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Radical therapies such as hepatic resection, orthotopic liver transplantation and percutaneous local ablation are strongly indicated in patients with very early and early stage tumours (<jats:styled-content style=\"fixed-case\">BCLC<\/jats:styled-content> O and A), a choice which mainly depends on a combination of tumour volume, status of underlying liver disease, the presence of comorbidities and the patient's age. Although radical therapies provide a survival rate of between 50% and 75% at year five in well selected patients, tumour recurrence is frequent following resection and ablation compared to transplantation (70% vs. 10% respectively), which has the additional advantage of preventing morbidity and mortality from portal hypertension. Generally, while radical therapies are contraindicated in patients with a large tumour burden, such as those with intermediate stage <jats:styled-content style=\"fixed-case\">BCLC<\/jats:styled-content> B, survival in the subset of these patients with well compensated cirrhosis may improve from 16 to 20\u00a0months, on average, following repeated treatments with transarterial chemoembolization (<jats:styled-content style=\"fixed-case\">TACE<\/jats:styled-content>). Survival may also improve in patients who are in poor condition or who do not respond to <jats:styled-content style=\"fixed-case\">TACE<\/jats:styled-content> and in those with an advanced <jats:styled-content style=\"fixed-case\">HCC<\/jats:styled-content> (<jats:styled-content style=\"fixed-case\">BCLC<\/jats:styled-content> C) following oral therapy with the multikinase inhibitor sorafenib. However, because most recommendations are based on uncontrolled studies and expert opinions rather than well designed, high powered randomized controlled trials, treatment criteria need to be adapted to special groups because real life cohorts do not match the selection criteria suggested by the guidelines. Indeed, up to one\u2010third of patients with early stage tumours who are unfit for radical therapy because of advanced age, the presence of significant comorbidities or a strategic location of the nodule, are forced to receive palliative care. <jats:styled-content style=\"fixed-case\">BCLC<\/jats:styled-content> A patients with moderate portal hypertension and certain <jats:styled-content style=\"fixed-case\">BCLC<\/jats:styled-content> B patients could still be eligible for hepatic resection if a chance for 50% survival at 5\u00a0years is still perceived as being cost\u2010effective by both the patient and caregivers.<\/jats:p>","DOI":"10.1111\/liv.12713","type":"journal-article","created":{"date-parts":[[2014,12,22]],"date-time":"2014-12-22T10:26:34Z","timestamp":1419243994000},"page":"129-138","source":"Crossref","is-referenced-by-count":50,"title":["Treatment of hepatocellular carcinoma: beyond international guidelines"],"prefix":"10.1111","volume":"35","author":[{"given":"Massimo","family":"Colombo","sequence":"first","affiliation":[{"name":"Head Division of Gastroenterology and Hepatology Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Universit\u00e0 degli Studi di Milano Via F. 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