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Giri S, Singh A. Epidemiology of Hepatocellular Carcinoma in India - An Updated Review for 2024. J Clin Exp Hepatol 2024; 14:101447. [PMID: 38957612 PMCID: PMC11215952 DOI: 10.1016/j.jceh.2024.101447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/13/2024] [Indexed: 07/04/2024] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common form of primary liver cancer and is a significant cause of morbidity and mortality, especially in patients with chronic liver disease. As a reflection of geographical variations in India, there is significant variation in the prevalence and etiological factors of HCC. In contrast to previous studies reporting viral hepatitis as the most common etiology, recent data indicates a changing etiological pattern of cirrhosis and HCC, with alcohol and metabolic dysfunction-associated steatotic liver disease (MASLD) emerging as the foremost cause. Thus, there was a need for an updated review of the current literature and databases for the changing epidemiology and etiological spectrum of HCC in India. The review included data primarily from the National Cancer Registry Program and the Global Burden of Diseases, Injuries, and Risk Factors Study, with the inclusion of other studies from India. The highlights of the present review are summarized in the following lines. Although the current incidence (2.15 per 100,000), prevalence (2.27 per 100,000), and mortality (2.21 per 100,000) rate of HCC in India remain lower compared to the global data, the annual rates of change in these parameters are higher in India. Among Indians, the present incidence, prevalence, and mortality related to HCC are higher in males, while the annual rate of change is higher in females. The Northeastern states have higher incidence, prevalence, and mortality related to HCC, but the Western states of Gujarat, Maharashtra, Goa, and Kerala are emerging as newer hotspots with higher annual rates of change in incidence, prevalence, and mortality. The incidence of HCC related to hepatitis B is on a downtrend, while those related to alcohol and MASLD are rising. Public health initiatives, awareness campaigns, and focused treatments are all necessary to combat these changes, particularly in areas with high incidence rates.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Ankita Singh
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
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Jahagirdar V, Rama K, Habeeb MF, Sharma M, Rao PN, Reddy DN, Singal AG, Kulkarni AV. Systemic Therapies for Hepatocellular Carcinoma in India. J Clin Exp Hepatol 2024; 14:101440. [PMID: 38975606 PMCID: PMC11225346 DOI: 10.1016/j.jceh.2024.101440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 04/30/2024] [Indexed: 07/09/2024] Open
Abstract
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 of ≤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 such as sorafenib, lenvatinib, regorafenib, and cabozantinib, with sorafenib being the most commonly used drug for a long time. Monoclonal antibodies such as 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.
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Affiliation(s)
- Vinay Jahagirdar
- Department of Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | - Kaanthi Rama
- Gandhi Medical College & Hospital, Secunderabad, India
| | | | - Mithun Sharma
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Padaki N. Rao
- Department of Hepatology, AIG Hospitals, Hyderabad, India
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Giri S, Choudhury A, Praharaj DL, Singh A, Vaidya A, Harindranath S, Anirvan P, Kalia S, Shukla A. Changing Etiological Spectrum of Hepatocellular Carcinoma in India-A Systematic Review and Meta-analysis. J Clin Exp Hepatol 2024; 14:101391. [PMID: 38559423 PMCID: PMC10979108 DOI: 10.1016/j.jceh.2024.101391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
Background Recent 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. Methods Electronic 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. Results A total of 60 studies (n = 12,327) 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 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 nonalcoholic 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 hepatitis C virus and alcohol did not change significantly. Conclusion Viral 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.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Dibya L Praharaj
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Ankita Singh
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Arun Vaidya
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Sidharth Harindranath
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Prajna Anirvan
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Shivam Kalia
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
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Ramegowda R, Gupta P. Abbreviated magnetic resonance imaging in hepatocellular carcinoma surveillance: A review. Indian J Gastroenterol 2024:10.1007/s12664-023-01511-z. [PMID: 38460056 DOI: 10.1007/s12664-023-01511-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/25/2023] [Indexed: 03/11/2024]
Abstract
Hepatocellular carcinoma (HCC) is one of the most common primary malignancies of the liver and a leading cause for cancer-related deaths worldwide. HCC surveillance aims at early detection. The recommended strategy for screening HCC is biannual ultrasound with or without alpha-fetoprotein. However, this strategy is associated with sub-optimal sensitivity. Abbreviated magnetic resonance imaging (AMRI) is a promising alternative to ultrasound (US) for surveillance of HCC. The data regarding the role of AMRI in HCC screening is evolving. There are different AMRI protocols, each having its merits and disadvantages. In this review, we discuss the need for AMRI, protocols of AMRI and hindrances to widespread adoption of AMRI.
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Affiliation(s)
- Rajath Ramegowda
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
| | - Pankaj Gupta
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India.
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Kumar A, Acharya SK, Singh SP, Duseja A, Madan K, Shukla A, Arora A, Anand AC, Bahl A, Soin AS, Sirohi B, Dutta D, Jothimani D, Panda D, Saini G, Varghese J, Kumar K, Premkumar M, Panigrahi MK, Wadhawan M, Sahu MK, Rela M, Kalra N, Rao PN, Puri P, Bhangui P, Kar P, Shah SR, Baijal SS, Shalimar, Paul SB, Gamanagatti S, Gupta S, Taneja S, Saraswat VA, Chawla YK. 2023 Update of Indian National Association for Study of the Liver Consensus on Management of Intermediate and Advanced Hepatocellular Carcinoma: The Puri III Recommendations. J Clin Exp Hepatol 2024; 14:101269. [PMID: 38107186 PMCID: PMC10724697 DOI: 10.1016/j.jceh.2023.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/12/2023] [Indexed: 12/19/2023] Open
Abstract
Hepatocellular carcinoma (HCC) presents significant treatment challenges despite considerable advancements in its management. The Indian National Association for the Study of the Liver (INASL) first published its guidelines to aid healthcare professionals in the diagnosis and treatment of HCC in 2014. These guidelines were subsequently updated in 2019. However, INASL has recognized the need to revise its guidelines in 2023 due to recent rapid advancements in the diagnosis and management of HCC, particularly for intermediate and advanced stages. The aim is to provide healthcare professionals with evidence-based recommendations tailored to the Indian context. To accomplish this, a task force was formed, and a two-day round table discussion was held in Puri, Odisha. During this event, experts in their respective fields deliberated and finalized consensus statements to develop these updated guidelines. The 2023 INASL guidelines offer a comprehensive framework for the diagnosis, staging, and management of intermediate and advanced HCC in India. They represent a significant step forward in standardizing clinical practices nationwide, with the primary objective of ensuring that patients with HCC receive the best possible care based on the latest evidence. The guidelines cover various topics related to intermediate and advanced HCC, including biomarkers of aggressive behavior, staging, treatment options, and follow-up care.
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Affiliation(s)
- Ashish Kumar
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110060, India
| | - Subrat K. Acharya
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, Odisha, 751 024, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, Dock Road, Manglabag, Cuttack, Odisha, 753 007, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Kaushal Madan
- Clinical Hepatology, Max Hospitals, Saket, New Delhi, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GSMC & KEM Hospital, Mumbai, 400022, India
| | - Anil Arora
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110060, India
| | - Anil C. Anand
- Department of Gastroenterology, Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, Odisha, 751 024, India
| | - Ankur Bahl
- Department of Medical Oncology, Fortis Memorial Research Institute, Sector - 44, Opp. HUDA City Center, Gurugram, 122002, India
| | - Arvinder S. Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, CH Baktawar Singh Road, Sector 38, Gurugram, Haryana, 122 001, India
| | - Bhawna Sirohi
- Medical Oncology, BALCO Medical Centre, Raipur Chattisgarh, 493661, India
| | - Debnarayan Dutta
- Radiation Oncology, Amrita Institute of Medical Sciences, Ponekkara, AIMS (P.O.), Kochi, 682041, India
| | - Dinesh Jothimani
- Department of Hepatology, Dr. Rela Institute & Medical Centre, #7, CLC Works Road, Chromepet, Chennai, 600044, India
| | - Dipanjan Panda
- Department of Medical Oncology, Apollo Cancer Centre, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, 110076, India
| | - Gagan Saini
- Radiation Oncology, Max Institute of Cancer Care, Max Super-Speciality Hospital, W-3, Ashok Marg, near Radisson Blu Hotel, Sector-1, Vaishali, Ghaziabad, 201012, India
| | - Joy Varghese
- Department of Hepatology & Transplant Hepatology, Gleneagles Global Health City, 439, Cheran Nagar, Perumbakkam, Chennai, Tamil Nadu, 600100, India
| | - Karan Kumar
- Department of HPB Sciences and Liver Transplantation, Mahatma Gandhi Medical College and Hospital, RIICO Institutional Area, Sitapura, Tonk Road, Jaipur, 302022, Rajasthan, India
| | - Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Manas K. Panigrahi
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, 751019, Odisha, India
| | - Manav Wadhawan
- Liver & Digestive Diseases Institute, Institute of Liver & Digestive Diseases, BLK Max Hospital, Delhi, 110 005, India
| | - Manoj K. Sahu
- Department of Medical Gastroenterology, IMS & SUM Hospital, K8 Kalinga Nagar, Shampur, Bhubaneswar, Odisha 751 003, India
| | - Mohamed Rela
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, #7, CLC Works Road, Chromepet, Chennai, 600044, India
| | - Naveen Kalra
- Department of Radio Diagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Padaki N. Rao
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, No. 6-3-661, Punjagutta Road, Somajiguda, Hyderabad, Telangana, 500 082, India
| | - Pankaj Puri
- Fortis Escorts Liver & Digestive Diseases Institute (FELDI), Fortis Escorts Heart Institute & Research Centre, Okhla Road, New Delhi, 110025, India
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, CH Baktawar Singh Road, Sector 38, Gurugram, Haryana, 122 001, India
| | - Premashis Kar
- Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, 201 012, India
| | - Samir R. Shah
- Department of Hepatology and Liver Intensive Care, Institute of Liver Disease, HPB Surgery and Transplant Global Hospitals, Dr E Borges Road, Parel, Mumbai, 400012, India
| | - Sanjay S. Baijal
- Diagnostic and Interventional Radiology, Medanta The Medicity, CH Baktawar Singh Road, Sector 38, Gurugram, Haryana, 122 001, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Shashi B. Paul
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Shivanand Gamanagatti
- Fortis Escorts Liver & Digestive Diseases Institute (FELDI), Fortis Escorts Heart Institute & Research Centre, Okhla Road, New Delhi, 110025, India
| | - Subash Gupta
- Centre for Liver & Biliary Sciences, Liver Transplant and Biliary Sciences, Robotic Surgery, Max Super Speciality Hospital, No. 1, 2, Press Enclave Road, Mandir Marg, Saket Institutional Area, Saket, New Delhi, Delhi, 110017, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Vivek A. Saraswat
- Department of Gastroenterology and Hepatology, Mahatma Gandhi Medical College and Hospital, RIICO Institutional Area, Sitapura, Tonk Road, Jaipur, 302022, Rajasthan, India
| | - Yogesh K. Chawla
- Department of Gastroenterology, Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, Odisha, 751 024, India
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Choudhuri G, Shah S, Kulkarni A, Jagtap N, Gaonkar P, Desai A, Adhav C. Non-alcoholic Steatohepatitis in Asians: Current Perspectives and Future Directions. Cureus 2023; 15:e42852. [PMID: 37664266 PMCID: PMC10473263 DOI: 10.7759/cureus.42852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2023] [Indexed: 09/05/2023] Open
Abstract
Non-alcoholic steatohepatitis (NASH) is a subset of non-alcoholic fatty liver disease (NAFLD), which, apart from excess fat in the liver, may be characterised by some level of inflammatory infiltration and fibrogenesis, occasionally progressing to liver cirrhosis or hepatocellular carcinoma (HCC). The objective of the current review is to elucidate the rising prevalence, the role of microbiome and genetics in pathogenesis, diagnostic challenges, and novel treatment alternatives for NASH. Newer diagnostic techniques are being developed since using liver biopsy in a larger population is not a reasonable option and is primarily restricted to clinical research, at least in developing countries. Besides these technical challenges, another important factor leading to deviation from guideline practice is the lack of health insurance coverage in countries like India. It leads to reluctance on the part of physicians and patients to delay required tests to curb out-of-pocket expenditure. There is no cure for NASH, with liver transplantation remaining the last option for those who progress to end-stage liver disease (ESLD) or are detected with early-stage HCC. Thus, lifestyle modification remains the only viable option for many, but compliance and long-term adherence remain major challenges. In obese individuals, bariatric surgery and weight reduction have shown favourable results. In patients with less severe obesity, endoscopic bariatric metabolic therapies (EBMT) are rapidly emerging as less invasive therapies. However, access and acceptability remain poor for these weight reduction methods. Therefore, intense research is being conducted for potential newer drug classes with several agents currently in phase II or III of clinical development. Some of these have demonstrated promising results, such as a reduction in hepatic fat content, and attenuation of fibrosis with an acceptable tolerability profile in phase II studies. The developments in the management of NASH have been fairly encouraging. Further well-designed long-term prospective studies should be undertaken to generate evidence with definitive results.
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Affiliation(s)
| | - Saumin Shah
- Gastroenterology, Gujarat Gastro and Vascular Hospital, Surat, IND
| | - Anand Kulkarni
- Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, IND
| | - Nitin Jagtap
- Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, IND
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Affiliation(s)
| | - Anand V Kulkarni
- Department of Hepatology, AIG Hospitals, Hyderabad, 500 032, India
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Koshy A, Devadas K, Panackel C, Philip M, Premaletha N, Zacharias P, Ramachandran TM, Gopalakrishna R, Mukkada RJ, Philips CA, Augustine P, Krishnakumar R, Sebastian B, Chettupuzha AP, Sadasivan S, Thomas GK, Siyad I, Sandesh K, Abhilash VB, Antony R, Kandathil JC, Pratap T, Mahadevan P. Multi-center prospective survey of hepatocellular carcinoma in Kerala: More than 1,200 cases. Indian J Gastroenterol 2023; 42:233-240. [PMID: 37154853 DOI: 10.1007/s12664-022-01314-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 11/22/2022] [Indexed: 05/10/2023]
Abstract
BACKGROUND 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. METHODS 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. RESULTS Forty-three doctors from 15 centers contributed the data. 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 > 400 ng/mL in 24%, total tumor diameter was > 5 cm 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 69 months) compared to matched patients given only TACE (median 18 months) (p = 0.03). CONCLUSION 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.
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Affiliation(s)
- Abraham Koshy
- Department of Gastroenterology, VPS Lakeshore Hospital, Kochi, 682 040, India.
| | - Krishnadas Devadas
- Department of Gastroenterology, Trivandrum Medical College, Trivandrum, 695 011, India
| | - Charles Panackel
- Department of Gastroenterology, Aster Medcity, Kochi, 682 027, India
| | - Mathew Philip
- Department of Gastroenterology, PVS Memorial Hospital, Kochi, 682 017, India
| | - N Premaletha
- Department of Gastroenterology, Kottayam Medical College, Kottayam, 686 008, India
| | - Prakash Zacharias
- Department of Gastroenterology, PVS Memorial Hospital, Kochi, 682 017, India
| | - T M Ramachandran
- Department of Gastroenterology, Calicut Medical College, Calicut, 673 008, India
| | - Rajesh Gopalakrishna
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, 682 041, India
| | - Roy J Mukkada
- Department of Gastroenterology, VPS Lakeshore Hospital, Kochi, 682 040, India
| | | | - Philip Augustine
- Department of Gastroenterology, Rajagiri Hospital, Aluva, 683 112, India
| | - Rema Krishnakumar
- Department of Gastroenterology, Moulana Hospital, Perinthalmanna, 679 322, India
| | - Benoy Sebastian
- Department of Gastroenterology, Medical Trust Hospital, Kochi, 682 016, India
| | | | - Shine Sadasivan
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, 682 041, India
| | - George K Thomas
- Department of Gastroenterology, Pushpagiri Medical College Hospital, Thiruvalla, 689 101, India
| | - Ismail Siyad
- Department of Gastroenterology, Aster Medcity, Kochi, 682 027, India
| | - K Sandesh
- Department of Gastroenterology, Calicut Medical College, Calicut, 673 008, India
| | - V B Abhilash
- Department of Gastroenterology, ESIC Hospital, Kollam, 691 002, India
| | - Rajesh Antony
- Department of Radiology, VPS Lakeshore Hospital, Kochi, 682 040, India
| | - Julio C Kandathil
- Department of Radiology, VPS Lakeshore Hospital, Kochi, 682 040, India
| | - Thara Pratap
- Department of Radiology, VPS Lakeshore Hospital, Kochi, 682 040, India
| | - Pushpa Mahadevan
- Department of Pathology, VPS Lakeshore Hospital, Kochi, 682 040, India
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Duseja A, Singh S, De A, Madan K, Rao PN, Shukla A, Choudhuri G, Saigal S, Shalimar, Arora A, Anand AC, Das A, Kumar A, Eapen CE, Devadas K, Shenoy KT, Panigrahi M, Wadhawan M, Rathi M, Kumar M, Choudhary NS, Saraf N, Nath P, Kar S, Alam S, Shah S, Nijhawan S, Acharya SK, Aggarwal V, Saraswat VA, Chawla YK. Indian National Association for Study of the Liver (INASL) Guidance Paper on Nomenclature, Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease (NAFLD). J Clin Exp Hepatol 2023; 13:273-302. [PMID: 36950481 PMCID: PMC10025685 DOI: 10.1016/j.jceh.2022.11.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 11/16/2022] [Accepted: 11/29/2022] [Indexed: 03/24/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a major cause of chronic liver disease globally and in India. The already high burden of NAFLD in India is expected to further increase in the future in parallel with the ongoing epidemics of obesity and type 2 diabetes mellitus. Given the high prevalence of NAFLD in the community, it is crucial to identify those at risk of progressive liver disease to streamline referral and guide proper management. Existing guidelines on NAFLD by various international societies fail to capture the entire landscape of NAFLD in India and are often difficult to incorporate in clinical practice due to fundamental differences in sociocultural aspects and health infrastructure available in India. A lot of progress has been made in the field of NAFLD in the 7 years since the initial position paper by the Indian National Association for the Study of Liver on NAFLD in 2015. Further, the ongoing debate on the nomenclature of NAFLD is creating undue confusion among clinical practitioners. The ensuing comprehensive review provides consensus-based, guidance statements on the nomenclature, diagnosis, and treatment of NAFLD that are practically implementable in the Indian setting.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- ALD, alcohol-associated liver disease
- ALT, alanine aminotransferase
- APRI, AST-platelet ratio index
- AST, aspartate aminotransferase
- BMI, body mass index
- CAP, controlled attenuation parameter
- CHB, chronic Hepatitis B
- CHC, chronic Hepatitis C
- CK-18, Cytokeratin-18
- CKD, chronic kidney disease
- CRN, Clinical Research Network
- CVD, cardiovascular disease
- DAFLD/DASH, dual etiology fatty liver disease or steatohepatitis
- EBMT, endoscopic bariatric metabolic therapy
- ELF, enhanced liver fibrosis
- FAST, FibroScan-AST
- FIB-4, fibrosis-4
- FLIP, fatty liver inhibition of progression
- FXR, farnesoid X receptor
- GLP-1, glucagon-like peptide-1
- HCC, hepatocellular carcinoma
- INASL, Indian National Association for Study of the Liver
- LAI, liver attenuation index
- LSM, liver stiffness measurement
- MAFLD
- MAFLD, metabolic dysfunction-associated fatty liver disease
- MR-PDFF, magnetic resonance – proton density fat fraction
- MRE, magnetic resonance elastography
- MetS, metabolic syndrome
- NAFL:, nonalcoholic fatty liver
- NAFLD, nonalcoholic fatty liver disease
- NAS, NAFLD activity score
- NASH
- NASH, nonalcoholic steatohepatitis
- NCD, noncommunicable diseases
- NCPF, noncirrhotic portal fibrosis
- NFS, NAFLD fibrosis score
- NHL, non-Hodgkin's lymphoma
- NPCDCS, National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke
- OCA, obeticholic acid
- PPAR, peroxisome proliferator activated receptor
- PTMS, post-transplant metabolic syndrome
- SAF, steatosis, activity, and fibrosis
- SGLT-2, sodium-glucose cotransporter-2
- SWE, shear wave elastography
- T2DM, DM: type 2 diabetes mellitus
- USG, ultrasound
- VAT, visceral adipose tissue
- VCTE, vibration controlled transient elastography
- fatty liver
- hepatic steatosis
- nonalcoholic steatohepatitis
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Affiliation(s)
- Ajay Duseja
- Departmentof Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S.P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, India
| | - Arka De
- Departmentof Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kaushal Madan
- Max Centre for Gastroenterology, Hepatology and Endoscopy, Max Hospitals, Saket, New Delhi, India
| | - Padaki Nagaraja Rao
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GSMC & KEM Hospital, Mumbai, India
| | - Gourdas Choudhuri
- Department of Gastroenterology and Hepato-Biliary Sciences, Fortis Memorial Research Institute, Gurugram, India
| | - Sanjiv Saigal
- Max Centre for Gastroenterology, Hepatology and Endoscopy, Max Hospitals, Saket, New Delhi, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Anil Arora
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Anil C. Anand
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Ashim Das
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Kumar
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Krishnadas Devadas
- Department of Gastroenterology, Government Medical College, Trivandrum, India
| | | | - Manas Panigrahi
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Manav Wadhawan
- Institute of Liver & Digestive Diseases, BLK Super Speciality Hospital, Delhi, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manoj Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Neeraj Saraf
- Department of Hepatology, Medanta, The Medicity, Gurugram, India
| | - Preetam Nath
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Sanjib Kar
- Department of Gastroenterology and Hepatology, Gastro Liver Care, Cuttack, India
| | - Seema Alam
- Department of PediatricHepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Samir Shah
- Department of Hepatology, Institute of Liver Disease, HPB Surgery and Transplant, Global Hospitals, Mumbai, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, Sawai Man Singh Medical College, Jaipur, India
| | - Subrat K. Acharya
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Vinayak Aggarwal
- Department of Cardiology, Fortis Memorial Research Institute, Gurugram, India
| | - Vivek A. Saraswat
- Department of Hepatology, Pancreatobiliary Sciences and Liver Transplantation, Mahatma Gandhi University of Medical Sciences and Technology, Jaipur, India
| | - Yogesh K. Chawla
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
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Shetty VV, Kellarai A. Comprehensive Review of Hepatocellular Carcinoma in India: Current Challenges and Future Directions. JCO Glob Oncol 2022; 8:e2200118. [PMID: 36198133 PMCID: PMC9812497 DOI: 10.1200/go.22.00118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Vijith Vittal Shetty
- K.S Hegde Medical Academy, Mangalore, India,Vijith Vittal Shetty, MD, DM, Medical Oncology, K.S Hegde Medical Academy, University Rd, Deralakatte, Mangalore, Dakshina Kannada, Karnataka 575018, India; e-mail:
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11
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Changing global epidemiology of liver cancer from 2010 to 2019: NASH is the fastest growing cause of liver cancer. Cell Metab 2022; 34:969-977.e2. [PMID: 35793659 PMCID: PMC9762323 DOI: 10.1016/j.cmet.2022.05.003] [Citation(s) in RCA: 171] [Impact Index Per Article: 85.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/19/2022] [Accepted: 05/12/2022] [Indexed: 12/17/2022]
Abstract
Liver cancer epidemiology is changing due to increasing alcohol consumption, rising prevalence of obesity, and advances in hepatitis B virus (HBV) and hepatitis C virus (HCV) treatment. However, the impact of these changes on global liver cancer burden remains unclear. We estimated global and regional temporal trends in the burden of liver cancer and the contributions of various liver disease etiologies using the methodology framework of the Global Burden of Disease study. Between 2010 and 2019, there was a 25% increase in liver cancer deaths. Age-standardized death rates (ASDRs) increased only in the Americas and remained stable or fell in all other regions. Between 2010 and 2019, non-alcoholic steatohepatitis (NASH) and alcohol had the fastest growing ASDRs, while HCV and HBV declined. Urgent measures are required at a global level to tackle underlying metabolic risk factors and slow the growing burden of NASH-associated liver cancer, especially in the Americas.
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Duseja A, Singh SP, Mehta M, Shalimar, Venkataraman J, Mehta V, Devadas K, Kar SK, Goyal O, Nagral A, Saigal S, Nijhawan S, Praharaj D, Shukla A, Sharma B, Narayanasamy K, Kumar P, Rao PN, Arora A, Mehta R, Asati P, Ranjan P, Koshy A, Alam S, Mukewar S, Mukewar S, Mohan Prasad VG, Rastogi M, Sanyal AJ. Clinicopathological Profile and Outcome of a Large Cohort of Patients with Nonalcoholic Fatty Liver Disease from South Asia: Interim Results of the Indian Consortium on Nonalcoholic Fatty Liver Disease. Metab Syndr Relat Disord 2022; 20:166-173. [PMID: 35085026 DOI: 10.1089/met.2021.0104] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Previous data from South Asia and India had shown that patients with nonalcoholic fatty liver disease (NAFLD) have mild liver disease severity. There are no data regarding long-term clinical outcomes in patients with NAFLD from South Asia. The aim of the study was to evaluate the clinicopathological profile, severity of NAFLD, and clinical outcomes in a large cohort of patients with NAFLD from South Asia. Methods: In an ongoing real-life study [Indian Consortium on nonalcoholic fatty liver disease (ICON-D)], interim data captured across 23 centers in India over 18 months was analyzed for clinicopathological profile, severity of NAFLD, and hepatic/extrahepatic events on follow-up. Results: Of 4313 patients (mean age 45 ± 12.2 years, males 52%), data on metabolic risk factors in 3553 (82.3%) patients revealed that 378 (10.6%) were lean, 575 (16.2%) overweight, 2584 (72.7%) obese; metabolic syndrome in 1518 (42.7%) and at least one metabolic risk factor in 3292 (92.6%) patients. Evidence of significant or advanced fibrosis assessed with [aspartate transaminase to platelet ratio index (APRI), n = 3196 (74%)], [fibrosis-4 (FIB-4), n = 3554 (82.4%)], [NAFLD fibrosis score (NFS), n = 1924 (44.6%)], [Fibroscan, n = 2475, (57.3%)], and histology [n = 267 (6.2%)] was present in 682 (21.3%), 676 (19%), 397 (20.6%), 715 (29%), and 41 (15.4%) patients, respectively; 246 (10%) patients on Fibroscan and 22 (8.2%) on histology had evidence of cirrhosis. On a mean follow-up 43.5 months, hepatic and extrahepatic events recorded in 1353 (31.3%) patients showed that patients with compensated cirrhosis [71 (5.2%)] had more hepatic [26 (36.7%)] and extrahepatic events [8 (11.3%)] in comparison with those without cirrhosis (P < 0.0001). Conclusion: Around one fifth of patients with NAFLD in South Asia have significant liver disease. Both hepatic and extrahepatic events on follow-up are observed more commonly in patients with nonalcoholic steatohepatitis-related compensated cirrhosis.
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Affiliation(s)
- Ajay Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shivaram P Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, India
| | - Manu Mehta
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Jayanthi Venkataraman
- Department of Hepatology, Sri Ramachandra Institute of Higher Education & Research, Chennai, India
| | - Varun Mehta
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Krishnadas Devadas
- Department of Gastroenterology, Government Medical College, Trivandrum, India
| | | | - Omesh Goyal
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, India
| | | | | | | | - Dibyalochan Praharaj
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneshwar, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GSMC & KEM Hospital, Mumbai, India
| | - Brij Sharma
- Department of Gastroenterology, Indira Gandhi Medical College & Hospital, Shimla, India
| | - K Narayanasamy
- Department of Hepatology, Madras Medical College, Chennai, India
| | - Pramod Kumar
- Centre of Liver Sciences, AIG Hospitals, Hyderabad, India
| | | | - Anil Arora
- Department of Gastroenterology and Hepatology, Sir Gangaram Hospital, New Delhi, India
| | - Rajiv Mehta
- Department of Gastroenterology, Surat Institute of Digestive Sciences, Surat, India
| | - Pankaj Asati
- NSC Bose Medical College and Hospital, Jabalpur, India
| | - Piyush Ranjan
- Department of Gastroenterology and Hepatology, Sir Gangaram Hospital, New Delhi, India
| | - Abraham Koshy
- Department of Hepatology, VPS Lakeshore, Kochi, India
| | - Seema Alam
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | | | | | - Mukul Rastogi
- Department of Hepatology, Gastroenterology and Liver Transplant, Fortis Hospital, Noida, India
| | - Arun J Sanyal
- Division of Gastroenterology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
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Takaya H, Namisaki T, Matsumoto K, Suzuki J, Murata K, Tsuji Y, Nakanishi K, Kaji K, Kitade M, Noguchi R, Yoshiji H. Comparison of Ablation Area and Change in Functional Liver Reserve after Radiofrequency Ablation for Hepatocellular Carcinoma Using the arfa ® and VIVA ® Systems. J Clin Med 2022; 11:jcm11020434. [PMID: 35054128 PMCID: PMC8780974 DOI: 10.3390/jcm11020434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 01/27/2023] Open
Abstract
Radiofrequency ablation (RFA) is recommended in Japan for patients with hepatocellular carcinomas (HCCs) one to three in number and ≤3 cm in size. The arfa® and VIVA® RFA systems are widely used for patients with HCC and this retrospective observational study aims to compare their performances. The study included 365 patients with HCCs one to three in number and ≤3 cm in size who underwent RFA using the arfa® system (arfa® group) or the VIVA® system (VIVA® group). The total bilirubin (T-Bil) level after RFA was higher in the arfa® group than in the VIVA® group. With a 3-cm electrode needle, the longest diameter (Dmax) and the shortest diameter were analyzed and found to be greater in the arfa® group than in the VIVA® group. Furthermore, Dmax with the 2.5-cm electrode needle was greater in the arfa® group than in the VIVA® group. Statistically significant differences in the ablation area and in the T-Bil value after RFA were observed between the groups; however, these differences are not considered clinical problems because the difference in the ablation area was only slight and the Child–Pugh score was the same between the groups. Thus, hepatologists can use either of the RFA systems based on their preference.
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Affiliation(s)
- Hiroaki Takaya
- Correspondence: ; Tel.: +81-744-22-3051; Fax: +81-744-24-7122
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Jearth V, Patil PS, Mehta S, Sundaram S, Seth V, Goel M, Patkar S, Bal M, Rao V. Correlation of Clinicopathological Profile, Prognostic Factors, and Survival Outcomes with Baseline Alfa-Fetoprotein Levels in Patients With Hepatocellular Carcinoma: A Biomarker that is Bruised but Not Broken. J Clin Exp Hepatol 2022; 12:841-852. [PMID: 35677513 PMCID: PMC9168719 DOI: 10.1016/j.jceh.2021.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 11/10/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND AIMS The role of Alfa-fetoprotein (AFP) in the management of hepatocellular carcinoma (HCC) is still debated, with differences in recommendations between international guidelines. We analyzed the relationship of the clinicopathological profile, prognostic features, and survival outcomes with baseline serum AFP levels in patients with HCC. METHODS Retrospective analysis of a prospectively accrued dataset of consecutive HCC patients was done. RESULTS 508 treatment naive patients were included in the analysis. AFP at presentation was normal (<10 ng/ml) in 18% patients. Patients with very high AFP (>400 ng/ml) had poor hepatic reserves (higher mean serum bilirubin, AST, ALT, INR, and lower mean albumin) and advanced disease at presentation (higher incidence of extrahepatic metastasis, and less proportion of patients with well-differentiated tumors). AFP >400 ng/ml was an independent predictor for presence of portal vein tumor thrombosis (PVTT) (OR, 4.08; 95% CI, 2.34-7.12; P < 0.001), higher tumor size (OR, 2.19; 95% CI, 1.36-3.54, P = 0.001) and advanced BCLC stage (OR, 4.19; 95% CI, 2.51-7.03; P < 0.001). Two-third of patients with small HCC (MTD <3 cm) and more than half with early-stage HCC (BCLC stage 0/A) had elevated AFP levels. No significant relationship was seen between overall survival (OS) and baseline AFP in patients who underwent surgery, but median OS in patients subjected to nonsurgical therapies was 19.4,10.5 and 5.7 months in patients having AFP <10 ng/ml, 10-400 ng/ml and >400 ng/ml respectively (P = 0.003). AFP >400 ng/ml was an independent predictor of survival in patients receiving any form of therapy (HR = 2.23; 95% CI = 1.19-4.18, P = 0.012). CONCLUSION AFP as a biomarker still has a significant role to play in the management of HCC patients and is here to stay till the search for an ideal biomarker in HCC is over.
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Key Words
- AFP, Alfa-fetoprotein
- BCLC, Barcelona clinic liver cancer
- BSC, Best supportive care
- Barcelona clinic liver cancer staging
- EHM, Extrahepatic metastasis
- HBHC, HBV or HCV related
- HBV, Hepatitis B virus
- HCC, Hepatocellular carcinoma
- HCV, Hepatitis C virus
- MDT, Multidisciplinary team
- MTD, Maximum tumor diameter
- NAFLD, Nonalcoholic fatty liver disease
- NBNC, Non B Non C related
- OS, Overall survival
- PVTT, Portal vein tumor thrombosis
- RFA, Radiofrequency ablation
- SBRT, Stereotactic body radiation therapy
- TACE, Transarterial chemo-embolization
- TARE, Transarterial radio-embolization
- alfa-fetoprotein
- biomarker
- hepatocellular carcinoma
- portal vein tumor thrombosis
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Affiliation(s)
- Vaneet Jearth
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Prachi S. Patil
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India,Address for correspondence: Prachi S. Patil, Professor, Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, Maharashtra, 400012, India. Tel.: +91-22-24177000. Ext-7205.
| | - Shaesta Mehta
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Vishal Seth
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Mahesh Goel
- Division of Hepatobiliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Shraddha Patkar
- Division of Hepatobiliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Munita Bal
- Department of Pathology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Vidya Rao
- Department of Pathology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India
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De A, Keisham A, Mishra S, Mehta M, Verma N, Premkumar M, Taneja S, Das A, Singh V, Duseja A. FibroScan-AST (FAST) Score for Nonalcoholic Steatohepatitis - Validation in an Indian Cohort. J Clin Exp Hepatol 2022; 12:440-447. [PMID: 35535068 PMCID: PMC9077185 DOI: 10.1016/j.jceh.2021.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/08/2021] [Indexed: 12/12/2022] Open
Abstract
Background The FibroScan-AST (FAST) score was recently described to detect patients with nonalcoholic steatohepatitis (NASH) having elevated nonalcoholic fatty liver disease (NAFLD) activity score (NAS ≥ 4) and significant fibrosis (≥ F2) on liver biopsy (NASH+ NAS ≥ 4 + F ≥ 2). Aim The aim of this study was to validate the FAST score in Indian patients with NAFLD and to derive optimal cut-offs. Methods Sixty patients with biopsy-proven NAFLD [men: 38 (63.3%), age 40 (32-52) years] with all parameters for assessing the FAST score within 3 months of liver histology were retrospectively analysed. Results Histological NASH was present in 17 patients (28.3%), while 11 (18.3%) patients had NASH + NAS ≥ 4 + F ≥ 2. The area under the curve (AUROC) of the FAST score for discriminating NASH + NAS ≥ 4 + F ≥ 2 was 0.81. Using cut-offs by Newsome et al, the rule-out cut-off (FAST: ≤ 0.35) had a negative predictive value (NPV) of 0.88 [sensitivity: 0.91, specificity: 0.14, negative likelihood ratio (LR): 0.64], while the rule-in cut-off (FAST: ≥ 0.67) had a positive predictive value (PPV) of 0.33 (sensitivity: 0.73, specificity: 0.67, positive LR: 2.22). Fifteen (25%) patients were correctly classified as per histology, while 28 (46.67%) patients fell in the grey zone. On recalculating the optimal cut-offs for our patients, the rule-out cut-off (FAST: ≤ 0.55) had an NPV of 0.95 (sensitivity: 0.90, specificity: 0.45, negative LR: 0.21), while the optimal rule-in cut-off (FAST: ≥ 0.78) had a PPV of 0.70 (sensitivity: 0.64, specificity 0.94, positive LR: 10.39). With these cut-offs, 27 (45%) patients fell in the grey zone and 29 (48.3%) were correctly classified as per histology, performing better than the cut-offs by Newsome et al (P < 0.001). Conclusion The FAST score demonstrates good AUROC for detecting NASH with significant fibrosis and inflammation on histology. Cut-offs should be recalibrated based on prevalence of disease. Lay summary India has a high burden of NAFLD with an estimated 25 million patients at potential risk for significant liver disease. Liver biopsy remains the gold standard for diagnosing NASH, although its application in routine clinical practice is limited. Noninvasive tests for the simultaneous detection of steatosis, inflammation and fibrosis are thus the need of the hour. The FAST score has been recently suggested for the noninvasive detection of NASH with significant fibrosis (≥ F2) and inflammation (NAS ≥ 4) on liver biopsy. We validated the utility of the FAST score for detecting NASH with significant fibrosis and inflammation on liver biopsy in Indian patients with NAFLD. This noninvasive, easy-to-use and nonproprietary FAST score can correctly classify disease severity in more than 50% patients. However, our results suggest that cut-offs should be recalibrated based on the anticipated prevalence of NASH + NAS ≥ 4 + F ≥ 2 in the given population.
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Key Words
- ALT, Alanine Aminotransferase
- AMA, Antimitochondrial Antibody
- ANAs, Antinuclear Antibodies
- AST, Aspartate aminotransferase
- BMI, Body Mass Index
- CAP, Controlled Attenuation Parameter
- FAST, FibroScan-AST
- FLIP, Fatty Liver Inhibition of Progression
- FibroScan
- HTN, Hypertension
- LKM, Antiliver Kidney Microsomal Antibody
- LSM, Liver Stiffness Measurement
- NAFLD
- NAFLD, Nonalcoholic Fatty Liver Disease
- NAS, NAFLD Activity Score
- NASH, Nonalcoholic Steatohepatitis
- NASH-CRN, NASH Clinical Research Network
- SAF, Steatosis, Activity and Fibrosis Score
- T2DM, Type 2 Diabetes Mellitus
- nonalcoholic fatty liver disease
- steatosis
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Ajay Duseja
- Address for correspondence: Dr. Ajay Duseja, MD, DM, FAASLD, FACG, FAMS, FSGEI, Professor, Department of Hepatology, Sector 12, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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16
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Acharya SK. Treatment for Hepatocellular Carcinoma in South Asia. J Clin Exp Hepatol 2021; 11:641-645. [PMID: 34866841 PMCID: PMC8617535 DOI: 10.1016/j.jceh.2021.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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De A, Duseja A. Nonalcoholic Fatty Liver Disease: Indian Perspective. Clin Liver Dis (Hoboken) 2021; 18:158-163. [PMID: 34691404 PMCID: PMC8518336 DOI: 10.1002/cld.1141] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/12/2021] [Accepted: 05/18/2021] [Indexed: 02/04/2023] Open
Affiliation(s)
- Arka De
- Department of HepatologyPostgraduate Institute of Medical Education and ResearchChandigarhIndia
| | - Ajay Duseja
- Department of HepatologyPostgraduate Institute of Medical Education and ResearchChandigarhIndia
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