Reply to: “Correspondence on the <BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update>”

Liver dysfunction in Barcelona Clinic Liver Cancer-2022 update: Clear as day or still in fog?Journal of HepatologyVol. 76Issue 5PreviewWe read with great interest the article by Reig and colleagues presenting the 2022 update of one of the most used staging systems for hepatocellular carcinoma (HCC), the Barcelona Clinic Liver Cancer (BCLC) staging system.1 The current version is improved over its predecessor, with further stratification of the heterogenous BCLC-B group, the addition of newer immunotherapy options for the BCLC-C group and consideration of liver transplant (LT) as an option for those with tumor burden acceptable for transplant regardless of their liver dysfunction. Full-Text PDF The updated BCLC staging system needs further refinement: A surgeon’s perspectiveJournal of HepatologyVol. 76Issue 5PreviewWe read with great interest the recent update to the Barcelona Clinic Liver Cancer (BCLC) staging system,1 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).1 To our knowledge, it is the fifth “major” update since the BCLC staging system was first introduced in 1999 by 3 well-known hepatologists. Full-Text PDF BCLC 2022 update: Important advances, but missing external beam radiotherapyJournal of HepatologyVol. 76Issue 5PreviewCongratulations to the Barcelona Clinic Liver Cancer (BCLC) group on the 2022 update of the staging, prognosis and treatment guidelines for hepatocellular carcinoma (HCC), which are commonly cited to guide clinical decision-making for HCC worldwide.1 This update of the 2018 guidelines incorporates recent, practice changing trials of systemic therapies in patients with advanced HCC (BCLC C). The BCLC group has incorporated clinical decision making when the “first treatment option” is not feasible or if there is progression, which the group refers to as “treatment stage migration” (TSM). Full-Text PDF BCLC strategy for prognosis prediction and treatment recommendation: The 2022 updateJournal of HepatologyVol. 76Issue 3PreviewThere 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 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. The comments by Hallemeier et al.[1]Hallemeier C.L. Apisarnthanarax S. Dawson L.A. BCLC 2022 update: important advances, but missing external beam radiotherapy.J Hepatol. 2022; 76: 1237-1239https://doi.org/10.1016/j.jhep.2021.12.029Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar call for the incorporation of radiation therapy into the recommendations based on scientific society guidelines and a series of published studies. Current data are encouraging and indicate that radiation has activity. However, the degree of evidence of survival benefit is not high and the recommendation could just be conditional. This justified the current BCLC model, but at the same time we already stated at the right part of the figure that other alternative sequences of treatment may be considered but that they are not proven. In this setting, SBRT could be considered and in the text we stated that “Stereotactic body radiation bears antitumoral activity but further prospective studies are needed to define its role”. This is fully concordant with the strong support of Hallemeier et al. for further prospective randomized controlled trials of radiation therapy. The letter by Xu et al.[2]Xu X. Lau W.Y. Yang T. The updated BCLC staging system needs further refinement: a surgeon’s perspective.J Hepatol. 2022; 76: 1239-1240https://doi.org/10.1016/j.jhep.2022.01.002Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar raises the controversy around the evaluation of performance status (PS) and to what extent PS 0 and 1 should be joined in a single category, while also asking for BCLC model guidance for specific clinical scenarios where the evidence is limited. Clinical evaluation of patients is not easy and clinicians have to spend the required time to assess the symptomatic or asymptomatic status of their patients. Performance status 0 is easy to assess because the patient is asymptomatic. When tumor-related symptoms are present the outcome of patients is impaired whether they are treated at an early, intermediate or advanced stage, or if left untreated. Hence, we strongly disagree with the proposal to merge PS 0 and PS 1 and we stress again that symptoms related to comorbidities do not mean PS 1. Regarding hepatic vein invasion, we have to recall that the BCLC model already includes the term vascular invasion, which also accounts for the hepatic veins. Such a pattern is far less common than portal vein invasion, which is why comments about vascular invasion usually refer to the portal vein. Management of biliary invasion is a complex and heterogeneous clinical event. It implies poor prognosis and interventions are usually palliative with limited impact on survival. Finally, recommendations for ruptured tumors are not included in the BCLC model because this is a complication of HCC and the heterogeneity of the clinical profiles of patients suffering such an event is part of the clinical decision-making section. The lack of prospective studies prevents a robust recommendation about its management. Finally, the letter by Elhence and Shalimar[3]Elhence A. Shalimar Liver dysfunction in Barcelona Clinic Liver Cancer-2022 update: clear as day or still in fog?.J Hepatol. 2022; 76: 1236-1237https://doi.org/10.1016/j.jhep.2021.12.016Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar comments on the evaluation of liver function and the need to provide a well-defined tool for it. We comment in the manuscript that evaluation of liver function will not be fully accomplished by the Child-Pugh system or MELD; clinicians should consider several parameters to provide an optimal assessment of the liver functional reserve for an adequate treatment recommendation for the specific evolutionary stage of the patient. This is why we felt that preserved vs. non-preserved were valid terms that require the evaluation by an expert hepatologist who should become a very active member of any multidisciplinary team devoted to liver cancer. In summary, we are pleased with these debates and interactions, and are confident that the updated BCLC model will be a key tool both for conventional clinical practice and research. The authors received no financial support to produce this manuscript. Both authors contributed equally. The authors declare no conflicts of interest that pertain to this work. Please refer to the accompanying ICMJE disclosure forms for further details. 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