| Stage hierarchy variants In a large multicentre study,28 only a third of patients undergoing liver resection worldwide met the original BCLC criteria. Similarly, in a single centre observational study in Italy,32 hepatocellular carcinoma treatment needed to adhere to guidelines in almost half of enrolled patients with intermediate and advanced-stage hepatocellular carcinoma. Non-adherence to the stage-specific recommended treatment was also found in a study of a large South Korean cohort,33 in which the Hong Kong algorithm was used.19 More flexibility to the stage hierarchy approach has been introduced into international guidelines over the past few years, particularly those by the European Association for the Study of the Liver,2 the American Association for the Study of Liver Diseases,34 and the 2022 updated version of the BCLC.18 Variations in stage hierarchy include treatment stage migration, treatment stage alternative, and clinical decision-making strategies.1 The treatment stage migration approach was initially defined as the possibility of offering the patient the next most suitable treatment option within the same stage, or the one indicated for the subsequent (more advanced) stage, when the first option is contraindicated.10 Not only is a horizontal left-to-right treatment stage migration suggested (ie, if ablation or surgical resection are contraindicated as first-line therapy in patients with BCLC A then intra-arterial treatment should be considered), but also a sequential left-to-right treatment stage migration, which is defined as a shift to the next most suitable option at the time of restaging following an
unsatisfactory response to the first-line therapy.10,35,36 The European Association for the Study of the Liver guidelines introduced an important innovation in 2018— namely, the allowance for a restricted right-to-left treatment stage migration in highly selected patients,
with parameters close to the thresholds defining the adjacent, less advanced stage.2 An example of evidencebased right-to-left sequential migration is represented by the possibility of offering liver transplants to selected patients with BCLC B within validated, extended
criteria.37–39 Another variant of the stage hierarchy approach is the treatment stage alternative approach.1 This model proposes
different therapeutic solutions for each stage of the disease, where initial options (standard of care) are presented alongside alternative solutions. The first refinement of the BCLC scheme according to the treatment stage alternative policy, together with a substratification of the
intermediate stage, was done by a group of experts in 2012.40 The American Association for the Study of Liver Diseases and the European Society of Medical Oncology have also proposed to give more flexibility to the BCLC scheme, by introducing a treatment stage alternative
modification of the algorithm.34,41 Finally, a clinical decision-making variant of stage hierarchy was introduced in the 2022 BCLC update.18 This variant is characterised by an innovative tumour board dedicated section, graphically represented as a second box
placed below the main algorithm, in which the possibility of left-to-right treatment stage migration is evaluated.
在一项大型多中心研究中【Roayaie S, 2015】，全世界只有1 / 3的肝切除术患者符合最初的BCLC标准。同样，在意大利的一项单中心观察性研究中【Sangiovanni A 2018】，在纳入的中晚期肝细胞癌患者中，近一半的肝细胞癌治疗需要符合指南。在一项对韩国大型队列进行的研究中【Kim KM 2016】（该研究使用了香港的算法【Poon RTP 2015】），也发现患者对分期特异性推荐治疗的依从性不高。过去几年中，国际指南对分期分级方法有了更大的灵活性，尤其是欧洲肝脏研究学会（European Association for the Study of the Liver）【Galle PR, 2018】 。美国肝病研究学会（American Association for the Study of Liver Diseases）【Marrero JA 2018】 和2022年更新版BCLC 的指南【Reig M 2022】。分期分级的变化包括治疗阶段的迁移、治疗阶段的替代方案和临床决策策略【Vitale A 2020】。治疗阶段迁移方法最初被定义为在同一阶段内向患者提供下一种最合适的治疗方案的可能性，或者在第一种方案禁忌的情况下为后续（更晚期）阶段提供适合的治疗方案的可能性【EASL 2012。本研究不仅建议进行水平的从左到右的治疗阶段迁移（即如果消融或手术切除禁忌作为BCLC a患者的一线治疗，那么应考虑动脉内治疗），而且还建议进行序贯的从左到右的治疗阶段迁移，其定义为在术后再分期时转向下一种最合适的治疗方案，对一线治疗的反应不理想。欧洲肝脏研究学会（European Association for Study of The Liver） 2018年推出了一项重要创新，即在经过严格选择的患者中，允许有限制的治疗阶段从右向左迁移。参数接近于定义相邻、较低级阶段的阈值基于证据的右向左序贯迁移的一个例子是，有可能在经过验证的扩展范围内向特定的BCLC B期患者提供肝移植标准。阶段分级法的另一种变化是治疗阶段替代法【Vitale A 2020】。该模型提出针对疾病的每个阶段提供不同的治疗方案，即初始方案（标准治疗）与替代方案同时呈现。根据治疗阶段替代策略对BCLC方案进了首次细化，并对治疗阶段替代策略进行了细分美国肝病研究协会（American Association for The Study of Liver Diseases）和欧洲肿瘤内科学会（European Society of Medical Oncology）也建议通过引入治疗阶段替代方案，为BCLC方案提供更多的灵活性算法的修改。最后，2022年的BCLC更新中引入了分期分级的临床决策变体18这种变体的特点是创新的肿瘤板专用部分，图形上表示为第二个盒子置于主算法下方，用于评估治疗阶段从左向右迁移的可能性。
Okay, let's tackle this query. The user provided a detailed text about stage hierarchy variants in hepatocellular carcinoma (HCC) treatment guidelines. They want me to explain the key concepts. Hmm. First, I need to understand the main points here. The text discusses how different guidelines (like BCLC, EASL, AASLD) have evolved to allow more flexibility in treatment approaches.
So, the original BCLC criteria were strict, but studies show many patients didn't fit them, leading to non-adherence. The response has been introducing variants like treatment stage migration (left-right and right-left), treatment stage alternatives, and clinical decision-making strategies.
Wait, treatment stage migration can be horizontal (same stage) or sequential (moving to next stage after restaging). Then there's right-to-left migration for selected patients, like transplants for BCLC B. Treatment stage alternatives offer different options per stage alongside standard care. The 2022 BCLC update adds a tumor board section for decision-making.
I need to structure this clearly. Start with the problem: strict guidelines lead to non-adherence. Then explain each variant with examples. Make sure to mention the studies cited (like the 28,32,33) but maybe not the references in the explanation. Differentiate between the types of migrations and alternatives. Highlight how guidelines have become more flexible over time. Also, note the tumor board's role in the 2022 update.
Check if there's any confusion between the variants. For instance, treatment stage migration vs. alternative. Migration is about moving along stages, alternatives are different options within the same stage. The clinical decision-making is a separate strategy involving a tumor board.
Make sure the explanation is concise but covers all key points. Use simple terms. Maybe start with an overview, then break down each variant with bullet points or sections. Ensure the examples are clear, like liver transplant for BCLC B patients. Also, mention why flexibility is important—personalized treatment, real-world applicability.
Double-check if all terms are correctly interpreted. The Hong Kong algorithm mentioned in the South Korean study—probably another guideline, but the user might not need details on that. Focus on the main guidelines discussed: EASL, AASLD, BCLC updates.
Okay, structure: Introduction/Context, Treatment Stage Migration (subtypes), Treatment Stage Alternative, Clinical Decision-Making, Conclusion on flexibility. Highlight the evolution from strict to flexible. Make sure the answer is organized so each concept is distinct but connected. Use headings if allowed. Avoid jargon, explain abbreviations (like BCLC first time). Alright, ready to draft.
文章提供了关于肝细胞癌（HCC）治疗指南中分期变异的详细文本。他们需要解释关键的概念。首先，需要理解这里的要点。本文讨论了不同的指南（如BCLC， EASL， AASLD）如何演变以允许治疗方法更灵活。
所以，最初的BCLC标准是严格的，甚至僵化，但研究表明，许多患者不符合这些标准，导致不遵守。应对措施一直在引入诸如治疗阶段迁移（从左向右和从右向左）、治疗阶段替代方案和临床决策策略等变化。
治疗阶段的迁移可以是水平的（同一阶段）或顺序的（再迁移后移动到下一阶段）。然后对选定的患者进行从右到左的移植，比如BCLC b的移植。治疗阶段的替代方案在标准治疗的基础上，为每个阶段提供不同的选择。2022年的BCLC更新增加了一个肿瘤委员会的决策部分。
需要清晰地组织。从问题开始：严格的指导方针导致不遵守。然后用例子解释每个变体。一定要提到引用的研究（比如28,32,33），但可能不包括解释中的参考文献。区分迁移和替代的类型。强调指导方针如何随着时间的推移变得更加灵活。此外，请注意肿瘤委员会在2022年更新中的作用。
检查这些变体之间是否有任何混淆。例如，治疗阶段迁移vs.替代。迁移是沿着阶段移动的过程，备选方案是同一阶段中的不同选择。临床决策是一个独立的策略，涉及肿瘤委员会。
确保你的解释简明扼要，但要涵盖所有的要点。使用简单的术语。也许可以从概述开始，然后用要点或章节分解每个变体。确保例子清晰，如BCLC B患者的肝脏移植。同时，要提到为什么灵活性很重要——个性化治疗，现实世界的适用性。
再次检查是否所有术语都被正确解释。韩国研究中提到的香港算法——可能是另一个指导方针，但用户可能不需要详细说明。重点讨论了主要指南：EASL， AASLD， BCLC更新。
好的，结构：介绍/背景，治疗阶段迁移（亚型），治疗阶段替代，临床决策，关于灵活性的结论。突出从严格到灵活的演变。确保答案是有组织的，这样每个概念都是不同的，但又有联系。如果允许的话，使用标题。避免术语，解释缩写（像BCLC第一次）。好了，准备起草了。
Stage Hierarchy Variants概述
Stage Hierarchy Variants定义
不同阶段的治疗方案差异
为何需要Stage Hierarchy Variants
治疗阶段迁移策略
水平治疗阶段迁移示例
垂直治疗阶段迁移定义
如何判断治疗阶段迁移的合理性
治疗阶段迁移的潜在风险
治疗阶段替代方案
标准治疗方案与替代方案对比
替代方案的适用条件
如何选择最佳治疗阶段替代方案
替代方案的效果评估方法
临床决策支持系统
临床决策支持系统的功能
肿瘤板在决策中的作用
如何利用系统优化治疗决策
系统误判的风险及应对措施
The management of hepatocellular carcinoma (HCC) has evolved to address the limitations of rigid staging systems like the original Barcelona Clinic Liver Cancer (BCLC) criteria, which showed low global adherence (only 30–50% of patients met criteria for recommended treatments). This has prompted guidelines to incorporate flexibility through three key stage hierarchy variants:
1. Treatment Stage Migration
Definition: Adjusting treatment based on contraindications or response, either within the same stage or across stages.
Types:
Horizontal (left-to-right): Switching to another therapy within the same stage if first-line options are contraindicated (e.g., using intra-arterial therapy instead of resection/ablation in BCLC A).
Sequential (left-to-right): Moving to therapies for a more advanced stage after unsatisfactory response (e.g., systemic therapy after failed locoregional treatment in BCLC B).
Right-to-left (restricted): Selectively using therapies from a less advanced stage for borderline cases (e.g., liver transplant in BCLC B patients under extended criteria like "up-to-seven" or downstaging protocols).
2. Treatment Stage Alternative
Definition: Offering multiple evidence-based options within the same stage, alongside standard-of-care therapies.
Examples:
Substratifying BCLC B into subgroups (e.g., by tumor burden/response) to guide choices like TACE, radiation, or systemic therapy.
AASLD/ESMO guidelines now include alternatives (e.g., resection for multifocal HCC in select BCLC A patients).
3. Clinical Decision-Making (2022 BCLC Update)
Innovation: A dedicated "tumor board" section in the algorithm, emphasizing multidisciplinary evaluation for personalized decisions.
Purpose: Facilitate structured left-to-right migration (e.g., considering systemic therapy for BCLC B if TACE is unsuitable) while maintaining guideline cohesion.
Drivers of Change
Low adherence to original BCLC: Due to heterogeneity in HCC biology, liver function, and real-world patient complexity.
Evidence for flexibility: Studies showing benefits of transplant in extended BCLC B, or resection in intermediate-stage HCC.
Guideline updates: EASL (2018), AASLD (2018), and BCLC (2022) now prioritize tailored approaches over strict staging.
Key Takeaways
Rigid → Adaptive: Staging systems now balance structure with personalized care.
Multidisciplinary input: Tumor boards formalize flexibility, ensuring decisions align with patient-specific factors.
Research gaps: Long-term outcomes of stage migration (e.g., right-to-left) require further validation.
This shift reflects a broader trend in oncology toward precision medicine, acknowledging that HCC management must adapt to individual patient profiles and evolving therapeutic options.
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