BCLC guidelines for HCC

1. Barcelona Clinic Liver Cancer (BCLC)
staging for hepatocellular carcinoma.
Dr. Abhilash

2. Introduction
• Fifth most common neoplasm.
• Third most common cause of death.
• No universally accepted staging system.

3. Ideal staging system
• Predict treatment outcome.
• Aid selection for various treatment modalities.

4. Why not in HCC?
Prognosis is multifactorial.
1. Tumor related factors.
2. Anatomical extent.
3. Liver function.
4. Etiology.
5. Interaction between the above factors.

5. Prognostic factors in HCC
PATIENT
FACTORS
• Performance
status
• Quality of life
score
• General
medical
condition
TUMOR
FACTORS
• Number and
size
• Histopathologic
al grade
• DNA
aneuploidy
• Vascular
invasion
• Genotype
• VEGF levels
• Serum AFP
LIVER FACTORS
• Child Pugh
Score
• MELD score
• FIBROSIS score
• Active
inflammation
• Functional
hepatic reserve
• GSA Rmax
• PIVKA-II serum
levels
ETIOLOGY
• Alcohol
• Hepatitis C
• Hepatitis B
Llovet JM, Bru C, Bruix J. Prognosis of hepatocellular carcinoma: the BCLC staging
classification. Semin Liver Dis. 1999;19:329–338

6. Staging systems
• Okuda stage
• French score
• CLIP score
• BCLC staging
• CUPI score
• TNM staging
• JIS score
• ER score.

7. 1999 2003 2008 2010 2012
BCLC Staging
created.
BCLC revised to
include stage
0(very early
stage) and
chemoembolizati
on for HCC
BCLC modified
to incorporate
sorafenib as the
1st line
treatment in
advanced HCC
Recommended by
AASLD in Practice
Guidelines
Recommended
by EASL-EORTC
as part of their
practice
guidelines.

8. BCLC
Based on several cohort studies and RCTs by the barcelona
group.
Has 5 stages - 0, A, B, C, D
Prognostic variables based on
1. Tumor factors (size, number, vascular invasion, N1, M1)
2. Liver function (Child–Pugh’s)
3. Health status of the patient.(ECOG)
Treatment allocation variables -
1. Bilirubin
2. Portal hypertension
3. Presence of symptoms-ECOG.

10. BCLC STAGES
Stage 0 -
• Very early HCC
• Single tumor < 2 cm in diameter
• Without vascular invasion or satellites
• ECOG-0
• Child-Pugh Class A
• 5-10 % detected in this stage.

11. STAGE A
• Early HCC
• single tumor > 2cm
OR
3 nodules <3 cm diameter.
• ECOG-0
• Child Pugh class A or B

12. STAGE B
Multinodular tumors
Asymptomatic
Poor candidates for resection.

13. STAGE C
• Advanced HCC
• Symptomatic tumors
• ECOG 1-2
• Macrovascular invasion
• Extrahepatic spread

14. STAGE D
• End stage HCC
• Symptomatic tumors
• Tumor related disability ECOG 3-4

16. Stage migration
• For treatment allocation.
• All patients do not fulfil all the criterias of a
particular stage.
• Provide next most suitable option.

17. Surgical resection
First line treatment option for
• solitary tumors with well preserved liver
function.
• Multifocal tumors meeting Milan criteria ( less
than or equal to 3 nodules less than or equal
to 3 cm)
In case of recurrence re-assess patient with
BCLC.

18. Liver transplantation
First line treatment option for
• single tumors less than 5 cm with liver
dysfunction
• tumors adhering to Milan criteria not suitable
for resection.
Five year survival - 70%
Neo-adjuvant therapy can be considered if
waiting list exceeds 6 months.

19. Local ablation
1. Radiofrequency ablation.
2. Percutaneous ethanol injection.
• Standard of care for BCLC 0-A not suitable for
surgery.
• In BCLC 0 and tumors less than 2 cm -
complete response in 90%.

20. TACE
BCLC stage B
• Multinodular asymptomatic tumors without
vascular invasion or extrahepatic spread.
• Most widely used primary therapy for unresectable
HCC.
• Rationale - strong cytotoxic and ischemic effect
• Delays tumor progression and macrovascular
invasion.
• Increases mean survival from 16 months to 20
months.

21. Sorafenib
Indications
• Child Pugh Class A
• BCLC stage C
• tumors progressing on loco-regional
therapies.
Oral multi-tyrosine kinase inhibitor.
Only drug with survival benefit in HCC.

22. Stage D
Pallitative support
• Pain
• Nutrition
• Psychological support.

24. References
I. Llovet JM, Bru C, Bruix J. Prognosis of hepatocellular
carcinoma: the BCLC staging classification. Semin Liver Dis.
1999;19:329–338
II. ASSLD Practice guideline 2010
III. EASL–EORTC Clinical Practice Guidelines: Management of
hepatocellular carcinoma, Journal of Hepatology, Volume 56,
Issue 4, April 2012