BCLC Staging & Treatment Strategy (2022 Update)

The BCLC system links prognosis to treatment allocation in hepatocellular carcinoma and was updated in 2022. Very early stage (0) is a solitary HCC of 2 cm or less with preserved liver function and performance status (PS) 0. Early stage (A) covers solitary HCC of any size, or up to 3 nodules each 3 cm or smaller, again with preserved liver function and PS 0. Intermediate stage (B) is multinodular disease exceeding these limits with PS 0 and preserved function, stratified into three profiles: well-defined nodules meeting extended transplant criteria, TACE-suitable disease with preserved portal flow and selective arterial access, and diffuse/infiltrative extensive bilobar disease. Advanced stage (C) includes portal (macrovascular) invasion, extrahepatic spread, or cancer-related symptoms (PS 1-2) with preserved liver function. Terminal stage (D) is defined by end-stage liver function or PS 3-4 regardless of tumor burden. First-line strategies per the update: stage 0 - ablation (resection first choice in transplant candidates meeting surgical criteria); stage A - resection or ablation for solitary tumors (TARE an option for a single nodule up to 8 cm), liver transplantation for multifocal disease within Milan criteria; stage B - transplantation (extended criteria), TACE, or systemic therapy according to profile; stage C - systemic therapy with atezolizumab-bevacizumab as first choice, durvalumab-tremelimumab as an alternative, and sorafenib or lenvatinib when immunotherapy is not feasible; stage D - best supportive care. Expected median survivals are over 5 years (0/A), over 2.5 years (B), over 2 years (C) and about 3 months (D). The update emphasizes treatment stage migration and untreatable progression: individual profiles may shift a patient to the strategy of a more advanced stage.