Re-evaluating surgical strategies in Barcelona Clinic Liver Cancer-B hepatocellular carcinoma

Abstract

The incidence of hepatocellular carcinoma (HCC) has been steadily rising, underscoring the need for a clear, stage-specific treatment approach. The Barcelona Clinic Liver Cancer (BCLC) staging system remains the most widely used framework for classifying HCC and guiding therapy. Among its classifications, the intermediate stage (BCLC-B) encompasses a highly heterogeneous patient population, with varying degrees of tumor burden and liver function. Traditionally, transarterial chemoembolization has been the standard treatment for this stage, based on earlier evidence. However, recent studies suggest that a subset of BCLC-B patients-particularly those with localized disease-may benefit more from liver resection. This review summarizes current treatment paradigms for BCLC-B HCC, explores emerging subclassifications within this group, and highlights evolving guidelines that support the selective use of surgery in appropriately chosen patients.

Key Words: Hepatocellular carcinoma; Barcelona Clinic Liver Cancer; Surgical resection; Guidelines; Minireview

Core Tip: Patients with intermediate-stage (BCLC-B) hepatocellular carcinoma (HCC) represent a highly heterogeneous group, making the establishment of uniform treatment guidelines particularly challenging. Traditionally, transarterial chemoembolization has been the standard of care for this stage. However, emerging evidence suggests that liver resection may offer superior outcomes in a carefully selected subset of patients. This literature review synthesizes current research on treatment strategies for BCLC-B HCC, with a particular emphasis on the evolving role and indications for surgical intervention.

INTRODUCTION

Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related mortality worldwide, with more than 700000 cases reported in 2019, reflecting a 70% increase since 1990[1]. This trend underscores HCC as a growing global public health concern. While historically driven by hepatitis viruses, the epidemiology of HCC has shifted toward chronic risk factors, such as metabolic syndrome and alcohol use[2]. Efforts to combat HCC are further hindered by the lack of robust, population-wide screening strategies and ongoing disparities in access to timely diagnosis and care, particularly among high-risk groups. These barriers contribute to delayed diagnosis and inferior survival, highlighting the urgent need for improved strategies in prevention, public education, and early detection[3]. HCC is classified according to the Barcelona Clinic Liver Cancer (BCLC) into five stages: Very early (0), early (A), intermediate (B), advanced (C), and terminal (D), based on tumor burden, liver function (assessed using the Child-Pugh score), performance status, and the presence of cancer-related symptoms[4,5]. The BCLC-B stage, classified as intermediate-stage HCC, encompasses a heterogeneous group of patients characterized by a significant variation in tumor burden and liver function. Patients in this stage may present with multiple tumors, with tumor size exceeding 3 cm, or a single tumor larger than 5 cm, without the presence of macrovascular invasion or extrahepatic spread[5,6]. This stage is particularly notable for its broad spectrum of clinical presentation, ranging from patients who may still be candidates for curative treatments to those who may not be[7,8].

The treatment of BCLC-B HCC remains a topic of ongoing debate, largely due to the aforementioned significant heterogeneity within this stage. To address this variability and guide treatment, the 2022 BCLC guidelines further stratified BCLC-B into three subgroups based on tumor burden and liver function[9]. Patients in the first group (Group B1) present with well-defined HCC nodules. The second group (Group B2) encompasses patients who have preserved portal vein flow and a defined tumor burden. Lastly, patients in the third group (Group B3) present with diffuse, infiltrative, or extensive HCC involvement within the liver. The 2022 update of the BCLC system (Figure 1) recommends specific management strategies for the BCLC-B subgroups. Notably, it is suggested that Group B1 patients undergo liver transplantation (LT), while Group B2 patients should be firstly considered for transarterial chemoembolization (TACE). Importantly, apart from transplantation, the role of resection in BCLC-B patients who are not transplant candidates or exceed Milan criteria is increasingly recognized as a potential alternative with acceptable survival outcomes[10]. For Group B3 patients, who present with diffuse, infiltrative, or extensive HCC, systemic therapy is recommended over TACE, as these patients may not benefit from locoregional treatment modalities[9].

Figure 1 Simplified Barcelona Clinic Liver Cancer 2022 algorithm focused on Barcelona Clinic Liver Cancer-B hepatocellular carcinoma, and Pros and Cons of Surgical Interventions for this group. HCC: Hepatocellular carcinoma; BCLC: Barcelona Clinic Liver Cancer; TACE: Transarterial chemoembolization.

Historically, TACE has been the first-line treatment for intermediate-stage HCC in patients not eligible for LT, a recommendation strongly supported by two randomized controlled trials (RCTs) in 2002, which demonstrated a survival benefit over best supportive care[11,12]. This endorsement was later supported by several meta-analyses[13,14]. Conversely, surgical resection has traditionally been reserved for patients with early-stage HCC (BCLC-0 and BCLC-A). Nonetheless, even more recent evidence and clinical experience suggest that certain patients within the BCLC-B stage-particularly those with better liver function and fewer, larger, resectable tumors-may achieve better outcomes with surgical resection compared to TACE alone [hazard ratio (HR) = 1.92, 95% confidence interval (95%CI): 1.45-2.56][15,16] and to TACE combined with ablation (HR = 1.78, 95%CI: 1.15-2.75)[17]. On the same note, according to data from a recent meta-analysis of 3163 patients from 31 studies, liver resection confers a median overall survival (mOS) of 50 months (95%CI: 38-62 months) and a median recurrence-free survival of 15 months (95%CI: 12-18 months)[18]. Considering this evolving paradigm, the present review aims to explore the disease variability within the BCLC-B subclassification, efforts to address it, the current guidelines for the management of patients with this disease and, ultimately, the place of surgery in their treatment. This review is particularly timely given the emergence of new data challenging older treatment paradigms. By discussing recent guideline updates alongside the timeline of proposed changes to the BCLC classification, we aim to contextualize these developments, while focusing on the evolving role of surgical resection in this patient population.

THE ISSUE

Hyun et al[19] highlighted the significant issue of the inadequacy of the BCLC staging system, particularly regarding its inability to account for the aggressiveness of BCLC-B stage HCC. The BCLC staging system is widely adopted for prognostic prediction and treatment allocation; however, it has been criticized for not reflecting the heterogeneity of patients within the intermediate stage. This stage includes a heterogeneous patient population characterized by diverse tumor burdens and varying degrees of liver function, which may contribute to suboptimal treatment decisions. On that note, significant heterogeneity was observed among the included studies, likely reflecting the complexity of the HCC BCLC-B patient population and the broad spectrum of survival outcomes. Therefore, even among this meta-analysis of high-quality studies, variability in outcomes persisted despite robust sensitivity analyses[19]. Additionally, as differences in imaging modalities, surgical techniques and institutional expertise also contribute to significant heterogeneity in patient management and outcomes[20]. Among patients that undergo curative intent resection for HCC, textbook outcome (TO) is achieved in 50.9% to 77%. Importantly, BCLC-B/C HCC cases were significantly less likely to achieve TO compared to BCLC-0 (HR: 0.23; 95%CI: 0.09-0.61). Therefore, even among this meta-analysis of high-quality studies, variability in outcomes persisted as well[21].

Hyun et al[19] argued that older BCLC treatment algorithms, which primarily recommend TACE for BCLC-B stage patients, may not adequately address the needs of all patients within this group[22-28]. On that note, the initial classification was formulated based on a relatively small cohort of early-and intermediate/Late-stage of patients with HCC back in 1999[19,22]. The authors emphasized that multiple courses of TACE can result in repeated ischemic injury to non-tumor liver parenchyma, potentially worsening survival outcomes[19]. They suggest that a subclassification of intermediate-stage HCC could be beneficial, allowing for more tailored treatment approaches based on individual patient characteristics.

A RCT conducted by Yin et al[29], compared primary hepatectomy to TACE in patients exceeding the Milan criteria. This trial demonstrated that patients undergoing primary hepatectomy exhibited superior survival at three years compared to patients undergoing TACE [3-year overall survival (OS) rate: 51.5% vs 18.1%, respectively]. This finding supports the notion that liver resection may be a viable treatment option for well-selected patients with BCLC-B stage HCC, challenging the traditional paradigm of TACE alone for this patient group. This underscores the need to revisit the BCLC staging system to incorporate factors related to tumor aggressiveness, thereby allowing for more effective treatment strategies for patients with intermediate-stage HCC.

PROPOSED SUBCLASSIFICATION OF BCLC-B HCC

The management of BCLC-B HCC has evolved significantly due to the recognition of patient heterogeneity within this group. The Bolondi subclassification system, proposed by Bolondi et al[4] in 2012, tried to address this complexity by introducing a more granular approach to treatment decision-making. This system categorizes patients into four distinct subgroups (B1 to B4) based on key parameters related to tumor burden and liver function, specifically the Child-Pugh score, presence of jaundice and/or ascites, and total bilirubin levels, which have demonstrated their prognostic importance in advanced HCC[30].

The B1 group includes patients with compensated cirrhosis and preserved liver function, corresponding to Child-Pugh class A or Child-Pugh class B with a score of 7. These patients do not exhibit any current or previous decompensation, such as clinical ascites or jaundice. They present with a large multinodular tumor burden but still meet the up-to-seven criteria, which combine the number of nodules and the size of the largest tumor, when considering LT.

Patients in the B2 group have Child-Pugh class A status but their HCC exceeds the up-to-seven criteria. They do not present with clinical ascites or jaundice and have an Eastern Cooperative Oncology Group (ECOG) performance status of 0. While TACE is suggested as a treatment option, Bolondi et al[4] note that the evidence for clinical benefit is weak due to the likelihood of insufficient response in patients with very large tumors or numerous nodules. Transarterial radioembolization with yttrium-90 is a potential promising alternative, yet no RCT has compared its outcomes to TACE.

The B3 group is defined by patients with a Child-Pugh score of 7 (class B) and an ECOG performance status of 0, who also exceed the up-to-seven criteria. The authors expressed concern regarding the risk of excessive liver injury that TACE may cause in this group, suggesting that careful assessment of liver function and tumor burden is warranted[4]. The initiation of systemic treatment with sorafenib is also recommended, as it poses a lower risk of liver injury. It should be noted however, that, although sorafenib exhibits a generally manageable safety profile, which remains consistent across tumors[31], it is hepatotoxic at its Cmax concentration[32]. To this end, in vitro testing showed that sorafenib acts as a mitochondrial toxicant, impairing the activity of the respiratory chain via inhibition of complex I and III in a time- and concentration-dependent fashion[33]. Additionally, in vivo evidence from sorafenib-treated mice suggest that sorafenib induces expression of proapoptotic proteins while it significantly reduces the levels and activity of antioxidant enzymes and antiapoptotic proteins, leading to oxidative stress and hepatocellular death[34]. Regarding clinical evidence, grade 3 and 4 Liver dysfunction is observed in 1% of patients receiving sorafenib[35]. Liver dysfunction led to discontinuation of sorafenib in 5% of patients with adverse-effect-associated treatment discontinuation in the SHARP trial[36]. Importantly, discontinuation of sorafenib because of worsening liver function is associated with a mOS of 1.8 months[37].

Lastly, the B4 group encompasses patients with decompensated Child-Pugh class B status, characterized by severe ascites or jaundice. The prognosis for these patients is poor, and the treatment options are limited. While some may be candidates for LT if their HCC meets the up-to-seven criteria, Bolondi et al[4] emphasized that many will require best supportive care due to the high risk of treatment-related complications.

In 2015, Kudo et al[7] proposed the modified Bolondi subclassification by introducing the Kinki criteria. These criteria aimed to simplify the classification process and enhance treatment decision-making. The Kinki criteria categorize patients into three distinct groups (B1, B2, and B3) based on two primary factors: Liver function, measured with the Child-Pugh score, and tumor status, i.e., whether the tumors are within the up-to-seven criteria or beyond Milan criteria. This simplification reduces the complexity associated with the Bolondi system, which includes multiple substages equivalent to Child-Pugh scores of 5-7, 5-6, and 7[4]. The Kinki criteria allow for an array of treatment options, including resection and ablation for B1 patients with compensated cirrhosis and preserved liver function, who may be also considered for LT if they meet the up-to-seven criteria, something not emphasized in Bolondi system[7]. The treatment strategies discussed in these criteria stemmed from the 2012 EASL-EORTC guidelines[38]. Importantly, the Kinki criteria eliminate the consideration of portal vein thrombosis as a defining factor, streamlining the decision-making process for treatment. Overall, the Kinki criteria aim to provide a more straightforward and clinically applicable framework for managing intermediate-stage HCC and proposed that patients classified as BCLC-B stage with Child-Pugh class A liver function or Child-Pugh class B with a score of 7 and without current or previous decompensation (no clinical ascites nor jaundice) may be considered for resection or LT[7].

CURRENT GUIDELINES

In the management of BCLC-B HCC, various guidelines propose different approaches regarding the potential role of surgery[39]. The Korean Liver Cancer Association-National Cancer Center of Korea guidelines, published in 2022, recommend liver resection for patients with up to three intrahepatic tumors, without vascular invasion, and provided that liver function is well-preserved[40]. This approach is more aggressive compared to the BCLC guidelines from 2022, which primarily recommend TACE for patients with multinodular HCC without vascular invasion[9]. Surgery is supported for BCLC-B patients who may be candidates of LT and have well-defined cancer nodules. However, this strategy has been associated with increased recurrence that hinders long term survival[41]. Importantly, even if classified as Child-Pugh class A, the prognosis of HCC, regardless of the BCLC stage, is directly correlated with factors such as alpha-fetoprotein concentration and the degree of liver function impairment[9,42-45]. In summary, the 2022 BCLC update indicates that while surgical options may be considered, they are hampered by a high risk of recurrence, rendering TACE a more favorable option for these patients[9].

The Japan Society of Hepatology (JSH) guidelines, updated in 2021 and revised in 2023, advocate for surgical resection in patients with up to three tumors and Child-Pugh class A liver function, even in cases with vascular invasion, under certain circumstances[46,47]. This recommendation was founded on the basis of better outcomes with hepatectomy compared to non-surgical treatment in cases of either hepatic vein invasion (median survival time 3.4 years vs 1.8 years, P = 0.02)[48] or portal vein invasion (median survival time 2.45 years vs 1.57 years, P < 0.001)[49]. The Asia-Pacific Association for the Study of the Liver guidelines, updated in 2024, focus mainly on systemic therapy, but acknowledge the role of surgery in cases of intermediate HCC that meet the Milan criteria and do not exhibit vascular invasion or extrahepatic spread[50,51]. Lastly, the Asia-Pacific Primary Liver Expert consensus statement from 2020 suggest that for intermediate-stage HCC surgical options may be considered on a case-by-case basis[52]. Key characteristics that play an important role for the consideration of surgery are: Tumor anatomy characteristics (i.e., single tumor without significant vascular invasion), Child-Pugh Score, overall patient status, and good response to other therapy (i.e., good response to TACE that reduced the tumor burden to a manageable level)[52].

In Europe, the British Society of Gastroenterology guidelines recommend surgery for patients with HCC BCLC-B, under the following criteria: Limited disease burden, defined as a solitary nodule less than 7 cm or fewer than four tumors, preserved liver function (Child A or B without ascites), and preserved performance status (ECOG < 2)[53]. The European Association for the Study of the Liver guidelines from 2018 highlight the importance of careful patient selection for surgical resection, proposing that large solitary HCC tumors exceeding 5 cm with expansive growth be classified as intermediate-stage, provided that vascular invasion and tumor dissemination are excluded via imaging[54]. On the other hand, if surgical resection is technically feasible for these patients, they should be classified as early-stage. Additionally, patients with large multifocal HCC affecting both lobes, without vascular invasion or extrahepatic spread, may correspond to more advanced tumor stages (BCLC C or D)[54]. LT is recommended for patients with refractory ascites or complications, such as spontaneous bacterial peritonitis, hyponatremia, and recurrent encephalopathy, which predict poor outcomes without LT[54-56]. The European Society for Medical Oncology guidelines highlight that for patients with BCLC-B HCC the selection criteria for surgical intervention include Child-Pugh A patients without significant portal hypertension[57]. These patients are generally good candidates for minor or major liver resections. Carefully selected patients with Child-Pugh B status and/or portal hypertension may also be candidates for minor liver resection[57-59].

In the United States, the American Association for the Study of Liver Disease (AASLD) guidelines from 2023 and the National Comprehensive Cancer Network guidelines from 2025 emphasize a multidisciplinary approach, suggesting that patients with BCLC-B HCC who are good surgical candidates and have preserved liver function may benefit from liver resection[60,61]. The AASLD 2023 update introduced a shift in the treatment of BCLC-B patients, indicating that liver resection and LT should be considered more frequently for select patients with limited tumor burden and preserved liver function[60]. These patients typically include those with 1-3 Lesions confined to a single lobe, with a maximum diameter of 5 cm for a single lesion and 3 cm for multiple lesions[60]. Emerging evidence suggests that select patients with macrovascular portal vein tumor thrombus may also be candidates for liver resection, especially in cases of subsegmental or segmental involvement[60,62].

The 2024 American Society of Clinical Oncology and the 2022 American Gastroenterological Association guidelines also recognize the potential for surgical intervention in resectable BCLC-B HCC, but mainly focus on the systematic therapies available[63,64]. The 2022 BCLC update indicates that surgery is not strongly supported for BCLC-B patients due to the high recurrence risk associated with resection and ablation, favoring TACE instead[39]. However, the AASLD guidelines advocate for a more personalized treatment strategy, where patients have to be discussed in multidisciplinary tumor boards[60]. Surgery should be considered the first line treatment for patients with localized disease and absence of cirrhosis. In cases with cirrhosis, surgery is still strongly recommended when the cirrhosis is well compensated and the tumor burden is limited[19,60,65].

All the above guidelines were based on studies with various inclusion and exclusion criteria, Importantly, the inclusion and exclusion criteria regarding portal hypertension and microvascular invasion differ across the major studies and guidelines. For surgical resection, most guidelines recommend careful patient selection, favoring those with preserved liver function and without clinically significant portal hypertension; however, the presence of portal hypertension is not an absolute exclusion in all studies, and selected patients may still be considered for resection if other criteria are favorable[38,54]. Microvascular invasion is typically identified postoperatively and, while it is a known adverse prognostic factor, it is not routinely used as a preoperative exclusion criterion in the referenced studies and guidelines[60]. Instead, these factors are incorporated into risk stratification and influence postoperative surveillance and adjuvant therapy decisions. A brief summary of all the mentioned guidelines is shown in Table 1.

Table 1 Summary of the current indications for surgery in hepatocellular carcinoma Barcelona Clinic Liver Cancer-B.

Guideline (region)	Surgery for BCLC-B	Key criteria/exceptions
Japan Society of Hepatology (Asia)	Yes	Up to 3 tumors, Child-Pugh A liver function, including cases with portal/hepatic vein invasion based on propensity score-matched data
Korean Liver Cancer Association-National Cancer Center (Asia)	Yes	Up to 3 intrahepatic tumors, well-preserved liver function, no vascular invasion
Asia-Pacific Association for the Study of the Liver (Asia)	Case-by-case	Focus on systemic therapy, but allow surgery in intermediate HCC if Milan criteria are met and no vascular or extrahepatic spread
Asia-Pacific Primary Liver Expert Consensus (Asia)	Case-by-case	Consider factors like tumor anatomy (single, no major vascular invasion), Child-Pugh score, good performance status, and favorable response to TACE
British Society of Gastroenterology (Europe)	Yes	Solitary nodule < 7 cm or < 4 tumors, Child-Pugh A or B without ascites, ECOG < 2
European Association for the Study of the Liver (Europe)	Yes (select patients)	Large solitary tumors (> 5 cm) without vascular invasion may still be considered BCLC-B; if technically resectable, may be classified as BCLC-A
European Society for Medical Oncology (Europe)	Yes	Child-Pugh A without significant portal hypertension; Child-Pugh B may be eligible for minor resection
American Association for the Study of Liver Disease (United States)	Yes	1-3 tumors confined to one lobe, well-preserved liver function; includes macrovascular invasion if subsegmental or segmental
National Comprehensive Cancer Network (United States)	Yes	Multidisciplinary evaluation encouraged; surgery for patients with preserved liver function and localized disease
American Society of Clinical Oncology/American Gastroenterological Association (United States)	Limited	Mainly focus on systemic therapies; surgery recognized only for select resectable HCC cases
Barcelona Clinic Liver Cancer (Europe-United States)	Generally no	TACE is preferred due to high recurrence risk; surgery may be considered for transplant candidates or in highly selected patients

BCLC: Barcelona Clinic Liver Cancer; HCC: Hepatocellular carcinoma; ECOG: Eastern Cooperative Oncology Group; TACE: Transarterial chemoembolization.

Lastly it is worth noting that TACE combined with radical therapies (radiofrequency ablation, resection or LT) has not showed to be beneficial in overall or tumor-free survival rates. Importantly, TACE combined with resection had higher complication rates (36.9% vs 29.4%, P = 0.014), mainly biliary leakage (15.3% vs 8.8%, P = 0.004).

LIMITATIONS AND FUTURE DIRECTIONS

The current status of approaching patients with BCLC-B HCC reflects a significant evolution in treatment strategies, particularly regarding the role of liver resection. According to the updated BCLC guidelines, TACE is primarily recommended for patients with intermediate-stage HCC, which is characterized by either multiple nodules or larger tumors[9]. However, recent evidence suggests that liver resection may yield superior OS compared to TACE for select patients within this category. Specifically, a recent meta-analysis of 3355 patients indicated that patients undergoing liver resection had a significantly prolonged OS than those undergoing TACE (HR: 1.92; 95%CI: 1.44-2.56)[16].

Despite these promising findings, the current studies on patients with BCLC-B HCC have several limitations. Most current studies were retrospective in nature, which introduces biases in patient selection and treatment assignment. This retrospective design limits the generalizability of the findings, as patients selected for surgery may not represent the broader population of BCLC-B HCC. Additionally, the patient populations of the current studies are characterized by substantial variations in tumor burden, liver function, and underlying liver disease, thus complicating the interpretation of meta-analytical results and the establishment of standardized treatment protocols. Lastly, given that most current studies were conducted in Asia, hepatitis B virus infection is more commonly the underlying cause of the malignancy, compared to the West[2,16,18]. As such, caution is warranted when extrapolating outcome data across regions, and future studies should prioritize inclusive, multiethnic cohorts to ensure generalizability of their results. According to a meta-analysis of 58186 patients, Asian patients were more likely to receive treatment compared to other racial groups (White vs Black vs native American vs Asian: 29.2% vs 25.2% vs 27.6% vs 34.4%, P < 0.001), and were also more likely to undergo surgery (OR: 1.48; 95%CI: 1.13-1.95, P = 0.01)[66]. Despite these trends, mOS does not differ significantly between Black, White and Hispanic patients with BCLC-B HCC; a statistically significant association with race appears to be established in more advanced disease stages[67].

There is a pressing need for prospective studies to better define the patient population that may benefit from liver resection vs TACE. RCTs would provide the highest level of evidence via direct comparison of outcomes across matched patient groups. In parallel, multicenter prospective cohort studies could enhance external validity and capture real-world outcomes. Such studies should aim to refine the selection criteria, considering factors such as tumor biology, liver function, and patient performance status, as well as prevalence of underlying factors. Additionally, future research should explore further endpoints and incorporate patient-reported outcomes, quality-of-life measures and long-term survival data to provide a more comprehensive assessment of the comparative effectiveness of each treatment strategy. Given the impact of both the disease and its treatments on daily functioning, physical and psychological well-being, it is essential to evaluate the long-term symptomatic burden associated with liver resection or TACE[68]. Ultimately, integrating such metrics will assist in formulating a more individualized care for patient with HCC.

The integration of molecular biomarkers and advanced imaging techniques could further enhance patient stratification and treatment personalization. The current meta-analyses highlight the necessity of RCTs to validate the role of liver resection in BCLC-B patients, particularly those with favorable tumor characteristics and preserved liver function[16,18]. Recent work by Tsilimigras et al[65] has indicated that the tumor burden score (TBS), calculated by adding the square roots of the number of tumors and the maximum tumor diameter (TBS² = maximum tumor diameter² + number of tumors²) could be used to select surgical candidates. To this end, patients with comparable TBS exhibit similar OS, irrespective of BCLC stage (5-year OS of 61.6% vs 58.9% in BCLC-A/medium and BLCL-B/medium cases, respectively), while patients with BCLC-B/medium disease experience better OS compared to BCLC-A/high patients (58.9% vs 45.0%, respectively)[69]. Furthermore, a preoperative TBS-model, combining TBS with American Society of Anesthesiologists class, cirrhosis presence, alpha-fetoprotein levels, tumor grade and the presence of lymphovascular invasion, effectively stratified patients relative to 5-year OS (low-risk: 73.7%, intermediate risk: 45.1%, high-risk: 13.1%)[65]. These data suggest that the use of validated risk calculators for individualized risk assessment of patients with intermediate-stage HCC would allow for more optimal determination of surgical candidacy.

CONCLUSION

In conclusion, while the evidence increasingly supports the potential of liver resection as a viable treatment option for well-selected BCLC-B patients, the limitations of existing studies underscore the need for rigorous prospective research. This will not only clarify the optimal treatment strategies but also ensure that patients receive the most effective and individualized care possible. According to the current guidelines, patients with BCLC-B HCC who may benefit from liver resection typically include those with a limited number of tumors (generally up to three), preserved liver function (i.e., Child-Pugh class A), and no evidence of vascular invasion. JSH and AASLD present exceptions to this “no vascular invasion” rule. JSH suggests that portal and hepatic vein invasion is not a contraindication for surgery, whereas AASLD suggests that in subsegmental and segmental portal vein thrombus, resection can still offer a survival benefit. These characteristics are crucial in determining surgical candidacy, as they are associated with improved survival following liver resection. The convergence of these guidelines highlights the importance of individualized treatment plans that consider both tumor burden and liver function, ensuring optimal management of the patient with HCC BCLC-B, through multidisciplinary decision-making.