Reconsidering vascular invasion terminology in hepatocellular carcinoma staging: implications for accurate prognosis and treatment

We read with great interest the recent update on the Barcelona Clínic Liver Cancer (BCLC) staging system for 2026 authored by Reig et al. 1 The 2026 revision of the BCLC strategy enhances the staging and treatment guidelines for hepatocellular carcinoma (HCC), incorporating the latest scientific developments.While retaining the simplicity of the 2022 system, the update provides clearer definitions, such as replacing the term "multifocal " in BCLC-B with more precise criteria.The treatment approach now follows the Complexity, Uncertainty, Subjectivity, Emotion (CUSE) framework, which integrates complexity, uncertainty, subjectivity, and emotion to facilitate shared, multidisciplinary decisionmaking.This framework allows for treatment strategies that are personalized to each patient's unique clinical, biological, and psychosocial profile.By emphasizing the importance of individualized care, the update encourages continual adaptations in response to emerging evidence, fostering a more dynamic, patient-centered approach to HCC management.Although the recommendations provide valuable guidance for the treatment of HCC, we believe that the terms "vascular invasion " and "vascular involving " may lead to potential misinterpretations in staging, as used in both the Tumor-Node-Metastasis (TNM) and BCLC systems.Both the TNM and BCLC systems define "vascular invasion " or "vascular involving " specifically as the formation of tumor thrombus within the vessels.However, these terms encompass a broader range of vascular involvement, including tumor contact with or compression of blood vessels, tumor intravasation, vascular tumor thrombosis, and tumor extravasation.Of them, tumor compression and vascular tumor thrombosis can be detected using imaging techniques such as ultrasound, computed tomography (CT), or nuclear magnetic resonance imaging (MRI) ( Fig. 1 ).Tumor compression is observed when a tumor contacts the hepatic or portal vein, causing its narrowing or complete occlusion, but without tumor thrombus within the venous lumen.On the other hand, vascular tumor thrombosis is characterized by the presence of a thrombus in the hepatic or portal vein that mirrors the primary tumor