• Alessandro Vitale, Giuseppe Cabibbo, Massimo Iavarone, Luca Viganò, David J Pinato, Francesca Romana Ponziani, Quirino Lai, Andrea Casadei-Gardini, Ciro Celsa, Giovanni Galati, Martina Gambato, Laura Crocetti, Matteo Renzulli, Edoardo G Giannini, Fabio Farinati, Franco Trevisani, Umberto Cillo, and HCC Special Interest Group of the Italian Association for the Study of the Liver.
• Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy. Electronic address: alessandro.vitale@unipd.it.
• Lancet Oncol. 2023 Jul 1; 24 (7): e312e322e312-e322.

AbstractAdvances in the surgical and systemic therapeutic landscape of hepatocellular carcinoma have increased the complexity of patient management. A dynamic adaptation of the available staging-based algorithms is required to allow flexible therapeutic allocation. In particular, real-world hepatocellular carcinoma management increasingly relies on factors independent of oncological staging, including patients' frailty, comorbid burden, critical tumour location, multiple liver functional parameters, and specific technical contraindications impacting the delivery of treatment and resource availability. In this Policy Review we critically appraise how treatment allocation strictly based on pretreatment staging features has shifted towards a more personalised treatment approach, in which expert tumour boards assume a central role. We propose an evidence-based framework for hepatocellular carcinoma treatment based on the novel concept of multiparametric therapeutic hierarchy, in which different therapeutic options are ordered according to their survival benefit (ie, from surgery to systemic therapy). Moreover, we introduce the concept of converse therapeutic hierarchy, in which therapies are ordered according to their conversion abilities or adjuvant abilities (ie, from systemic therapy to surgery).Copyright © 2023 Elsevier Ltd. All rights reserved.

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