The multiparametric therapeutic hierarchy: a multidisciplinary approach to HCC management

Abstract

Hepatocellular carcinoma (HCC) remains a leading cause of cancer-related deaths worldwide, characterised by significant clinical heterogeneity and therapeutic complexity. The Barcelona Clinic Liver Cancer system has long been the primary framework for staging and treatment allocation; however, its 2025 update, while introducing important refinements, retains the structural limitations inherent to stage-based algorithms. Recent guidelines from international organisations - including the European Association for the Study of the Liver (2025), the European Society for Medical Oncology (2025), the American Association for the Study of Liver Diseases (2023), and various national bodies - have shifted towards flexible, patient-centred approaches that emphasise multidisciplinary tumour board decision making, feasibility assessment, and dynamic therapeutic adaptation. The multiparametric therapeutic hierarchy (MTH) has been introduced as an expert opinion framework to formalise this evolving approach. MTH maintains the prognostic value of staging while separating it from treatment decisions, replacing inflexible algorithms with a tri-axial model: an ordinal hierarchy of therapies ranked by survival benefit, a structured multiparametric feasibility assessment, and a converse therapeutic hierarchy allowing upward movement through curative-intent strategies over time. The model aligns with the conceptual and methodological directions of current guidelines, offering an auditable, adaptable, and ethically consistent decision-making tool for expert multidisciplinary teams. Although based on strong evidence supporting its conceptual foundations, MTH remains a “checklist” that requires prospective validation and additional detail with evidence-based parameters, including biomarkers, imaging criteria, patient-reported outcomes, and integration of artificial intelligence. By providing the conceptual basis for this Special Issue “The Multiparametric Therapeutic Hierarchy: A Multidisciplinary Approach to HCC Management”, MTH aims to support a coherent, multidisciplinary, and future-oriented framework for personalised management of HCC.

Keywords

Hepatocellular carcinoma / multiparametric therapeutic hierarchy / converse therapeutic hierarchy / multidisciplinary tumour board

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