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Hepatobiliary SurgeryDiagnostic

HCC Staging and Resection Candidacy (BCLC 2022 / AASLD 2023)

HCC Staging and Resection Candidacy (BCLC 2022 / AASLD 2023): HCC diagnosed: LR-5 in an at-risk liver, or biopsy → Stage the HCC and discuss at the HCC ...

Pathway Overview

19 steps

Algorithm Steps

19 total

  1. 01Start

    HCC diagnosed: LR-5 in an at-risk liver, or biopsy

    LI-RADS imaging diagnosis is valid only in at-risk patients: cirrhosis, at-risk chronic hepatitis B or prior HCC. Otherwise, or for LR-M, confirm HCC by biopsy.

  2. 02Action

    Stage the HCC and discuss at the HCC MDT

    Tumour burden, liver function and ECOG performance status (PS).

    • Multiphase CT or MRI abdomen; non-contrast CT chest if beyond BCLC 0
    • Liver function: Child-Pugh, MELD, ALBI, bilirubin
    • Portal hypertension: varices, ascites, platelets <100 x10^9/L, liver stiffness ≥25 kPa, HVPG ≥10 mmHg
    • AFP; hepatitis B (HBsAg, anti-HBc, HBV DNA) and hepatitis C serology
  3. 03Warning

    Hepatitis B: start antiviral before HCC treatment

    HBsAg positive: start entecavir or tenofovir before, or with, resection, ablation, TACE or systemic therapy. HBV reactivation can cause hepatitis flare and liver failure.

    • Do not delay urgent HCC treatment: start the antiviral at the same time
    • HBsAg negative, anti-HBc positive: HBV DNA monitoring or prophylaxis, with hepatology advice
    • Hepatitis C: plan direct-acting antiviral therapy with hepatology
  4. 04Decision

    BCLC stage (BCLC 2022)

    • 0: single ≤2 cm, preserved liver function, PS 0
    • A: single (any size), or 2-3 nodules each ≤3 cm; preserved liver function; PS 0
    • B: multifocal beyond A; preserved liver function; PS 0; no vascular invasion or spread
    • C: vascular invasion or extrahepatic spread, or cancer-related symptoms (PS 1-2); preserved liver function
    • D: PS >2, or end-stage liver function and not a transplant candidate
  5. BCLC 0
  6. 05Action

    BCLC 0 (single ≤2 cm): curative treatment

    Thermal ablation (RFA or MWA) or resection give similar survival at ≤2 cm. Choose by tumour site, liver function and portal pressure.

  7. 06Decision

    Resection candidate? Child-Pugh A, no clinically significant portal hypertension

    CSPH: HVPG ≥10 mmHg, or varices, ascites, platelets <100 x10^9/L or liver stiffness ≥25 kPa. Bilirubin should be normal. 2-3 nodules: transplant preferred; resect only if in one lobe and not for transplant.

  8. If Yes
    1. Child-Pugh A, no CSPH
    2. 07Decision

      Future liver remnant (FLR) adequate on CT or MRI volumetry?

      Minimum FLR: >30% without cirrhosis (≥20% only if the liver is fully normal); >40% with cirrhosis.

    3. If Yes
      1. Adequate FLR
      2. 08Action

        Resection: Child-Pugh A, no CSPH, adequate FLR

        Aim for margin-negative (R0) resection.

        • Laparoscopic or robotic resection when feasible (fewer complications)
        • Microvascular invasion or satellites on pathology: MDT review for transplant
        • Surveillance: CT or MRI abdomen, CT chest and AFP every 3-6 months
      3. 09End

        MDT follow-up and surveillance

        After resection or ablation: CT or MRI abdomen, CT chest and AFP every 3-6 months. Re-stage at recurrence or progression.

      If No
      1. FLR too small
      2. 10Action

        FLR too small: portal vein embolisation, then re-image

        Resect if the FLR becomes adequate. If not: transplant assessment or locoregional therapy.

      3. 11Action

        Liver transplant assessment

        For early HCC with CSPH or decompensation, multifocal HCC, or not resectable.

        • Milan: 1 tumour ≤5 cm, or 2-3 tumours each ≤3 cm; no vascular invasion or spread
        • Australia and NZ (TSANZ): UCSF (up to 3 tumours ≤4.5 cm, total ≤8 cm; or 1 tumour ≤6.5 cm) or Metroticket 2.0
        • AFP >1000 ng/mL (= µg/L): TSANZ says consider as an exclusion; AASLD requires a fall to <500 ng/mL with locoregional therapy
        • Beyond criteria: downstaging (for example TACE), then at least 3 months within criteria before listing
        • Bridging locoregional therapy if the expected wait is more than 6 months
      4. Path rejoins step 09Shared downstream outcome
    If No
    1. CSPH, Child-Pugh B or decompensation
    2. 12Action

      Resection high risk: CSPH, Child-Pugh B or decompensation

      Resection risks liver failure. Refer for transplant assessment if eligible.

      • Tumour ≤3 cm: thermal ablation
      • Not for transplant: minor laparoscopic resection only in selected patients (MDT)
      • Otherwise TACE, TARE or SBRT
    3. Path rejoins step 11Shared downstream outcome
  9. BCLC A
  10. 13Action

    BCLC A (single, or 2-3 nodules ≤3 cm): curative treatment

    Resection, transplant or ablation, by tumour number, liver function and portal pressure.

    • Single tumour, well-compensated liver, no CSPH: resection is first choice
    • Tumour ≤3 cm: thermal ablation is an alternative to resection
    • 2-3 nodules ≤3 cm: transplant preferred; if not possible, MDT choice of resection, ablation or TACE
    • Not for surgery or ablation: TACE, radiation segmentectomy (TARE) or SBRT
  11. Path rejoins step 06Shared downstream outcome
  12. BCLC B
  13. 14Action

    BCLC B (multifocal, PS 0): TACE

    Selective or segmental TACE if liver function is preserved and tumour burden is defined.

    • Within extended transplant criteria: transplant assessment
    • TARE is an alternative to TACE
    • Poor TACE candidates: bilirubin >34 µmol/L (2 mg/dL), ascites on diuretics, ALBI grade 2-3 or worsening liver function, >50% liver involvement, marked AFP rise
    • Diffuse or infiltrative disease, main portal vein tumour thrombus, or TACE failure: systemic therapy
  14. Path rejoins step 09Shared downstream outcome
  15. BCLC C
  16. 15Action

    BCLC C (vascular invasion, extrahepatic spread or PS 1-2)

    Systemic therapy if Child-Pugh A (or well-selected Child-Pugh B). Check bleeding risk and immunotherapy exclusions first.

  17. 16Warning

    Before bevacizumab: varices and bleeding risk

    Bevacizumab raises GI and variceal bleeding risk, including fatal bleeding.

    • Upper endoscopy before starting (IMbrave150: within 6 months)
    • High-risk varices or GI bleed within 6 months: treat varices first (band ligation), or use durvalumab-tremelimumab
    • Other VEGF exclusions: severe proteinuria, uncontrolled hypertension, arterial thrombosis
  18. 17Warning

    No immunotherapy after liver transplant

    Checkpoint inhibitors can cause graft rejection and graft loss after transplant. Also avoid with severe autoimmune disease.

    • Use lenvatinib or sorafenib instead
    • Check drug interactions with immunosuppression
  19. 18Action

    First-line systemic therapy (BCLC C, or BCLC B not suitable for TACE)

    Child-Pugh A, ECOG PS 0-1. Oncologist-led.

    • Preferred: atezolizumab + bevacizumab, or durvalumab + tremelimumab
    • Varices not treated or recent GI bleed: durvalumab + tremelimumab
    • Immunotherapy contraindicated: lenvatinib or sorafenib
    • Well-selected Child-Pugh B: sorafenib, lenvatinib or single-agent PD-1/PD-L1 inhibitor
  20. Path rejoins step 09Shared downstream outcome
  21. BCLC D
  22. 19Action

    BCLC D (PS >2, or end-stage liver function): best supportive care

    HCC treatment does not improve survival. Symptom control, palliative care and advance care planning.

    • Decompensated cirrhosis with HCC within transplant criteria is not BCLC D: refer for transplant assessment
  23. Path rejoins step 09Shared downstream outcome

Guideline Source

AASLD Practice Guidance on prevention, diagnosis and treatment of HCC (Singal et al., Hepatology 2023); BCLC 2022 update (Reig et al., J Hepatol 2022)

DOI: 10.1097/HEP.0000000000000466View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Guides MDT discussion; it does not replace an HCC multidisciplinary team decision for each patient.
  • Resection and transplant selection vary by centre; in Australia and NZ, transplant listing follows TSANZ criteria and the local unit.
  • Liver function assessment needs more than Child-Pugh: MELD, ALBI and portal pressure change resection risk.
  • Drug doses are not given; use the product information and the treating oncologist's protocol.

Contraindicated Populations

Child-Pugh C or decompensated cirrhosis: not resection candidates (transplant assessment if within criteria)Liver transplant recipients: immune checkpoint inhibitors contraindicatedNo cirrhosis, no at-risk chronic hepatitis B and no prior HCC: LI-RADS imaging diagnosis not valid; biopsy neededChildren: pathway is for adults

Applicable Regions

USAUUKEU

AU: Transplant listing follows TSANZ Clinical Guidelines for Organ Transplantation from Deceased Donors (v1.17, 2026): UCSF or Metroticket 2.0 criteria; AFP >1000 ng/mL should be considered an exclusion; 3-month observation after downstaging.

EU: EASL Clinical Practice Guidelines on HCC (J Hepatol 2025).

JP: Japanese HCC guidelines differ (wider use of resection).

US: AASLD 2023 HCC practice guidance; UNOS downstaging criteria for transplant.

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the HCC Staging and Resection Candidacy (BCLC 2022 / AASLD 2023)?

The HCC Staging and Resection Candidacy (BCLC 2022 / AASLD 2023) is a diagnostic clinical algorithm for Hepatobiliary Surgery. It provides a structured decision tree to guide clinical decision-making, based on AASLD Practice Guidance on prevention, diagnosis and treatment of HCC (Singal et al., Hepatology 2023); BCLC 2022 update (Reig et al., J Hepatol 2022).

What guideline is the HCC Staging and Resection Candidacy (BCLC 2022 / AASLD 2023) based on?

This algorithm is based on AASLD Practice Guidance on prevention, diagnosis and treatment of HCC (Singal et al., Hepatology 2023); BCLC 2022 update (Reig et al., J Hepatol 2022) (DOI: 10.1097/HEP.0000000000000466).

What are the limitations of the HCC Staging and Resection Candidacy (BCLC 2022 / AASLD 2023)?

Known limitations include: Guides MDT discussion; it does not replace an HCC multidisciplinary team decision for each patient.; Resection and transplant selection vary by centre; in Australia and NZ, transplant listing follows TSANZ criteria and the local unit.; Liver function assessment needs more than Child-Pugh: MELD, ALBI and portal pressure change resection risk.; Drug doses are not given; use the product information and the treating oncologist's protocol.. Individual patient factors may require deviation from these recommendations.

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