Abstract
In the treatment of early hepatocellular carcinoma (HCC), resection ablation and transplantation
have had excellent initial success. Choices have to be based on a broad and long-term
vision integrating—besides patients' interests—the community's needs and resources.
In this scenario, guidelines such as the Barcelona Clinic Liver Cancer (BCLC) staging
system can be viewed as a hideous frame (symbolized by the myth of Procrustes, Poseidon's
son who stretched or maimed travelers to fit into his bed), or as a useful structure
against which personalized or innovative treatments must be reality checked. In this
article, the latter view is taken: For resection, portal hypertension must still represent
a powerful caveat, particularly because of poor long-term results. Expansion of the
criteria may instead be explored for multiple tumors and vascular invasion, where
good indications can consistently be selected in expert surgical centers. For ablation,
competitive results can be obtained although a small, but appreciable proportion of
patients with early vascular invasion (∼ 10%), as they could probably benefit from
anatomical resections. Conversely, ablative techniques overcoming the location and
size limitations are developing and may prove competitive. For transplantation, several
equivalent careful expansions of Milan's Criteria can be accepted, but as more patients
have access to the waiting list—often prioritized on non-HCC indications—current allocation
models prove to be insufficient, if not plainly inequitable, and should be revised.
Keywords
hepatocellular carcinoma - liver resection - liver transplantation - radiofrequency
ablation
