Early hepatocellular carcinoma on the procrustean bed of ablation, resection, and transplantation

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.