The Barcelona Clinic Liver Cancer (BCLC) advanced stage (BCLC C) of hepatocellular carcinoma (HCC) includes a heterogeneous population, where sorafenib alone is the recommended treatment. In this study, our aim was to assess treatment and overall survival (OS) of BCLC C patients subclassified according to clinical features (performance status [PS], macrovascular invasion [MVI], extrahepatic spread [EHS] or MVI + EHS) determining their allocation to this stage. From the Italian Liver Cancer database, we analyzed 835 consecutive BCLC C patients diagnosed between 2008 and 2014. Patients were subclassified as: PS1 alone (n = 385; 46.1%), PS2 alone (n = 146; 17.5%), MVI (n = 224; 26.8%), EHS (n = 51; 6.1%), and MVI + EHS (n = 29; 3.5%). MVI, EHS, and MVI + EHS patients had larger and multifocal/massive HCCs and higher alpha‐fetoprotein (AFP) levels than PS1 and PS2 patients. Median OS significantly declined from PS1 (38.6 months) to PS2 (22.3 months), EHS (11.2 months), MVI (8.2 months), and MVI + EHS (3.1 months; P < 0.001). Among MVI patients, OS was longer in those with peripheral than with central (portal trunk) MVI (11.2 vs. 7.1 months; P = 0.005). The most frequent treatments were: curative approaches in PS1 (39.7%), supportive therapy in PS2 (41.8%), sorafenib in MVI (39.3%) and EHS (37.3%), and best supportive care in MVI + EHS patients (51.7%). Independent prognostic factors were: Model for End‐stage Liver Disease score, Child‐Pugh class, ascites, platelet count, albumin, tumor size, MVI, EHS, AFP levels, and treatment type. Conclusion: BCLC C stage does not identify patients homogeneous enough to be allocated to a single stage. PS1 alone is not sufficient to include a patient into this stage. The remaining patients should be subclassified according to PS and tumor features, and new patient‐tailored therapeutic indications are needed. (Hepatology 2018;67:1784‐1796).

中文翻译：

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晚期肝细胞癌患者需要个性化管理：临床实践的教训

巴塞罗那临床肝癌 (BCLC) 晚期 (BCLC C) 的肝细胞癌 (HCC) 包括异质人群，其中索拉非尼单独是推荐的治疗方法。在本研究中，我们的目的是评估根据临床特征（体能状态 [PS]、大血管侵犯 [MVI]、肝外扩散 [EHS] 或 MVI + EHS）细分的 BCLC C 患者的治疗和总生存期 (OS)。分配到这个阶段。我们从意大利肝癌数据库分析了 2008 年至 2014 年间诊断出的 835 名连续 BCLC C 患者。 = 224；26.8%）、EHS（n = 51；6.1%）和 MVI + EHS（n = 29；3.5%）。MVI、EHS、MVI + EHS 患者比 PS1 和 PS2 患者具有更大的多灶性/大块 HCC 和更高的甲胎蛋白 (AFP) 水平。中位 OS 从 PS1（38.6 个月）显着下降到 PS2（22.3 个月）、EHS（11.2 个月）、MVI（8.2 个月）和 MVI + EHS（3.1 个月；P < 0.001）。在 MVI 患者中，外周 MVI 患者的 OS 比中央（门脉干）MVI 患者的 OS 更长（11.2 个月与 7.1 个月；P = 0.005）。最常见的治疗方法是：PS1 的治愈方法 (39.7%)、PS2 的支持疗法 (41.8%)、MVI (39.3%) 和 EHS (37.3%) 的索拉非尼，以及 MVI + EHS 患者的最佳支持治疗 (51.7%) ）。独立的预后因素有：终末期肝病评分模型、Child-Pugh 分级、腹水、血小板计数、白蛋白、肿瘤大小、MVI、EHS、AFP 水平和治疗类型。结论：BCLC C 分期不能确定患者的同质性足以分配到单个分期。仅 PS1 不足以将患者纳入此阶段。其余患者应根据 PS 和肿瘤特征进行亚分类，并需要新的患者量身定制的治疗适应症。（肝病学 2018 年；67：1784-1796）。