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Vascular and/or Interventional Radiology

E3302. The Barcelona Clinic Liver Cancer (BCLC) B Subclassification Classification: Ready for Primetime

Niekamp A,  Pillai A. University of Texas at Houston, Houston, TX

Address correspondence to A. Niekamp (

Background Information: BCLC algorithm classifies patients with HCC into 5 stages (0 and A–D), based on tumor burden (size, multiplicity, and evidence of vascular invasion), underlying liver disease and the patient’s performance status. Treatment options include surgical resection, liver transplantation and ablation for early stage disease. Transplant, guided by recently updated UNOS criteria, offers the best overall survival for early stage disease. Transarterial chemoembolization (TACE) is reserved for intermediate stage disease (BCLC B). Research has led to the emergence of subclasses to stratify treatments and outcomes in this group.

Educational Goals/Teaching Points: We present treatment options and outcomes in early (BCLC 0 and A) and intermediate stage (BCLC B) hepatocellular carcinoma (HCC). We review the organ allocation system and United Network of Organ Sharing (UNOS) criteria for liver transplant. We discuss the limitations of BCLC B class and introduce new subclassification systems.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques: The mainstay of treatment in early stage HCC is liver transplantation. Transplant eligibility is determined using Milan criteria and model for end stage liver disease (MELD) score. A MELD exception score prioritize patients with HCC due to increased mortality. To standardize the imaging characteristics that determine transplant eligibility the UNOS criteria was introduced. Recently, the application of the MELD exception score was delayed to 6 months due to imbalances in transplant opportunities between candidates with HCC exceptions and those with MELD score-based allocation priority. A tubular illustration of the organ allocation system with UNOS criteria will be presented. Other authors have expanded BCLC B to better cater to a diverse patient population with intermediate stage disease. The new subclassification provided more treatment options outside of TACE. Outcome studies with clinical examples of the new BCLC B subclasses will be reviewed.

Conclusion: Given the pivotal role of IR in managing HCC, a thorough understanding of the changes in classification, treatment options and outcomes are essential to enhance patient selection and to improve procedural outcomes.