Advertisement

The updated BCLC staging system needs further refinement: A surgeon’s perspective

  • Xiao Xu
    Affiliations
    Department of General Surgery, Cancer Center, Division of Hepatobiliary and Pancreatic Surgery, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China

    Department of Hepatobiliary Surgery, Affiliated Hospital of Nantong University, Nantong University, Jiangsu, China
    Search for articles by this author
  • Wan Yee Lau
    Affiliations
    Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Navy Medical University (Second Military Medical University), Shanghai, China

    Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
    Search for articles by this author
  • Tian Yang
    Correspondence
    Corresponding author. Address: Department of General Surgery, Cancer Center, Division of Hepatobiliary and Pancreatic Surgery, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China; Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Navy Medical University (Second Military Medical University), 225 Changhai Road, Shanghai 200438, China.
    Affiliations
    Department of General Surgery, Cancer Center, Division of Hepatobiliary and Pancreatic Surgery, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China

    Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Navy Medical University (Second Military Medical University), Shanghai, China
    Search for articles by this author
Published:January 20, 2022DOI:https://doi.org/10.1016/j.jhep.2022.01.002

      Keywords

      Abbreviations:

      BCLC (Barcelona Clinic Liver Cancer), ECOG (Eastern Cooperative Oncology Group), HCC (hepatocellular carcinoma), PS (performance status)

      Linked Article

      • BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update
        Journal of HepatologyVol. 76Issue 3
        • Preview
          There have been major advances in the armamentarium for hepatocellular carcinoma (HCC) since the last official update of the Barcelona Clinic Liver Cancer prognosis and treatment strategy published in 2018. Whilst there have been advances in all areas, we will focus on those that have led to a change in strategy and we will discuss why, despite being encouraging, data for select interventions are still too immature for them to be incorporated into an evidence-based model for clinicians and researchers.
        • Full-Text
        • PDF
      • Reply to: “Correspondence on the <BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update>”
        Journal of HepatologyVol. 76Issue 5
        • Preview
          We appreciate the interest garnered by the BCLC 2022 model update. The new version has incorporated the evidence-based novelties generated in recent years, while also adding a section devoted to clinical decision making at the time of first evaluation and during a patient’s clinical evolution. No clinical practice guideline or recommendation review will ever have enough granularity to firmly recommend the most beneficial approach for an individual patient.
        • Full-Text
        • PDF
      To the Editor:
      We read with great interest the recent update to the Barcelona Clinic Liver Cancer (BCLC) staging system,
      • Reig M.
      • Forner A.
      • Rimola J.
      • Ferrer-Fábrega J.
      • Burrel M.
      • Garcia-Criado A.
      • et al.
      BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update.
      which needed updating based on the remarkable high-level evidence on hepatocellular carcinoma (HCC) management that has been generated in recent years. The main updated contents included updating the recommended first- and second-line systemic drugs for advanced stage HCC (BCLC stage C), and refining intermediate stage HCC (BCLC stage B).
      • Reig M.
      • Forner A.
      • Rimola J.
      • Ferrer-Fábrega J.
      • Burrel M.
      • Garcia-Criado A.
      • et al.
      BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update.
      To our knowledge, it is the fifth “major” update since the BCLC staging system was first introduced in 1999 by 3 well-known hepatologists.
      • Llovet J.M.
      • Bru C.
      • Bruix J.
      Prognosis of hepatocellular carcinoma: the BCLC staging classification.
      We, hepatic surgeons, appreciate the continuous efforts to improve the BCLC staging system, but we believe that this updated BCLC staging system is still not entirely satisfactory, and we have the following comments:
      First, the role that performance status (PS), as defined by the Eastern Cooperative Oncology Group (ECOG), plays in HCC staging and treatment recommendations has not been revised in any updated edition of the BCLC staging system.
      • Hsu C.Y.
      • Lee Y.H.
      • Hsia C.Y.
      • Huang Y.H.
      • Su C.W.
      • Lin H.C.
      • et al.
      Performance status in patients with hepatocellular carcinoma: determinants, prognostic impact, and ability to improve the Barcelona Clinic Liver Cancer system.
      Specifically, the BCLC staging still considers patients with a PS score of 1-2 to be at an advanced-stage of HCC and that this PS score contraindicates hepatic resection. However, in real-world clinical practice, PS, especially PS 1, is often not used as an absolute contraindication to HCC resection.
      • Wu H.
      • Xing H.
      • Liang L.
      • Huang B.
      • Li C.
      • Lau W.Y.
      • et al.
      Real-world role of performance status in surgical resection for hepatocellular carcinoma: a multicenter study.
      Furthermore, even some patients with PS 3-4, such as selected patients with ruptured HCC and hemorrhagic shock, can have favorable long-term survival after emergency or staged HCC resection.
      • Yang T.
      • Sun Y.F.
      • Zhang J.
      • Lau W.Y.
      • Lai E.C.
      • Lu J.H.
      • et al.
      Partial hepatectomy for ruptured hepatocellular carcinoma.
      As assessment of PS for patients with HCC is subjective, and it is often difficult to decide whether the patients’ symptoms at diagnosis of HCC are caused by the tumors or the underlying chronic liver diseases,
      • Hsu C.Y.
      • Lee Y.H.
      • Hsia C.Y.
      • Huang Y.H.
      • Su C.W.
      • Lin H.C.
      • et al.
      Performance status in patients with hepatocellular carcinoma: determinants, prognostic impact, and ability to improve the Barcelona Clinic Liver Cancer system.
      we agree with the recent comment made by Marrero JA et al., “the PS for BCLC stages 0, A, and B has been changed to 0-1 to better reflect clinical practice, given the significant overlap that exists between PS 0 and PS 1 and the potential bias of patient-reported and physician-reported PS.”
      • Marrero J.A.
      • Kulik L.M.
      • Sirlin C.B.
      • Zhu A.X.
      • Finn R.S.
      • Abecassis M.M.
      • et al.
      Diagnosis, staging, and management of hepatocellular carcinoma: 2018 practice guidance by the American association for the study of liver diseases.
      Therefore, we suggest that the latest updated version of the BCLC staging system should be adjusted to reflect this.
      Second, although the BCLC constitutors tried very hard to take into consideration every possible situation, some patients with HCC have complicated clinical presentations. For example, the BCLC staging system considers portal vein invasion to be representative of an advanced HCC stage, but it never mentions biliary invasion
      • Kim D.S.
      • Kim B.W.
      • Hatano E.
      • Hwang S.
      • Hasegawa K.
      • Kudo A.
      • et al.
      Surgical outcomes of hepatocellular carcinoma with bile duct tumor thrombus: a Korea-Japan multicenter study.
      or hepatic vein invasion,
      • Kokudo T.
      • Hasegawa K.
      • Matsuyama Y.
      • Takayama T.
      • Izumi N.
      • Kadoya M.
      • et al.
      Liver resection for hepatocellular carcinoma associated with hepatic vein invasion: a Japanese nationwide survey.
      both of which are specific but not uncommon presentations of HCC. Previous studies showed that the prognosis of patients with biliary invasion or hepatic vein invasion is as poor as in those with portal vein invasion despite treatment. We wonder whether biliary invasion and hepatic vein invasion should also be included into the BCLC staging system. In our opinion, these special but not unusual presentations of HCC should be supplemented to fill up these blind spots in the updated BCLC staging system. As HCC invades into bile ducts to form a bile duct tumor thrombus, obstructive jaundice becomes a significant clinical manifestation of HCC, as such, neither Child-Pugh grade nor ALBI score are suitable for assessing a patients’ liver function. Management of these patients requires methods to relieve jaundice such as percutaneous transhepatic cholangial drainage, and/or surgical resection with concomitant thrombectomy or hepaticojejunostomy.
      • Kim D.S.
      • Kim B.W.
      • Hatano E.
      • Hwang S.
      • Hasegawa K.
      • Kudo A.
      • et al.
      Surgical outcomes of hepatocellular carcinoma with bile duct tumor thrombus: a Korea-Japan multicenter study.
      Admittedly, controversies exist among hepatologists, physicians and surgeons, as well as between clinicians in the East and the West regarding HCC management. However, as a Chinese proverb goes, “seeking common ground while reserving differences”, we, hepatic surgeons, sincerely hope that hepatologists and physicians can listen to the voices of hepatic surgeons and attach more importance to the evidence obtained from real-world clinical practice, as the common goal of all clinicians is to maximize survival benefit for patients with HCC.
      • Yang T.
      • Lau W.Y.
      • Zhang H.
      • Wu M.C.
      • Shen F.
      Hepatic surgeons are like the child who rescued dying fishes.
      ,
      • Yang T.
      • Melloul E.
      • Tabrizian P.
      • Schwartz M.
      Expanded criteria for resection: are current guidelines too conservative.
      By so doing, the upgraded version of the BCLC staging system can win support from surgeons all around the world. We hope to further discuss this with our peers and colleagues around the world, with the aim of making the BCLC staging system more applicable to clinical practice in the future.

      Financial support

      The authors received no financial support to produce this manuscript.

      Authors’ contributions

      Conception: Xiao Xu, Tian Yang; Manuscript preparation: Xiao Xu, Tian Yang; Critical revision: Wan Yee Lau, Tian Yang. All authors reviewed the paper and approved the final version.

      Conflicts of interest

      All authors declared no conflict of interest.
      Please refer to the accompanying ICMJE disclosure forms for further details.

      Supplementary data

      The following are the supplementary data to this article:

      References

        • Reig M.
        • Forner A.
        • Rimola J.
        • Ferrer-Fábrega J.
        • Burrel M.
        • Garcia-Criado A.
        • et al.
        BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update.
        J Hepatol. 2022; 76: 681-693
        • Llovet J.M.
        • Bru C.
        • Bruix J.
        Prognosis of hepatocellular carcinoma: the BCLC staging classification.
        Semin Liver Dis. 1999; 19: 329-338
        • Hsu C.Y.
        • Lee Y.H.
        • Hsia C.Y.
        • Huang Y.H.
        • Su C.W.
        • Lin H.C.
        • et al.
        Performance status in patients with hepatocellular carcinoma: determinants, prognostic impact, and ability to improve the Barcelona Clinic Liver Cancer system.
        Hepatology. 2013; 57: 112-119
        • Wu H.
        • Xing H.
        • Liang L.
        • Huang B.
        • Li C.
        • Lau W.Y.
        • et al.
        Real-world role of performance status in surgical resection for hepatocellular carcinoma: a multicenter study.
        Eur J Surg Oncol. 2019; 45: 2360-2368
        • Yang T.
        • Sun Y.F.
        • Zhang J.
        • Lau W.Y.
        • Lai E.C.
        • Lu J.H.
        • et al.
        Partial hepatectomy for ruptured hepatocellular carcinoma.
        Br J Surg. 2013; 100: 1071-1079
        • Marrero J.A.
        • Kulik L.M.
        • Sirlin C.B.
        • Zhu A.X.
        • Finn R.S.
        • Abecassis M.M.
        • et al.
        Diagnosis, staging, and management of hepatocellular carcinoma: 2018 practice guidance by the American association for the study of liver diseases.
        Hepatology. 2018; 68: 723-750
        • Kim D.S.
        • Kim B.W.
        • Hatano E.
        • Hwang S.
        • Hasegawa K.
        • Kudo A.
        • et al.
        Surgical outcomes of hepatocellular carcinoma with bile duct tumor thrombus: a Korea-Japan multicenter study.
        Ann Surg. 2020; 271: 913-921
        • Kokudo T.
        • Hasegawa K.
        • Matsuyama Y.
        • Takayama T.
        • Izumi N.
        • Kadoya M.
        • et al.
        Liver resection for hepatocellular carcinoma associated with hepatic vein invasion: a Japanese nationwide survey.
        Hepatology. 2017; 66: 510-517
        • Yang T.
        • Lau W.Y.
        • Zhang H.
        • Wu M.C.
        • Shen F.
        Hepatic surgeons are like the child who rescued dying fishes.
        Hepatology. 2016; 63: 1054
        • Yang T.
        • Melloul E.
        • Tabrizian P.
        • Schwartz M.
        Expanded criteria for resection: are current guidelines too conservative.
        Curr Hepatol Rep. 2016; 15: 323-326