Hepatocellular Carcinoma · Resection/Ablation/Transplant (BCLC)

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] BCLC stage (tumor + liver function + PS)
   BCLC stage (tumor burden + Child + performance status PS)?
   • BCLC 0/A: single or ≤3 nodules ≤3 cm, Child A-B, PS0 → Early · resection/ablation/transplant
   • BCLC B: multinodular, preserved liver function, PS0 → BCLC B → TACE
   • BCLC C: portal invasion/extrahepatic spread, PS1-2 → BCLC C → systemic therapy
   • BCLC D: Child C / PS3-4 → BCLC D → supportive care
2. [Decision] Early · resection/ablation/transplant
   Early: resection, ablation or transplant? (Choose by liver function, portal hypertension, remnant liver and whether transplant criteria are met.)
   • Single, Child A, no significant portal hypertension, adequate remnant → resection → Liver resection
   • ≤3 cm (especially ≤2 cm) or unfit for surgery → ablation RFA/MWA → Ablation (RFA/MWA)
   • Within Milan (single ≤5 cm or ≤3 nodules each ≤3 cm), especially with poor liver function/portal hypertension → transplant → Liver transplant
3. [End] Liver resection
   Liver resection — single, Child A, no significant portal hypertension, adequate remnant; curative, monitor for recurrence postoperatively.
4. [End] Ablation (RFA/MWA)
   Ablation (radiofrequency/microwave) — ≤3 cm (≤2 cm gives efficacy near resection), for those unfit for surgery or as a bridge to transplant; percutaneous/laparoscopic.
5. [End] Liver transplant
   Liver transplant — within Milan criteria, treats both the tumor and underlying cirrhosis with the best recurrence-free survival; donor supply is limited, may downstage/bridge (TACE/ablation) while waiting.
6. [End] BCLC B → TACE
   BCLC B (intermediate) → transarterial chemoembolization (TACE) ± ablation; some may downstage to resection/transplant; TARE (yttrium-90) is an option.
7. [End] BCLC C → systemic therapy
   BCLC C (advanced) → systemic therapy: first-line atezolizumab + bevacizumab or durvalumab + tremelimumab; alternatives lenvatinib/sorafenib; second-line regorafenib/cabozantinib/ramucirumab, etc.
8. [End] BCLC D → supportive care
   BCLC D (terminal, Child C/PS3-4) → best supportive care and symptom management; assess liver transplant for selected eligible patients.

Source guidelines & references

• Staged HCC treatment (BCLC 2022; Milan transplant criteria; AASLD/EASL)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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