HCC Resection Candidacy - BCLC/AASLD 2024

Algorithm Steps

1. ▶

   Start

   Confirmed HCC (LI-RADS 5 or Biopsy)

   Diagnosis confirmed by imaging or pathology

   1. ●

      Action

      BCLC Staging Assessment

      Tumor burden, liver function, performance status

      • Tumor number and size (imaging)
      • Child-Pugh score
      • ECOG performance status
      1. ◆

         Decision

         BCLC Stage

         • 0 (Very Early): Single <2cm
         • A (Early): Single or up to 3 ≤3cm
         • B (Intermediate): Multinodular, no vascular invasion
         • C (Advanced): Vascular invasion or extrahepatic
         • D (Terminal): Child-Pugh C or PS >2
         1. ●

            Action

            BCLC 0: Very Early

            Single <2cm, Child-Pugh A, PS 0

            1. ◆

               Decision

               Liver Function Assessment

               • Child-Pugh A: proceed to resection eval
               • Child-Pugh B: transplant preferred
               • Portal HTN (HVPG >10): caution
               1. ●

                  Action

                  FLR Assessment

                  Future liver remnant evaluation

                  • CT volumetry
                  • Normal liver: FLR >20%
                  • Cirrhosis: FLR >40%
                  • Consider PVE if insufficient
                  1. ●

                     Action

                     Surgical Resection

                     Anatomic or non-anatomic hepatectomy

                     • Parenchymal-sparing when possible
                     • Laparoscopic if feasible
                     • R0 resection goal (1cm margin)
                     1. ■

                        End

                        Treatment & Surveillance

                        Regular imaging, AFP monitoring, MDT review

                  2. ●

                     Action

                     Transplant Evaluation

                     Milan or expanded criteria

                     • Milan: 1 ≤5cm or 3 ≤3cm
                     • UCSF, Up-to-7, AFP score
                     • Bridging/downstaging if needed
         2. ●

            Action

            BCLC A: Early

            1-3 tumors ≤3cm, preserved function

         3. ●

            Action

            BCLC B: Intermediate

            Multinodular, no invasion

            1. ●

               Action

               Locoregional Therapy

               TACE, Y90, ablation

               • TACE for multinodular BCLC B
               • Ablation for small tumors if not surgical
               • Y90 for portal vein involvement
         4. ●

            Action

            BCLC C/D: Advanced

            Vascular invasion, mets, or terminal

            1. ●

               Action

               Systemic Therapy

               TKIs, immunotherapy

               • Atezolizumab-bevacizumab first-line
               • Sorafenib/lenvatinib alternatives
               • BSC for terminal (BCLC D)