, BCLC_2022 recommendations first choice “lower priority options”. (D) BCLC B, BCLC_2022 recommendations versus “upward stage migration” versus “downward stage migration”. (E) BCLC C, BCLC_2022 recommendations versus “upward stage migration” versus “downward stage migration.” Abbreviations: BCLC, Barcelona Clinic Liver Cancer; OS, overall survival.
FIGURE 4
FIGURE 4
Overall survival rate stratified according to treatment allocation. (A) BCLC 0, BCLC_2022 recommendations versus “upward stage migration” versus “downward stage migration with curative intent” versus “downward stage migration without curative intent”. (B) BCLC A, BCLC_2022 recommendations versus “upward stage migration” versus “downward stage migration with curative intent” versus “downward stage migration without curative intent”. (C) BCLC A, BCLC_2022 recommendations first choice “lower priority options”. (D) BCLC B, BCLC_2022 recommendations versus “upward stage migration” versus “downward stage migration”. (E) BCLC C, BCLC_2022 recommendations versus “upward stage migration” versus “downward stage migration.” Abbreviations: BCLC, Barcelona Clinic Liver Cancer; OS, overall survival.
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