Hepatocellular Carcinoma In India Research Articles

Systemic Therapies for Hepatocellular Carcinoma in India

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality in India. This review explores the epidemiological trends and the landscape of systemic therapy for HCC in the Indian context, acknowledging the recent shift in etiology from viral hepatitis to lifestyle-associated factors. A comprehensive review of the literature was conducted, including data from the Global Cancer Observatory and the Indian Council of Medical Research, along with a critical analysis of various clinical trials. The article investigates systemic therapies in-depth, discussing their mechanisms, efficacy, and adaptation to Indian healthcare framework. Progression-free survival with a hazard ratio (HR) ≤0.6 compared to sorafenib, overall survival of ∼16-19 months, and objective response rate of 20-30% are the defining thresholds for systemic therapy clinical trials. Systemic therapy for advanced HCC in India primarily involves the use of tyrosine kinase inhibitors (TKIs) such as sorafenib, lenvatinib, regorafenib, and cabozantinib, with sorafenib being the most commonly used drug for a long time. Monoclonal antibodies like ramucirumab and bevacizumab and immune checkpoint inhibitors such as atezolizumab, nivolumab and pembrolizumab, are expanding treatment horizons. Lenvatinib has emerged as a cost-effective alternative, and the combination of atezolizumab and bevacizumab has demonstrated superior outcomes in terms of overall survival and progression-free survival. Despite these advances, late-stage diagnosis and limited healthcare accessibility pose significant challenges, often relegating patients to palliative care.Addressing HCC in India demands an integrative approach that not only encompasses advancements in systemic therapy but also targets early detection and comprehensive care models. Future strategies should focus on enhancing awareness, screening for high-risk populations, and overcoming infrastructural disparities. Ensuring the judicious use of systemic therapies within the constraints of the Indian healthcare economy is crucial. Ultimately, a nuanced understanding of systemic therapeutic options and their optimal utilization will be pivotal in elevating the standard of HCC care in India.

Liver transplantation for hepatocellular carcinoma in India: Are we ready for 2040?

Liver transplantation (LT) for hepatocellular carcinoma (HCC) has been widely researched and is well established worldwide. The cornerstone of this treatment lies in the various criteria formulated by expert consensus and experience. The variations among the criteria are staggering, and the short- and long-term out comes are controversial. To study the differences in the current practices of LT for HCC at different centers in India and discuss their clinical implications in the future. We conducted a survey of major centers in India that performed LT in December 2022. A total of 23 responses were received. The centers were classified as high- and low-volume, and the current trend of care for patients und ergoing LT for HCC was noted. Of the 23 centers, 35% were high volume center (> 500 Liver transplants) while 52% were high-volume centers that performed more than 50 transplants/year. Approximately 39% of centers had performed > 50 LT for HCC while the percent distribution for HCC in LT patients was 5%-15% in approximately 73% of the patients. Barring a few, most centers were divided equally between University of California, San Francisco (UCSF) and center-specific criteria when choosing patients with HCC for LT, and most (65%) did not have separate transplant criteria for deceased donor LT and living donor LT (LDLT). Most centers (56%) preferred surgical resection over LT for a Child A cirrhosis patient with a resectable 4 cm HCC lesion. Positron-emission tomography-computed tomography (CT) was the modality of choice for metastatic workup in the majority of centers (74%). Downstaging was the preferred option for over 90% of the centers and included transarterial chemoembolization, transarterial radioembolization, stereotactic body radiotherapy and atezolizumab/bevacizumab with varied indications. The alpha-fetoprotein (AFP) cut-off was used by 74% of centers to decide on transplantation as well as to downstage tumors, even if they met the criteria. The criteria for successful downstaging varied, but most centers conformed to the UCSF or their center-specific criteria for LT, along with the AFP cutoff values. The wait time for LT from down staging was at least 4-6 wk in all centers. Contrast-enhanced CT was the preferred imaging modality for post-LT surveillance in 52% of the centers. Approximately 65% of the centers preferred to start everolimus between 1 and 3 months post-LT. The current predicted 5-year survival rate of HCC patients in India is less than 15%. The aim of transplantation is to achieve at least a 60% 5-year disease free survival rate, which will provide relief to the prediction of an HCC surge over the next 20 years. The current worldwide criteria (Milan/UCSF) may have a higher 5-year survival (> 70%); however, the majority of patients still do not fit these criteria and are dependent on other suboptimal modes of treatment, with much lower survival rates. To make predictions for 2040, we must prepare to arm ourselves with less stringent selection criteria to widen the pool of patients who may undergo transplantation and have a chance of a better outcome. With more advanced technology and better donor outcomes, LDLT will provide a cutting edge in the fight against liver cancer over the next two decades.

Changing Etiological Spectrum of Hepatocellular Carcinoma in India—A Systematic Review and Meta-analysis

BackgroundRecent studies from both India and outside India have shown a change in the etiological profile of hepatocellular carcinoma (HCC). We aimed to analyze the etiological spectrum and changing trends of HCC etiology in India using a systematic review of current literature and meta-analysis. MethodsElectronic databases of Pubmed/Medline, Scopus, and Embase were searched from inception to July 2023 for studies reporting the data on the etiology of HCC from India. The pooled proportions with 95% confidence interval were calculated using summative statistics. ResultsA total of 60 studies (n = 12327) were included in the final analysis. The pooled proportions of HCC cases with at least one positive and negative viral marker were 56.0 (49.5 – 62.6) and 43.1% (36.5 – 49.8), respectively. The pooled proportion of HCC cases with positive hepatitis B virus (HBV) markers was 41.0 (35.8 – 46.1), while those with positive markers for hepatitis C virus (HCV) were 20.3 (17.0 – 23.6). The pooled proportion of cases with HCC with significant alcohol intake was 19.0% (15.6 – 22.4), and those related to non-alcoholic fatty liver disease (NAFLD) were 16.9% (12.1 – 21.7). Around 7.9% (5.8 – 10.0) of the cases had HCC with multiple etiologies. Subgroup analysis showed a significant variation with the location of the study based on zone. Meta-regression analysis based on publication year (1990-2023) showed a significant reduction in the proportion of cases with HBV and an increase in cases with NAFLD. In contrast, the proportion of cases with HCV and alcohol did not change significantly. ConclusionViral hepatitis is the most common etiology of HCC in India, predominantly HBV. The proportions of cases with HCC related to NAFLD are increasing, and those related to HBV are declining.

Multi-center prospective survey of hepatocellular carcinoma in Kerala: More than 1,200 cases.

Hepatocellular carcinoma (HCC) is considered uncommon in India. The aim of this study was to document the demographic characteristics and clinical aspects of HCC in Kerala, India. A survey of HCC in Kerala was performed. All gastroenterologists in the region were invited. From May 2018 to April 2020, data was collected in a standardized questionnaire. Forty-three doctors from 15 centers contributed thedata.Total 1217 patients were analyzed. This is the largest state-wide survey of HCC in India. HCC was more common in men (90%) than in women (p < 0.01). The etiology of liver disease was hepatitis B virus (7%), hepatitis C virus (4%) and alcohol (40%). Diabetes mellitus was present in 64%, hypercholesterolemia in 17% and hypertension in 38%. Obesity was present in 33% and 15% were overweight. Non-alcoholic fatty liver disease (NAFLD) with or without metabolic syndrome was present in 44%. Serum alpha-fetoprotein was > 400ng/mL in 24%, total tumor diameter was > 5cm in 59%, portal vein invasion was seen in 35% and distant metastasis was seen in 15%. Specific therapy was given to 52%. Treatments given included liver transplantation (n = 24), liver resection (n = 39) and transarterial chemoembolization (TACE, n = 184). Although the study was not designed to compare survival, patients who had liver transplantation had longer survival (median 69months) compared to matched patients given only TACE (median 18months) (p = 0.03). HCC is common in Kerala, India. NAFLD has a predominant association with HCC in Kerala. Most of the patients report late when curative treatment is not possible.

Etiologic fractions in patients of hepatocellular carcinoma in India with and without a background of cirrhosis: a multi-centric study.

Hepatocellular cancer (HCC) typically arises in the background of cirrhosis. The epidemiology of HCC has changed in recent years due to availability of newer antivirals, changing life-styles and greater possibility for early detection. We undertook a multicentric national sentinel surveillance for liver cirrhosis and HCC to assess the attributable risk factors for the development of HCC, both with and without a background of cirrhosis. Data from January 2017 till August 2022 from hospital-based records of eleven participating centers were included. Diagnosed cases of cirrhosis [radiological (multiphase and/or histopathological] and HCC [as per AASLD 2018] were included. History of significant alcohol intake was elicited by AUDIT-C questionnaire. Altogether 5798 enrolled patients were assessed, of which 2664 patients had HCC. The mean age was 58.2 ± 11.7years and 84.3% (n = 2247) were males. Diabetes was found in over a third of those with HCC (n = 1032;39.5%). The most common etiology of HCC was NAFLD (n = 927;35.5%) followed by viral hepatitis B and C and harmful levels of alcohol. Among those with HCC, 27.9% (n = 744) had no cirrhosis. Higher proportion of cirrhotic HCC patients had alcohol as an etiological factor as compared to non-cirrhotic (17.5 vs. 4.7%, p ≤ 0.001). NAFLD was an etiological factor for a higher proportion of non-cirrhotic HCC patients as compared to cirrhotic HCC (48.2 vs. 30.6%, p ≤0.001). Diabetics more commonly had non-cirrhotic HCC (50.5 vs. 35.2%). The following factors were associated with an occurrence of cirrhotic HCC: male gender (OR 1.372 and 95% CI 1.070-1.759), age above 60years (OR 1.409 and 95% CI 1.176-1.689), HBV (OR 1.164 and 95% CI 0.928-1.460), HCV (OR 1.228 and 95 CI 0.964-1.565) and harmful consumption of alcohol (OR 3.472 and 95% CI 2.388-5.047). The adjusted odds of non-cirrhotic patients having NAFLD was 1.553 (95% CI 1.290-1.869). This large multi-centric study demonstrates that NAFLD is the most important risk factor for development of both cirrhotic and non-cirrhotic HCC in India and has overtaken viral hepatitis. Awareness campaigns and large-scale screening are required to reduce the high burden of NAFLD-related HCC in India.

Hepatocellular carcinoma in India: Time for a new focus

Hepatocellular carcinoma in India: Time for a new focus

Comprehensive Review of Hepatocellular Carcinoma in India: Current Challenges and Future Directions.

There is not much information on hepatocellular carcinoma (HCC) in India. Here, we review the existing data, available treatment choices, and future directions in HCC management. An extensive search was conducted through PubMed and MEDLINE for studies published between January 2000 and June 2022 on the epidemiology of HCC in India using the following key words: atezolizumab, BCLC staging, hepatocellular carcinoma, immune checkpoint inhibitors, immunotherapy, and programmed cell death ligand-1, with the filters humans and English language. The most frequent risk factors for the development of HCC in India include nonalcoholic fatty liver disease, hepatitis B virus and hepatitis C virus infection, liver cirrhosis, and alcohol intake. On the basis of new findings, the Barcelona Clinic Liver Cancer (BCLC) Staging Criteria need to be revised. As most cases in India are discovered at a later stage, curative treatments such as surgical resection, ablation, or liver transplantation may not be an option. Clinical trials are underway for a number of immune checkpoint drugs that target cytotoxic T-cell lymphocyte-4 and programmed cell death-1/programmed cell death-ligand 1. In India, phase III trials of atezolizumab in combination with other drugs are underway for the treatment of various malignancies. Renin angiotensin system inhibitors, antivirals, primary hepatocyte transplantation, and bioartificial liver devices are among the future options for the management of HCC. In developing countries like India, HCC is often diagnosed at an advanced stage because of a delay in routine testing or screening. Therefore, developing effective treatment regimens for such stages is critical. Immunotherapy is a promising treatment option that has the potential to increase overall response and survival rate.

A proposed five-step simplified algorithm for the management of hepatocellular carcinoma in India

Hepatocellular carcinoma (HCC) is the eighth-most frequent cause of cancer mortality in India. The staging system most often used for treatment decisions in India is the Barcelona clinic liver cancer (BCLC) system. However, this staging system is often criticised for several reasons, such as heterogeneity of patient prognosis in each BCLC stage, limited guidance on expanding the role of liver transplantation (LT), no recommendation on combination therapies, no guidance on downstaging and limited treatment options for late presenters (stages C or D). Hence, we propose a simplified five-step algorithm for making treatment decisions for HCC patients in India. This algorithm incorporates evidence-based treatment allocations based on the step-by-step assessment of major prognostic and treatment-related parameters. The five steps of the algorithm are – Step 1: assessment of performance status, Step 2: assessment of extrahepatic spread and macrovascular invasion, Step 3: assessment for living donor LT, Step 4: assessment for the eligibility of liver resection and Step 5: assessment for appropriate locoregional therapy. Each of these steps does not require any separate investigations, and the initial workup for the diagnosis of HCC (dynamic computed tomography/magnetic resonance imaging and routine laboratory tests) would suffice in this five-step algorithm. We hope that this algorithm will not only simplify the management approach to HCC patients in India, but also it will bring uniformity in the treatment protocol for HCC in India.

Radiological Outcome of Subcentimeter Arterially Enhancing Nodules Detected during Surveillance for Hepatocellular Carcinoma- A Cohort Study

Introduction: Hepatocellular Carcinoma (HCC) is the sixth most diagnosed cancer and the fourth leading cause of cancerrelated death globally. The male: female ratio for HCC in India is 4:1 with age of presentation ranging from 40 to 70 years. There is limited clinical information on the course of SubcentimeterSized Nodules (SCSNs) detected during surveillance for HCC. Aim: To evaluate the serial outcome of subcentimeter arterially enhancing nodules evolving into HCC and henceforth, to identify specific radiological features which can prognosticate and, if possible, predict which SCSNs will turn into HCC. Materials and Methods: A prospective cohort study was conducted in a tertiary care center in Delhi NCR, in the Department of Radiodiagnosis between 1st May 2018 and 30th April 2019. Total of 72 lesions in 59 patients were evaluated during the study period of one year, which included images spanning over a mean duration of three years (range 2-6.5 years). Dynamic contrast enhanced imaging was done as per Liver Imaging Reporting and Data System version 2018 (LI-RADS version 2018) using either Magnetic Resonance Imaging (MRI) or Computed Tomography (CT). The gold standard for HCC diagnosis was LR 5 lesion. Size cut-off, rate of growth, enhancement features were studied and calculated. Student’s t-test was used for comparison of quantitative outcome parameters. Results: A total of 59 patients were analysed with mean age 53±12 years, of which 85% were males. The cumulative HCC development rate was 47.5%. A 60.9% of the SCSNs which turned into HCCs showed an increase in size, 31.6% of the non HCC-SCSN lesions also showed an increase in size. Upon baseline comparison, the growth difference was more in the HCC group (8.2±12.24 mm) than in the non HCC group (3.37±7.39 mm). The optimal cut-off points after which the likelihood of an arterially enhancing lesion turning into HCC increased significantly was 8.5 mm on CT and 10.5 mm on MRI. Conclusion: Around 47.5% of arterially enhancing SCSN converted into HCC; this percentage is much higher than quoted literature. A six monthly follow-up may be considered as 52.2 percent of lesions turned into HCC in a span of 1 year. The optimal cut-off points after which the likelihood of an arterially enhancing lesion turning into HCC increases can be taken as 8.55 mm on CT and 10.5 mm on MRI. Among the lesions showing washout, 80.8 % on CT and 91.3% nodules on MRI changed into HCC.

Hepatocellular Carcinoma in India

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world. The incidence of HCC is rising in India and is one of the leading GI cancers. The prevalence of HCC in India varies from 0.2 to 1.6%. The age adjusted incidence rate of HCC in India for men ranges from 0.7 to 7.5 per 100,000 populations, and for women 0.2 to 2.2 per 100,000 populations. The male to female ratio for HCC in India is 4:1. The incidence of HCC in cirrhotic in India is 1.6% per year. The age standardized mortality rate for HCC in India for men is 6.8/100,000 and for women is 5.1/100,000. HBV is the main etiological factor associated with HCC in India. Due to high prevalence of HBV infection in India, the surveillance is poor and there has been no comprehensively analyzed data for HCC. Despite recent advances in the treatment of HCC, many patients cannot be cured due to the advanced stage of HCC at the time of diagnosis in India. Optimal application of multidisciplinary team approach and active involvement in clinical studies with new agents in HCC patients are critically important.

Epidemiology of HIV, Hepatitis B and C virus in emergency and elective surgical patients: Our experience of 275 patients in a single surgical ward

Human immunodeficiency, hepatitis B and hepatitis C virus are major health problems throughout the world. All over the world surgeons have the highest risk for exposure to blood and its products during performing their procedures. Human immunodeficiency, hepatitis B and hepatitis C affecting more than three billion people worldwide and hepatitis B and hepatitis C virus is the single most important factor of chronic liver disease and hepato-cellular carcinoma in India and abroad. Universally preoperative testing of these blood born virus HIV, HBV, HCV has been a accepted strategy to reduce the risk of virus transmission. This study was designed to analyse the magnitude of these infections as a global health problem, affecting millions of population throughout globe. This study also describe the prevalence of Human Immunodeficiency Virus, Hepatitis B and Hepatitis C virus in surgical patients undergoing elective and emergency surgeries. Material and Methods: This is a retrospective study done on 275 patients who were admitted for general surgical care between July 2016 and May 2020 in single surgical ward and were positive for HBsAg, anti-HCV, and anti-HIV antibodies. Results: Patients included in the study were between 16-18 years of age and included both male as well as female. There were 182 male and 93 female with male: female ratio 1: 0.51. Out of 275 patients 33.45% patients were positive for HBsAg, 34.54% were positive for anti-HCV, and 29.09% were positive for anti-HIV. Conclusions: Education of all healthcare workers including doctors along with routine preoperative testing of all patients undergoing elective and emergency surgeries are highly important to enhance the awareness of these infection in order to reduce the transmission of disease. As the common message is ‘Prevention is better than cure ‘It is highly important to prevent further spread of these infections by screening of every patient before any surgery whether elective or emergency and also counselling should be done of all patients. All the doctors and paramedical staff must follow the proper ethical practice to ensuring the use of sterile disposables in all these patients where indicated and also protecting themselves from these viral infections.

Single-nucleotide polymorphisms in dendritic cell (dendritic cell-specific intercellular adhesion molecule 3-grabbing nonintegrin) gene of hepatocellular carcinoma patients from India.

Hepatocellular carcinoma (HCC) is one of the major causes of morbidity and mortality in the world. Numerous genomic and proteomic studies have been carried out across the globe to understand cancer biology related to HCC. Dendritic cell-specific intercellular adhesion molecule 3-grabbing nonintegrin (DC-SIGN) is also known as cluster of differentiation 209. The current study was designed to investigate the association of mutation in DC-SIGN promoter region in HCC patients and healthy controls and to analyze the association of these mutations as a risk factor for HCC development from India. total of 40 cases of HCC and 40 healthy controls without any underlying liver diseases were included in the study. A total of 5 ml of peripheral blood samples were collected, and genomic DNA was isolated using phenol-chloroform method. Polymerase chain reaction amplification was carried out for DC gene, and the amplicons were subjected to direct sequencing (Macrogen, Korea). Mutations were analyzed comparing these sequences with those published sequences from the database using bioinformatics software. A total of eight point mutations were observed in the HCC cases. The natures of mutation observed were deletion, transition, and transversion. All mutations were located in the 19th chromosome at nine different loci (51,079, 51,493, 51,561, 51,124, 51,125, 51,127, 51,169, 51,170, and 51,172). Mutation in the promoter region of the DC-SIGN gene may be a possible risk factor for the development of HCC in India. The findings of the study reveal the possible role of these mutants with HCC, and future large-scale prospective studies will further validate the findings of the current study.

Cost-effectiveness of Sorafenib for Treatment of Advanced Hepatocellular Carcinoma in India

Majority of patients of hepatocellular carcinoma (HCC) in India present in advanced stages, when curative treatment options are limited. We undertook this study to assess the cost-effectiveness of treating advanced HCC patients with sorafenib compared with best supportive care (BSC). A Markov model was parameterized to model the lifetime costs and consequences of treating advanced HCC patients with sorafenib versus BSC using a societal perspective. Cost of routine care, diagnostics, management of complications in both the arms and management of adverse effects of sorafenib treatment were considered. A probabilistic sensitivity analysis was undertaken to assess the effect of parameter uncertainty. The incremental cost and benefit gained by treating HCC using sorafenib was Indian rupees 94,182 ($1459) and 0.19 quality adjusted life years (QALYs) per patient, implying an incremental cost of Indian rupees 507,520 ($7861) per QALY gained. Sorafenib is not cost-effective for use in advanced hepatocellular carcinoma treatment in India.

8. Cost effectiveness of sorafenib for treatment of advanced hepatocellular carcinoma in India

8. Cost effectiveness of sorafenib for treatment of advanced hepatocellular carcinoma in India

Risk factors for non-alcoholic fatty liver disease are common in patients with non-B non-C hepatocellular carcinoma in India.

The aim of the study was to analyze the prevalence of risk factors for non-alcoholic fatty liver disease (NAFLD) in patients with non-B non-C hepatocellular carcinoma (HCC). Between June 2012 and November 2014, patients with HCC, negative for hepatitis B surface antigen and hepatitis C virus antibody, were included in this study. All patients were assessed for risk factors for NAFLD such as diabetes mellitus (DM), hypertension, dyslipidemia, metabolic syndrome, and obesity. Forty-seven patients with non-B non-C HCC (males, 37; age, 60±10 years; mean±SD) were studied. Model for end-stage liver disease score was 11±4. Twenty-five patients were in Child's class A. History of significant alcohol intake was noted in 11 (23%) patients. Prevalence of risk factors for NAFLD were obesity 24 (51%), DM 22 (47%), metabolic syndrome 21 (45%), hypertension 16 (34%), and dyslipidemia 13 (28%). Forty (85%) patients had at least one risk factor for NAFLD. The mean duration of at least one NAFLD risk factor was 7.5years, prior to diagnosis of HCC. Thirteen (28%) patients were positive for anti-HBc; however, none of the study patients had detectable HBV DNA in blood. Eighty-five percent of the patients with non-B non-C HCC had at least one risk factor for NAFLD. None of the study patients had occult hepatitis B infection. NAFLD is emerging as the major etiological contributing factor for non-B non-C HCC in India.

Role of adipokines in the pathogenesis of nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is the hepatic manifestation of metabolic syndrome. The increased prevalence of obesity, diabetes, hypertension, hypertriglyceridaemia and hypercholesterolemia are considered to be the potential causative factors for NAFLD. NAFLD is emerging as a major clinical problem worldwide. Recently much attention has been focused in India as the prevalence of obesity and diabetes is rising. NAFLD is responsible for unexplained raise in transaminases, and an important cause of cryptogenic cirrhosis and cryptogenic hepatocellular carcinoma in India. NAFLD is a spectrum of disease ranging from simple steatosis to nonalcoholic steatohepatitis (NASH), potentially leading to fibrosis and cirrhosis. Studies have suggested that the adipokines are involved in the pathogenesis of NAFLD and its progression to NASH, through their metabolic and pro- or anti-inflammatory activity. Adipokines in particular tumor necrosis factor-α and interleukin-6 are believed to mediate the shift in pathology from steatosis to steatohepatitis. In addition, other adipokines such as adiponectin, leptin and resistin also play a crucial role in the development and progression of NAFLD through their metabolic and pro-or anti-inflammatory activity. This suggests that imbalance between pro-inflammatory and anti-inflammatory cytokines may have a role in the development of liver damage in NAFLD. Understanding the relationship between adipokines and NAFLD may play an important role in the early identification/diagnosis, treatment and also help in preventing disease progression.

Current Practices in Management of Hepatocellular Carcinoma in India: Results of an Online Survey

Prior to INASL guidelines, there were no Indian guidelines for management of hepatocellular carcinoma (HCC) in India. The guidelines given by other societies like AASLD, EASL etc are not uniform and not tailored for Indian patients. Hence management practices for HCC in India largely depended on physicians' individual preferences. This survey aimed to study current practices in management of HCC in India. An online survey was conducted from the platform of a survey portal (www.surveymonkey.com), from December 2012 to April 2013. Invitation to participate in the survey was sent to 1383 doctors of India who were expected to be involved in management of patients of HCC. The survey was of 10min duration and consisted of questions on how the respondents diagnosed and managed patients of HCC. Three hundred and seventy-seven doctors answered the survey questions (72% gastroenterologists, 95% working in India). The important points which emerged from the survey are following: (i) The incidence of HCC is increasing in India; (ii) The most common etiologic agent is Hepatitis B responsible for 43% cases; (iii) Only 14% patients present in early stage when curative treatment is possible (BCLC-A); (iv) 90% of these respondents screen for HCC when they first evaluate a cirrhotic patient; (v) While following a patient of cirrhosis most respondents screen for HCC by ultrasound and AFP at every 6 months to 1 year; and (vi) Most (82%) respondents follow some international guideline for staging and treatment of HCC. The respondents also suggested that there is a need for spreading awareness about HCC in public as well as in medical fraternity, and there is a need for a national registry of HCC. This is the first survey on management practices on HCC. With the publication of the INASL guidelines on HCC, the diagnosis and treatment of HCC will be more uniform and protocol based. Further such surveys should be carried out at periodic interval to track increasing awareness and better management practices for HCC in India.

Differential Expression of MicroRNA and HBV Related Hepatocellular Carcinoma in India

Background and Aims: Hepatitis B Virus (HBV) related hepatocellular carcinoma (HCC) is the third most frequent cause of cancer related death in India. microRNA (miR), a short (20 bp long) regulatory RNA fragment, deregulation plays a vital role in human hepatocellular carcinoma (HCC). This study is designed with aim to find out differential expression of cancer related micro RNA, miR-21 during HBV-HCC.

Hepatocellular carcinoma in India.

Cancers of the liver are one of the commonest cancers that occur in the world, the commonest of which is the hepatocellular carcinoma (HCC). It is considered to be the 5th commonest cancer in the world. In the areas that are endemic for hepatitis B and C, it is extremely common. Unfortunately, India which is an endemic zone for hepatitis B, there has been no comprehensive analyzed data for HCC. Incidence of HCC in India occurs at two peaks, one at a young age between 40 to 55 years and another above 60 years. Eighty per cent of all HCCs occurring in India occur with cirrhosis of liver in the background and 60% of all these cases are hepatitis B positive carriers. Symptoms are reflective of late presentation with advanced disease. Surgery, the only curative modulus available, unfortunately is not possible in 95% of HCC patients. Majority of the patients are treated with palliative and supportive care and life spans are limited. Sorafenib is used in a small section of patients. Characterization of HCC with molecular sub-typing is the need of the hour.

Hepatitis B Virus Infection can Cause Hepatocellular Carcinoma in Less Advanced Liver Cirrhosis: A Comparative Study of 142 Patients from North India

The clinical profile of patients with hepatocellular carcinoma (HCC) may differ depending on the etiology of HCC. There is no study from India comparing the clinical profile of patients of HCC due to hepatitis B virus (HBV) infection with other etiologies. We retrospectively reviewed the records of patients clinically diagnosed as HCC between Nov 2000 and Dec 2012 admitted under a single unit of Department of Gastroenterology at our hospital. We compared the clinical presentation of patients of Hepatitis B virus etiology (HBV group) with other etiologies (Non-HBV group). One hundred and forty-two patients were included (median age 60 years [range 30-83], 92% males). The etiology was HBV in 56 (39%) and among the non-HBV group (n=86, 61%) the etiological spectrum was following: alcohol 31 (22%), cryptogenic 26 (18%), HCV 27 (19%), and miscellaneous 2 (1%). The median age of presentation was significantly less for HBV group than in non-HBV (56 [30-77] vs. 62 [42-83] years, P<0.01). Clinical evidence of cirrhosis was significantly less common in the HBV group than non-HBV group (74% vs 98%, P<0.01). HBV group had lower CTP score than non-HBV (median CTP score 7 vs 8,P<0.05). Ascites was more common in non-HBV group than HBV group (65% vs 43%, P=0.018). The BCLC staging was: A 13%, B 23%, C 35%, and D 29%, and there was no difference in tumor characteristics or BCLC staging between HBV or the non-HBV group. HBV is a common cause of HCC in India, accounting for 39% of cases. The tumor characteristics of HCC due to HBV is similar to other etiologies, however, HBV causes HCC at an earlier age, and in less advanced or even absence of cirrhosis, thus further consolidating the directly carcinogenic potential of HBV.