Is it time to reconsider the BCLC/AASLD therapeutic flow-chart?

PURPOSE: Recommendations of the Barcelona Clinic Liver Cancer (BCLC) therapeutic flow-chart, endorsed by the American Association for the Study of Liver Diseases (AASLD), are the most applied worldwide. Over recent years, however, several referral centers have questioned some of the BCLC treatment allocations and proposed alternative strategies. The present study plans to review and discuss these suggestions, with the aim to evaluate whether there are well-grounded reasons to reconsider some of the BCLC/AASLD recommendations. METHODS: A search was made into the MEDLINE database, focusing on randomized controlled trials, meta-analysis reviews, case-control studies, concordant clinical trials on novel therapies and studies reporting the opinion of respected experts. Their results and conclusions were compared stage by stage with BCLC/AASLD recommendations. RESULTS: In stage 0 (very early, or single <2  cm, or carcinoma in situ, Child A) radiofrequency should replace resection. In stage A (early, or single or three nodules up to 3  cm, Child A-B) radiofrequency and resection should expand their indications. In stage B (intermediate, or multinodular, Child A-B) resection and transplantation should expand their indications, while intra-arterial therapies are changing from conventional to selective treatments. In stage C (advanced, portal invasion or extrahepatic disease, Child A-B) systemic therapies should offer previously unknown promising options. CONCLUSION: In our opinion, so much evidence leads to suggest it is time to reconsider several BCLC/AASLD recommendations. Some treatments are comparable in results but vary in costs, local availability, or complication rates.