1Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy. Electronic address: email@example.com.
2Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, Gastroenterology & Hepatology Unit, University of Palermo, Palermo, Italy. Electronic address: firstname.lastname@example.org.
3Division of Gastroenterology and Hepatology, Foundation Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
4Hepatobiliary Unit, Department of Minimally Invasive General & Oncologic Surgery, Humanitas Gavazzeni University Hospital, Bergamo, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy.
5Department of Surgery & Cancer, Imperial College London, London, UK; Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy.
6Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Università Cattolica del Sacro Cuore, Rome, Italy.
7General Surgery and Organ Transplantation Unit, Azienda Ospedaliero-Universitaria Policlinico Umberto I, Sapienza University of Rome, Rome, Italy.
8Department of Oncology, Istituto di Ricovero Cura a Carattere Scientifico San Raffaele Scientific Institute Hospital, Vita-Salute San Raffaele University, Milan, Italy.
9Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, Gastroenterology & Hepatology Unit, University of Palermo, Palermo, Italy; Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy.
10Unit of Clinical Medicine and Hepatology, University Campus Bio-Medico, Rome, Italy.
11Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy.
12Department of Radiology and Interventional Radiology, University of Pisa, Pisa, Italy.
13Department of Radiology, Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
14Gastroenterology Unit, Department of Internal Medicine, University of Genova, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Policlinico San Martino, Genova, Italy.
15Unit of Semeiotics, Liver and Alcohol-related diseases, Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
Advances 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).