DISCUSSION
This is the largest study in Nepal of this type where we analyzed the
clinical, etiological, and radiological profile of 54 patients with HCC
visiting the OPD or admitted to the ward under the Department of
Gastroenterology. Previous studies have shown that the incidence of HCC
increases with age such that its occurrence before 40 years of age is
minimal in the Western world.10 The age distribution
of patients with HCC in this study is similar to a study by Kumar R. et
al. in India which has shown the maximum incidence of HCC in the sixth
decade.10 Regarding the sex-wise distribution of HCC,
our study showed that there is a male preponderance in the prevalence of
HCC in our study with a male: female ratio of 5:1. Similar finding with
a higher preponderance of HCC in male is shown in other previous studies
with the male: female ratios ranging from 3:1 to
10:1.9-11 This suggests that older age and male sex
are the risk factors for liver cancer. However, the higher incidence of
HCC in males might be because of the higher tendency of males in seeking
medical treatment in comparison to females.
The current study demonstrated that most of the patients (88.89%) were
symptomatic at the time of presentation, and the most common
presentations were abdominal discomfort/pain, abdominal distention, and
anorexia. This finding corresponds with other similar studies where only
16.81% of total patients were asymptomatic and the rest presented with
similar complaints.11, 12 This reflects the late
presentation of the patients with HCC to the medical facility when the
tumor is no longer resectable with complaints like abdominal pain and
abdominal distension.
Non-cirrhotic HCC accounted for 22.22% of all patients in our study,
while the majority (77.78%) had liver cirrhosis. Most of the patients
with cirrhosis (80.95%) had decompensated disease in various forms. A
multinational cross-sectional study by Yang J.D et al. in Africa
revealed that all the patients with HCC in Egypt (100%) and around
two-thirds in other African nations (66%) had cirrhosis. The findings
in our study and other similar studies suggest that hepatic cirrhosis is
also a strong risk factor for HCC.13
The etiological factors for HCC vary in different geographical regions.
The majority of our patients with HCC had alcohol abuse as a cause of
cirrhosis, and HBV as the sole cause of cirrhosis was seen only in 11%
of patients. These findings contradict the outputs of other studies
conducted in India which found HBV as the most common cause of
HCC.10,12 However, a similar study conducted by Egypt
showed HBV infection in only 22.4% of total cases of
HCC.14 Similarly, another study by Aljumah A. et al.
indicated HCV infection as the most common cause of HCC affecting
46.80% of the total cases.6 This could be due to the
fact that there is a very low prevalence of HBV and HCV in Nepal, and
alcohol-related cirrhosis is quite common in our
country.15-17
We also analyzed the tumor markers of these patients. Serum AFP level
was elevated in 81.48% of our patients and median AFP level was
286ng/ml. In a study by Bhatti et al., the median AFP level among
patients with HCC was only 43.6ng/ml. This difference could be because
most of the patients presented with advanced HCC in our study. Though
serum AFP measurement is used as a screening tool for HCC, the rise in
its levels in serum is neither sensitive nor specific to
HCC.18, 19
We observed that most of our patients presented either with advanced
stage (BCLC stage C) (35.19%) or terminal stage (BCLC stage D)
(38.89%) HCC despite the fact that the majority (42.59%) of them had
Child-Turcotte-Pugh (CTP) score A. This is in contrast to the study by
Aljumah A. et al. where BCLC combined stages A and B comprise nearly
70% of total cases, with the majority having preserved liver function,
CTP score class A.6 Moreover, macrovascular invasion
and metastases were seen in 44.44% and 14.81% of patients
respectively, which is in accordance with the study, by Masunuri et al.,
where portal vein thrombosis (PVT) was seen in 40.4% of
patients.11 However other similar studies found PVT in
less than 20% of total cases only.6, 14 Since, tumor
cells are more likely to disseminate via portal circulation to distant
organs, presence of PVT in a HCC is a critical issue leading to early
deterioration of hepatic function and worse
prognosis.6 Thus, PVT was the major reason that more
than one-third of the patients in our study belonged to the advance
stage HCC despite being in a good functional status. Notably,
potentially curative therapies were underutilized i.e. only 7.41%
received surgical and 3.70% received non-surgical curative services.
Because of the presence of poor prognostic factors and aggressive
behavior of HCC, 38.89% of them received only the best supportive care
for their symptoms. However, the treatment approaches for patients with
HCC in Africa varied compared to our setting. For example, 35% of total
HCC patients in Egypt and less than 1% in other African countries
received curative treatment.13
In this study, though we tried to include all the patients with HCC at a
tertiary care center in Nepal, and analyzed their clinical, etiological,
and radiological profile, there are certain limitations. Being a
single-center study, it does not reflect the actual scenario of HCC in
Nepal and therefore the results are not generalizable. Being a tertiary
care center, most cases we received were at advanced stages, therefore,
we could not analyze the actual outcomes of the treatment in all the
stages. In addition, we did not follow up on these patients to evaluate
the outcomes of the treatment.