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

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.