In addition, systemic therapy is recommended for patients with BCLC-C HCC, whereas palliative or best supportive care should be considered for individuals with BCLC-D HCC (Fig. TACE is recommended for individuals with well-defined nodules, preserved portal flow, and selective access to tumor feeding arteries in contrast, systemic therapy is recommended for patients with diffuse or extensive bilobar liver involvement. Among BCLC-B HCC patients, transplant may be considered for patients meeting extended LT criteria or individuals beyond transplant criteria following successful downstaging with transarterial chemoembolization (TACE). Among individuals with multifocal BCLC-A HCC (three or more nodules, each ≤ 3 cm), the 2022 BCLC updated guidelines do not recommend resection rather, these patients are recommended to undergo ablation for non-LT candidates, while LT is suggested for acceptable LT candidates. In general, resection and ablation have been demonstrated to provide comparable long-term outcomes among individuals with HCC ≤ 2 cm. Among patients with single BCLC-A HCC, resection is favored over ablation owing to lower recurrence especially treating tumors > 2 cm. In brief, patients with BCLC-0 HCC are generally recommended to undergo ablation as the preferred option alternatives include resection or transplantation. In particular, rather than blindly following an algorithm that establishes an initial general approach to treatment, the new guidelines provide more bandwith to tailor HCC care.Īs a result, the new BCLC algorithm appears much more complex than the previous version. In turn, these concepts highlight the need ultimately to personalize treatment decision making after carefully evaluating each patient and the specific disease characteristics in a multidisciplinary setting. Although TSM/untreatable progression have been long noted in real-life clinical practice, these concepts have only now been introduced into the latest BCLC guidelines. Untreatable progression is defined as treatment failure or progression after stage-appropriate treatment that necessitates consideration of more advanced-stage therapy despite a patient still fitting into an initial BCLC stage. 4, 5 In addition, the concept of untreatable progression has been introduced into the new BCLC guidelines. TSM is applied on the basis of clinical judgement when first-line treatment based on a particular stage is not feasible owing to the patient’s profile in turn, treatment for a more advanced stage is therefore offered. In the updated algorithm, the BCLC groupings have further highlighted the value of clinical decision making by introducing the concept of treatment stage migration (TSM) (i.e., treatment recommendations that would usually be considered for a more advanced stage). 1 Since transition to second-line treatment after sorafenib was traditionally the standard of care, future studies will need to refine systemic treatment guidelines as new data emerge with atezo-bev as the preferred first-line approach over sorafenib for BCLC-C individuals. Of note, compared with the 2018 version of the BCLC guidelines in which LT was only recommended for patients with multifocal HCC that were all 400 ng/dl, irrespective of tolerance to sorafenib). The third subgroup include patients with diffuse, infiltrative, and extensive bilobar liver involvement who are recommended to receive systemic therapy. In turn, these patients are candidates for transarterial chemoembolization (TACE). The second subgroup comprises patients without an option for LT, but who had preserved portal flow and well-defined nodules allowing selective access to feeding tumor arteries. The first subgroup corresponds to patients who are candidates for liver transplantation (LT) if the patient meets the local extended LT criteria based on size and/or alpha-fetoprotein (AFP).
1 In particular, the 2022 BCLC edition stratifies BCLC-B into three groups of patients according to tumor burden and liver function. The recent 2022 BCLC guidelines have been updated to further refine intermediate-stage HCC (BCLC-B) and first- and second-line systemic therapy for patients with advanced-stage HCC (BCLC-C), as well as introduce the concept of treatment stage migration (TSM).
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