The Barcelona Clinic Liver Cancer (BCLC) staging system is widely recognized as a prognostic tool for HCC. However, despite many updates, the BCLC staging system has several limitations and shortcomings, including ambiguity about underlying liver disease and a lack of subdivisions in advanced and terminal stages. The INASL has modified the existing BCLC staging system to address these limitations. The INASL-BCLC system offers clarity, specifying its application to HCC patients with liver cirrhosis. It subdivides stages C and D to cater to varied patient needs, emphasizing the role of locoregional therapy and potential liver transplantation. While the BCLC overlooks combination therapies and downstaging, the INASL-BCLC recognizes their importance and integrates treatments like Transarterial Radioembolization (TARE) and Stereotactic Body Radiation Therapy (SBRT). Overall, the INASL-BCLC offers a more nuanced approach to HCC management than BCLC. Table 1 provides a comparative analysis between the BCLC staging and the INASL modification of BCLC staging for hepatocellular carcinoma (HCC). INASL recommends the use of the ‘INASL modification of the BCLC staging system (INASL-BCLC Staging)’ for improved prognosis prediction and treatment of HCC in India and Asia (Figure 1).  

Table 1: Comparison of BCLC staging and INASL modification of BCLC staging.

Criteria for Comparison	BCLC Staging	INASL-BCLC Staging
Consideration of Underlying Liver Disease	Initial condition only mentions HCC.	Initial condition explicitly mentions HCC in patients with liver cirrhosis.
Division of Stage C	No subdivision of advanced stage BCLC-C (PVTT and EHM).	INASL-BCLC stage C is subdivided into stages C1 and C2 to allow for the role of locoregional therapy in stage C1.
Division of Stage D	Terminal stage is a single, undivided stage; only offers best supportive care.	INASL-BCLC stage D is subdivided into stages D1 and D2. Stage D1 includes patients with advanced liver disease whose tumors still fit liver transplantation criteria, offering potential for LT.
Inclusion of Combination/Adjuvant Therapy	No mention of combination/adjuvant therapy.	Recognizes the emerging role of combination therapy, particularly the combination of locoregional with systemic therapy; expands indication of systemic therapy to patients receiving LRT.
Provision for Downstaging	The algorithm does not consider downstaging.	In patients with INASL-BCLC stage B1, if the tumor is beyond UCSF criteria, downstaging is indicated.
Role of TARE and SBRT	These treatment modalities are not included.	With robust evidence supporting TARE and SBRT, both modalities are included at appropriate stages.

 

Figure 1: The ‘INASL modification of BCLC staging’ (INASL-BCLC) for prognosis prediction and treatment of HCC.