Global Survey Reveals Wide Gap Between Liver Cancer Guidelines and Real-World Practice

Hepatocellular carcinoma, the most common form of primary liver cancer, sits at the center of one of the most algorithm-driven fields in oncology. The Barcelona Clinic Liver Cancer (BCLC) staging system assigns patients to treatment categories based on tumor burden, liver function, and physical performance status, and it is meant to guide every clinical decision from surveillance to transplantation. Yet a new international survey published in CVIR Oncology suggests that what actually happens in hospitals around the world often departs, sometimes dramatically, from what the guidelines prescribe. The study, built around a two-step questionnaire administered before and during the Mediterranean Interventional Oncology Live (MIO-Live) 2024 congress, offers one of the most candid snapshots to date of how interventional radiologists and their multidisciplinary colleagues truly manage liver cancer with locoregional therapies.

The initiative, called the Think Tank HCC Meeting (TTHM), was designed by a team led by Roberto Iezzi and colleagues at Fondazione Policlinico Universitario Gemelli IRCCS in Rome, together with experts from institutions across Europe and beyond. Before the congress, 80 of 127 registered participants completed a 61-question online survey covering demographics, hospital facilities, ablation practice, transarterial chemoembolization (TACE), transarterial radioembolization (TARE), and combined treatment strategies. During the meeting itself, attendees voted anonymously through a live polling system while an expert panel, deliberately structured to simulate a multidisciplinary tumor board (MDTB), debated anonymized patient cases divided into early, intermediate, and advanced disease stages. Seventy-two, sixty-four, and seventy-eight participants voted in the three respective sessions, allowing the organizers to compare stated habits with decisions made under the pressure of a realistic clinical scenario.

The respondent pool skewed heavily toward experienced European radiologists. Roughly 82.5 percent were radiologists, of whom more than 91 percent were fully certified, and nearly 44 percent reported more than fifteen years of clinical experience. Almost 88 percent of the hospitals represented were in Europe, with nearly half of all respondents working in Italy, a detail that the authors themselves flag as a major limitation. Still, the infrastructure data were revealing: 72.5 percent of centers held a weekly multidisciplinary tumor board, 77.5 percent worked in or were networked with a transplant center, and 36.25 percent of hospitals had no access to radioembolization at all, a gap that inevitably shapes treatment choices regardless of what any algorithm recommends.

One of the most striking findings concerns thermal ablation, the recommended curative option for patients with tumors smaller than three centimeters who cannot undergo resection or transplantation. Microwave ablation has now overtaken radiofrequency ablation as the dominant technique, particularly for lesions up to four centimeters, reflecting its ability to reach higher temperatures faster and with less susceptibility to heat-sink effects near blood vessels. Yet the survey exposed a sobering quality gap: only about 36 percent of respondents systematically assessed the ablative margin, the rim of treated tissue surrounding the tumor that is widely recognized as a key predictor of local recurrence. Even more concerning, a quarter of respondents never used a multiprobe approach, and the same proportion performed ablations without any navigation system, suggesting that the technological tools available to guarantee complete tumor coverage are not being uniformly deployed.

For larger tumors, the panel showed a clear preference for combining ablation with transarterial embolization or chemoembolization rather than attempting a multiprobe ablation alone, with more than two-thirds of voters favoring the combined strategy. The technical logic is compelling: embolization can be performed in a single step alongside ablation, shortening procedural time and hospitalization, and the sequence matters. Most participants preferred to ablate first, because the hyperemic response induced by thermal injury increases drug uptake during subsequent chemoembolization, particularly in the peripheral zone of the ablation where sublethal heating may leave viable tumor cells. Post-ablation embolization also offers a safety net for patients at high risk of intraprocedural bleeding, such as those with low platelet counts or tumors in difficult locations. Cone-beam CT emerged as a pivotal adjunct in these combined procedures, improving lesion detection, identifying feeding vessels, and helping predict early treatment response.

In the intermediate-stage category, where TACE is the guideline-endorsed standard, the survey reproduced one of the field’s longest-running debates. In the pre-congress questionnaire, up to 40 percent of radiologists preferred drug-eluting bead TACE (DEB-TACE) while fewer than 20 percent favored the conventional lipiodol-based technique; during the live session, however, more than 50 percent switched their preference to conventional TACE. This inconsistency mirrors the literature itself: the PRECISION-V trial failed to demonstrate superiority of DEB-TACE over conventional TACE in overall survival, yet DEB-TACE is generally associated with lower toxicity and fewer complications. Interestingly, participants rated plain transarterial embolization as inferior to chemoembolization, even though a meta-analysis by Lawson and colleagues found comparable survival and complication rates between the two approaches, a perception the authors suggest reflects outdated habits rather than current evidence.

Perhaps the most actionable discrepancy involved balloon-occlusion microcatheters, devices that temporarily block outflow during chemoembolization to concentrate the therapeutic agent within the tumor. More than 72 percent of participants reported never using them, despite mounting evidence, including propensity-matched European multicenter analyses, that balloon-occluded TACE achieves higher complete response rates than conventional techniques. The authors argue that this represents a clear case where real-world practice lags behind the science. A similar pattern appeared with radioembolization: 36 percent of hospitals lacked access to it entirely, and although three randomized controlled trials in advanced-stage patients showed no overall survival advantage over systemic therapy, 64 percent of respondents still considered TARE more useful than systemic treatment, and many centers continue to use it in intermediate-stage patients, supported by retrospective data and by the DOSISPHERE-01 trial, which demonstrated that personalized dosimetry significantly improves response and survival compared with standard dosimetry.

The advanced-stage findings were equally revealing. BCLC guidelines recommend systemic therapy for patients with portal vein tumor thrombosis, extrahepatic spread, or declining performance status, and they do not endorse locoregional options. Yet more than half of the surveyed practitioners considered TACE feasible in these patients, a view echoed by the global BRIDGE observational study, which found that TACE is used as first-line treatment in nearly half of BCLC-C patients worldwide. The panel identified specific subgroups, such as patients with preserved liver function and peripheral tumor thrombus, so-called quasi-C patients, or those intolerant of systemic therapy, in whom degradable starch microsphere TACE, which delivers chemotherapy without ischemic injury to the compromised liver, may offer meaningful benefit. The authors caution, however, that the boundary between performance status 0 and 1 is often razor-thin, making stage classification itself a source of variability.

The overall picture that emerges is one of substantial, sometimes unjustified heterogeneity. Some deviations from the guidelines are backed by recent literature and reflect legitimate personalization, particularly as treatment migration across BCLC stages has become a de facto standard of care and multidisciplinary tumor boards increasingly override strict algorithmic allocation, in some published series with equal or superior survival outcomes. Other deviations, the authors argue, are simply outdated practices or misconceptions lacking scientific support, and clinical expertise alone should not justify divergence from evidence-based recommendations. They call for mandatory margin assessment using contrast-enhanced CT or cone-beam CT with margin-confirmation software, greater standardization of embolic agents, and continuous education to close the gap between what trials demonstrate and what physicians do.

The study’s limitations are acknowledged candidly: the sample was small, and the overwhelming European, largely Italian, composition means the results may reflect regional practice rather than a genuinely global picture. The authors also note that the reasons behind the observed heterogeneity, whether rooted in resource constraints, training traditions, or reimbursement structures, cannot be deduced from a questionnaire alone and deserve dedicated investigation at national and international meetings. Still, as a proof of concept, the Think Tank format demonstrates that live, tumor-board-style polling can surface the hidden variability of clinical practice in a way that retrospective database studies cannot. As long as each interventional radiologist follows an individual approach, the authors conclude, treatment results will remain inconsistent, complicating both patient care and the integration of locoregional procedures into universal oncological guidelines.

Subject of Research: Real-world practice of locoregional treatments for hepatocellular carcinoma compared with BCLC guideline recommendations

Article Title: Think tank on locoregional treatments in hepatocellular carcinoma: a snapshot of real-life practice

Article References: Iezzi, R., Contegiacomo, A., Posa, A., Scrofani, A. R., Rocco, B., Maresca, A., Bargellini, I., Bilhim, T., Crocetti, L., De Cobelli, F., Gasbarrini, A., Goldberg, S. N., Lucatelli, P., Muñoz, F. G., Pompili, M., & Filippiadis, D. (2025). Think tank on locoregional treatments in hepatocellular carcinoma: a snapshot of real-life practice. CVIR Oncology, 1(1), Article 15. https://doi.org/10.1007/s44343-025-00016-0

Image Credits: AI Generated

DOI: 10.1007/s44343-025-00016-0

Keywords: hepatocellular carcinoma, interventional radiology, locoregional therapy, BCLC staging system, transarterial chemoembolization, radioembolization, microwave ablation, multidisciplinary tumor board, clinical practice guidelines, drug-eluting beads, ablative margin, liver cancer